automated management information systems

Administration in Mental Health Vol. 8, No. 1, Fall 1980

AUTOMATED MANAGEMENT INFORMATION SYSTEMS

Jerome M. Siegel

ABSTRACT: The author describes the problems and potential of an automated information system in a mental health organization. Such issues as the purposes of the M.I.S., its data elements, staff and management involvement, implementing the system and manual versus automated systems are diseussed. The human and organizational dimensions as well as the possible eonflicts are reviewed.

The computerized management information system (MIS) currently in use at the Hahnemann Communi ty Mental Heal th/Mental Retardat ion Center ( H C M H / M R C ) succeeded an earlier manual M.I .S . which basically paral- leled the inputs of the current system although its outputs were much more ab- breviated. The major reason for the conversion from the manual to the compu-

ter system was that manual information processing had become too inefficient because of the great volume of data to be processed. The problems of the eon- version process have been described in detail elsewhere (St. Clair, Siegel, Caruso, & Spivack, 1976). Briefly, these problems included staff resistance to the new system which took the form of input errors such as illegible entries, incorrect entries, and missing forms; indifferent help from the computer service company; and insufficient time allocated for the conversion process.

We are now in the process ofchanging computer companies and redesigning our system. One of our major difficulties with the current automated system was that it was designed by a subcontractor. Consequently, when the system began to operate, personnel in the computer service organization seemed unfa- miliar with it. They had to learn the system on a p rob lem-by-prob lem basis and this created many difficulties, including delays in attending to output problems. We spoke mental health language and they spoke to us in "compu-

terese." We were ignorant of each others' terms. This failure to communicate

Jerome M. Siegel, Ph.D. is affiliated with H a h n e m a n n Medical Gollege and Hospital in Philadelphia, Penna. Requests for reprints may be addressed to the author at 112 N. Broad Street, 5th Floor, Philadelphia, PA 19102.

46 0090-1180/80/1500-0046500. 95 ©1980 Human Sciences Press

Jerome M. Siegel 47

precisely caused us much difficulty in the early days of our computer experience. For example, our use of the term "ep i sode" as a period of active treatment that ends with a discharge was difficult for the computer people to grasp. Much of the problem was our own solipsistic assumption that what we knew, everybody knew. Once "ep isode" had been defined precisely and mutually understood, our difficulties with the term ended. The assembling of a lexicon of common terms (discharge, file, cycle, transfer, etc.) at the beginning would have helped.

Ahhough communication difficulties diminished as time went on, we are still unclear about the basic ways in which our data is processed (programs, file structure, etc.). This ignorance has impeded our efforts to correct problems with our output reports, problems that existed since the system began. For example, we had been puzzled by the designation o f " u n k n o w n therapist" on the computer reports. We did not know that this was the computer 's way of com- municating that the therapist was no longer employed.

Mistakes in our outputs generally involved incorrect transposition of information, misunderstandings as to what was wanted originally, keypunch errors, and program errors based on miscommunication. These output mistakes have been very difficult to correct, sometimes taking months for what appeared to be relatively simple items.

. . . a d e q u a t e i n f o r m a t i o n a b o u t f i n a n c e s are o f c r u c i a l

i m p o r t a n c e .

The timeliness of our outputs has been another problem. In the original design of the system, the monthly output reports were to be received by us from the computer company about two weeks after the close of the month. In nearly five years we have, at times, fallen behind by three or four months. In this situation the administrators and unit directors were receiving information that was nearly useless. The situation became so serious that the county office of mental health began to threaten funding cuts because our reports were late. To correct this problem, we went on an accelerated " c a t c h - u p " schedule for data processing and with considerable effort (in the form of evening and weekend over- time) the gap gradually narrowed.

The current system also has its successes. Our current computer company processes a great deal of data for us and produces a very large nmber of monthly outputs at comparatively low cost. Billing has certainly improved and the system seems very cost efficient. Computerization has also made it much easier to keep track of individual patients in our large, geographically dispersed center in which outpatient sessions number 3,000 per month, inpatient days about 1,100, and partial hospitalization days about 3,100.

We are redesigning our system and changing to a new computer service organization. We hope to achieve a rauch more flexible online system that will

48 Administration in Mental Health

enable us to obtain quick, inexpensive answers to evaluation questions that cannot be answered by routine monthly outputs, e.g. , how many hours of treatment time per patient are required by psychotic patients compared to non-psychotic patients? We also are planning to redesign our outputs, elimi- nating some that have been little use and combining others. We are planning new outputs mainly concerned with providing more fiscal information. We do not have at the present time, an output that will tell us how rauch income a service unit generated from various payment sources and how much expense should be charged to that unit.

DECENTRALIZATION

A mental health organization that is decentralized into several facilities pre- sents special problems for an M.I .S. The major problem is of course the move- ment of paper necessary for the operation of the M.I .S. In a centralized center, paper can be, and usually is, walked from the clinical service to the data processing area. In a decentralized center, paper must flow by mail. Mail can be late; it can also be lost, misplaced, or stolen. Late or totally absent paper may disrupt the system in numerous ways- - i t is much less a problem for a centralized organization.

A second problem is the relationship between the initiators of paper, the service providers, and the people who process it. In a centralized organization, face-to-face contact between these groups is frequent. The psychological en- vironment is characterized by the informality of face-to-face contact, and frequently there is cooperation around mutual problems. In a decentralized organization the greater impersonality of communication may result in an atmos- phere of suspicion and lack of cooperation.

Finally, administrative solutions to MA.S. problems may be implemented more easily in a centralized system. The entire staff can be assembled more quickly and information about problems and solutions can be communicated. In a decentralized organization this is much more difficult.

GENERAL CONSIDERATIONS

Communi ty mental health centers and other mental health facilities contem- plating the start of a new M.I .S. or the replacement of an old one, may benefit from the accumulated wisdom of those who have trodden the road before.

To begin, a review of the purposes that the M.I .S. will serve is a necessary first step (Flaherty, 1977). In the most general sense experts agree that an M.I .S. should provide information for five general purposes: 1) to satisfy the accountability requirements of governmental funding agencies, 2) for decision making and program management, 3) for billing and fiscal needs, 4) to improve clinical services, and 5) for program evaluation. As Flaherty (1977) points out, there is no general agreement that an M.I .S. should be designed to meet all these purposes. Such a system might be costly and cumbersome. Even

Jerome M. Siegel 49

if the personnel responsible for the design of an M.I.S. agree on all five purposes, they might still disagree on priorities for meeting these purposes. Fiscal people might argue that billing and fiscal information get top priority while others might urge that clinical information is most important. Certain realities are inescapable, however. One of these is the accountability requirernents of the various governmental agencies that fund the organization. At every governmental level, there are reports that taust be generated. To ignore these requirements or to design an M.I.S. that does not adequately meet these reporting needs would put the organization at risk of a loss in funding. There- fore, the various governmental reporting requirements should be assembled during the design phase, and the inputs should include all the necessary information.

ù .research findings (Lucas, 1975) indicate that higher levels of management support seem to result in better morale among M.L S. personnel.

Billing and fiscal information is another high priority. The generation of income from first and third party payers, and adequate information about finan- ces are of crucial importance. Information for management , for the improve- ment of clinical services, and for program evaluation are also important.

The above purposes, disparate as they may seem, may.be served by the same data elements in the M.I.S. Although there may be disagreement about purposes and priorities, there is generaily little disagreement about which data elements should be captured (Flaherty, 1977). Data elements are the answers to the basic question: "Whereand Why Does Wh0 Do Whatto Whom with WhatRe- sult and at What Cost?" (Person, 1969; Cooper, 1973). Breaking this question down into its component patts answers the question of what data elements are needed in an M.I.S. " W h o m " can be answered by the need for information about patients; " w h o " is answered by information about staff; information about treatment modalities such as inpatient, outpatient, and partial hospitalization answers the "whe re" ; information about patient needs answers " w h y " ; information about treatrnent outcome the "what result"; and finally, fiscal information the "what cost".

Other aspects to be considered in the design and implementation of an M.I.S. are, staff involvement; management involvement; feedback; timeliness; integration of subsystems, sirnplicity; the use of consultants; documentation; and choice between an automated or a manual system. Each of these aspects will be briefly discussed below.

There is general agreement in the literature that staff involvement in all phases of system design and implementation is vital to the success of any M.I.S. (Chapman, 1976; Flaherty, 1977). At least two studies have indicated the importance of staff involvement. In the first, Crawford (1974) found that when a group of mental health and computer professionals set up a system to


replace nursing notes, the system never became operational because nurses, the intended users of the new system, were never consulted. The new system failed to meet nursing needs and this failure could have been avoided if the nurses had been included in the design. In the second study, Lucas (1975) studied thirteen M.I .S .s and found that the rnore users of the systems were involved in system design and operation, the more favorably they viewed the quality of their systems.

Management involvement in, and support for, the M.I .S. is another sine qua

non for the success of an M~I.S. (Chapman, 1976; Cooper, 1973), and should ent«il the allocation of adequate resources to develop and maintain the system (Cooper, 1973). In Cooper 's words, "The provision of adequate resources has many facets. It me«ns not only adequate staff and budget but it also means adequate collateral resources such as access to data processing equipment and other related resources such as programmers (p. 2) ." Once a system is established, management taust commit itself to using the information provided for decision-making. Chapman (1976) warns that an M.I .S. will face an early de«th if its reports do not make a difference in the organization's resource allocation. However, for an M.I .S. to be useful to management, it taust be timely. If decision-relevant information comes to management after a decision has al- ready been made, then the information, and by extension the information system that provided it, will not be seen as useful. One rinal word on management involvement: research findings (Lucas, 1975) indicate that higher levels of management support seem to result in better morale arnong M.I .S. personnel.

Prompt feedback, as Cooper (1973) points out, is another necessary element be«ause it helps maintain staff cooperation. It demonstrates that the data provided by clinical staff return to them in the form of a product that «an help them. Another benefit of a system with prompt feedback is that it provides a ve- hicle for timely information to other agencies and persons.

M.I.S.s are frequently «omplex te«hnological «flairs that include a myriad of detail covering all phases of the system.

Allocating enough time for the development of an M.I .S. is another important concern. Our own experience (St. Clair et al., 1976) and that of others (Elpers and Chapman, 1973; Sletten and Hedlund, 1974) indicates that imple- ment«tion generally takes longer than planned. Even the most meticulous and compulsive planning cannot take into account the numerous and frequently unanticipated crises that «ause delay. These include such events as a printer failing to meet a deadline on the input forms, a key programmer leaving for another position, and staff errors in de«fing with the new input forms. It is wise to allow extra "cris is" time for such delays in the timelines that «re drawn as part of the design.

Brome M. Siegel 51

Still another important aspect is the question of phasing in the new system versus an al l -or-none implementation. Davis (1974) defines a system as: " A system is composed of interacting parts that operate together to achieve some objective or purpose (p. 82)." Interacting parts in this definition might be con- ceived of as subsystems with, for example, one subsystem, billing, and a second, staffinformation. Collective wisdom (Cooper, 1973; Lucas, 1975) calls for the phasing in of subsystems in a stepwise fashion. Cooper (1973) sees three advantages to a stepwise phasing in: 1) resource allocation is easier to plan when subsystems are phased in rather than when the system is implemented as a whole. This is so because experience with earlier subsystems provides a more accurate basis for resource allocation in the later subsystems, 2) with new systems, problems with users are inevitable. They can be more easily solved while the system is simpler (fewer subsystems involved), and 3) the system may have some major fault that can be more easily corrected on an incremental rather than a total basis.

A key consideration in the decision of manual versus automated is the volume of data to be processed.

Simplicity is another important feature. Generally, good M.I.S.s are simple. Complex systems are sometimes difficult for users to understand and present many more problems involving data input, processing, and output than simpler systems. Systems can be kept simple by collecting statistics as by pro- ducts of other operations (Cooper, 1973). For example, one form may provide billing, treatment, and staff activity information.

The ability to enlist outside expertise is also important (Chapman, 1976). The design and implementation of an M.I.S. frequently demands technological knowledge that may not be available to agency personnel. When such knowledge is needed, it is sensible to enlist the aid o fa consultant. We have en- listed the aid of an outside consultant in our re-design effort and are finding it most useful.

Adequate documentation is another essential feature of a viable M.I.S. M.I.S.s are frequently complex technological affairs that include a myriad of detail covering all phases of the system. It is virtually impossible for all persons involved to remember these details. Also, people may not verbally communicate their separate knowledge of the system to each other. Finally, personnel come and go and new people have to be acquainted with the system. There- fore, whatever is known about the system should be written down. Documenta- tion should be detailed, comprehensive, and clear. Manuals to describe the dif- ferent operational spheres of the M.I.S. will be needed. One manual should be intended for all users of the system.

Our own User's Manual has sections that describe the purpose of the manual, and lists the personnel who should be using it. There are major sections for inputs, outputs, and special issues. The section on inputs describes


each input in detail and explains how to complete each item. There are also correctly filled-in examples of each. The output section lists each output and describes what the output is, an,d what it is meant to accomplish. The special issues section deals with such issues as how input forms move through the system, how to modify previously submitted input information, and how to regis- ter developmentally disabled or mentally retarded patients. Other manuals deal with the data processing end of the system. The computer service organization, of course, should have all documentation needed to process data such as program listings.

An important question is the relative advantages of a manual versus an automated M.I .S. This issue has to be faced by new organization developments of M.I .S.s of those considering the conversion of a manual to an automated system.

Chapman (1976) has suggested a general cost effectiveness approach to dealing with this issue with costs considered as either developmental or operating. Development costs are one-time expenses and include such things as design team time, consultant fees, start up costs, programming, and form design. Operating expenses include those incurred in data collection and processing, forms, records and billing personnel, and the time spent by secretaries and administrators in preparing statistical summaries in a manual system. Both types of costs should be considered in the choice between manual and automated systems.

A key consideration in the decision of manual versus automated is the vol- urne of data to be processed. (]hapman suggests that an automated M.I .S. is probably not indicated for an organization with less than 1,000 episodes annu- ally but is a must for one with 5,000 episodes or more. His rough measure is that one episode generates about 12.5 documents. Chapman indicates that data processing costs are divided into fixed and variable costs.

"Fixed costs are the normal part of any production operation and cover those expenses involved in setting up the job; variable costs are determined by the data-processing volume. One computer firm uses this simple formula: A fixed cost of $25,000 plus $1.00 per episode per year without financial outputs and $1.50 per episode with financial reports, providing that the average number of services rendered documents per episode does not exceed 10 (Chapman, 1976, p. 38-39)."

Chapman also indicates that decisions regarding manual versus automated M.I .S.s should take into account the amount of growth in volume that the system must handle. The decision in favor of a manual M.I .S. based on current needs may be the wrong decision in three years because of an increase in data base and volume. The initial cost of a computer system is generally much higher than a manual system, although Mader and Hagin (1974) have pointed out that operating a computerized information system may be less expensive than operating a manual system once the systems have been established.

For organizations planning computerization, the advantages of manual systems should not be overlooked. They are almost always on-premises operations, sometimes so compact that the essential summary information can be

Jerome M. Siegel 53

kept in a desk drawer. Such an operation has unlimited flexibility, a great ad- vantage in adapting to ever-changing accountability needs. Output errors can be quickly corrected and do not have to involve extensive changes in computer programming. Finally, the whole system is totally under the control of the organization. There are no outside people to deal with who taust be educated to mental health services and clinical terminology.

HUMAN AND ORGANIZATIONAL ASPECTS

Davis (1974) has provided an excellent exposition of some of the human limi- tations and needs that affect management information systems. The first is that the capacity of people to process input is limited. Empirical research con- firming this limitation has come from Miller (1956), who found that seven symbols plus or minus two is the maximum number that can be held in short term memory. Davis (1974) points out that codes therefore should not exceed 5 to 7 symbols. In a more general way, this human limitation suggests that all documents used in an M.I .S . , both inputs and outputs, should not be too complex for people to process.

A second limitation mentioned by Davis, is that people are frequently una- ware of changes in the value of data they receive on an ongoing basis, and M.I .S .s should highlight any differences that may be considered important so that people are alerted. For example, when a report showing the number of active patients goes to an administrator every month, any change that may exceed a certain level such as a 5 % increase, should be highlighted for the admin- istrafor by the M.I .S .

Another human limitation mentioned by Davis (1974) is the relative inability of people to handle probabilistic data. H u m a n beings seem to be poor intuitive statisticians who do not appear to have an understanding of tlae effect of sample size on variance. Specifically, Davis mentions that the'y, may draw erroneous conclusions from small sample sizes. This should be kept in mind when de- signing a system. '.

Another limitation is concreteness in information-handling. This means that decision-makers tend to use information at hand only in the form it is dis- played. In effect, this means that they do not search their memories for data or try to manipulate or transforrn the presented data. Information needed for decision-rnaking therefore should be presented in the form needed without the necessity for added processing.

The effect of data compression on performance is also considered as a factor by Davis. This r, aises the question of whether people do better with summar- ized rather than raw data. He reports the results of a research study that corn- pared decision-making in two groups. One group was given surnmarized data, the other, raw transaction data. Results indicated that the group with the sumrnarized data made better decisions but were less confident that they had made the right decision. The implication here is that an M. I.S. should present

54 Administration in Mentat Health

information needed for decision-making in the form needed for decision-making, but that administrators should be given the opportunity to look through the raw data as well.

A final and somewhat related issue, is something that Davis (1974) calls the "psychological value of unused data" . Organizations may accumulate and store data that they probably will not use. The confidence of decision-makers in their decision-making ability is enhanced by added data even though it is not utilized. Also, people attach value to the existence ofunused opportunities. As Davis mentions, this was'demonstrated in a recent study that examined rea- sons given by New York City residents for living in New York. People generally mentioned the cultural opportunities available, even though they did not avail themselves of them. They liked the idea that the opportunities were available. What this means for M.I.S. design is unclear. M.I.S. designers should be aware that unused data seems to have psychological value, but simplicity is still absolutely necessary.

The designers of a new M.LS. taust consider how information 3qows in the organization and should attempt to coordinate system design with this flow.

Decision making styles have implications for the M.I.S. Davis has identified two eognitive decision styles among administrators, analytic and heuristic.

The analytic decision maker, when faced with a decision, employs a planned, sequential approach that grapples with problems in a methodological, analytical fashion. The heuristic style, on the other hand, is more of an intuitive, gut-level approach to decision-making that engages a situation by acting rather than analyzing. Davis (1974) indicates that individual administrators may not be at the extremes in this classification hut may tend toward one end or the other.

These two styles affect M.I.S. design because most M.I.S.s are designed by and for analytic styles. A heuristic deeision-maker may not feel at home in an analytically oriented M.I .S. Consequently, he or she may not utilize the system for decision-making. Davis recommends that M.I.S.s be designed so that both styles can be accommodated. The system should be available to structure the decision, but the administrator may leave the structure to explore alterna- tive approaches.

The structure of the organization is another factor to be considered. The designers of a new M.I.S. taust consider how information flows in the organization and should attempt to coordinate system design with this flow. The impact of an M.I.S. on the organization at large is also of importance. Lucas (1975) has enumerated a number of conditions that may cause conflict between the M.I.S. department and other departments. Some involve the power of the information staff relative to others. Competition between the M.I.S. and other departments, communication difficulties, and personality factors may also cause problems.

Jerome M. Siegel 55

Walton and Dutton (1969) also discussed a conflict model. They list a number of conditions that may cause conflict in the organization and the information department is involved in many of these. The relationship between the information department and the users is asymmetrical. While the information people taust have some knowledge of what the people do who use the system, the reverse is not true. Also information people may differ from other staff by virtue of training, interests, and work habits. There may also be competition between the information department and other elements of the organization for common and possibly scarce resources. Finally, there may be communication problems between the information people and others because of the technical jargon used by information staff.

These and other factors can make the development and implemenation of an M.I .S . a cause of dissension in the organization. To the extent that they can be anticipated, the M.I .S . will be better developed and operate more successfulty.

REFERENCES

Chapman, R.L. The Design of Management Information Systems for Mental Health organizations: A Primer. Nation- al Institute of Mental Heahh, Mental Heahh Statistics, Series C, No. 13, D.H.E.W. Publication No. (ADM) 1976.

Cooper, E.M. Guildelines for a Minimum Statistical and Accounting System for Community Mental health Centers. National Institute of Mental Health, Mental Health Statistics, Series C, No. 7 D.H.E. I/K Publication No. (ADM) 74-14, 1973.

Crawford, J.L. Computer applications in mental health." A review. In." Crawford, J.L., Morgan, D. 14d, and Gianturco, D. 72 eds. Progress in Mental Health Information Systems: Computer Applications: Cambridge, MA: Ballinger Publishing Company, 1974.

Davis, G.B. Management Information Systems." Conceptual Foundations, Structure and Develop~nent. New York: McGraw-Hill, Inc., 1974.

Elpers, J .R. , and Chapman, R.L. Management information for mental heahh services. Administration In Menta[Health, 1:12-15, 1973.

Flaherty, E.W. Management information systems for drug abuse programs. In: Platt, J.J., Labate, C., and Wicks, R.J., eds. Evaluative Research in Correctional Drug A buse Treatment." A Guide for Professionals in Criminal Justice and the Behavioral Sciences. Lexington, MA: Lexington Books, 1977.

Lucas, H.C. Why Information Systems Fall. New York: Columbia University Press, 1975. Miller, G.A. The magical number seven plus or minus two: Some limits on our capability for processing

information. Psychological Review, 63:81-97, 1956. Person, P.H. A Statistical Information System for Community Mental Health Centers. National Institute of Mental

Heahh, MentaI Heahh Statistics, Series C, No. 1, U.S. Public Health Service Publication No. 1863, 1969.

Sletten, I.W., and Hedlund, J.L., The Missouri automated standard system of psychiatry: Current status, specia1 problems, and future plans. In: Crawford, J.L., Morgan, D.W., and Gianturco, D.T. eds. Progress in Mental Health Information Systems." Computer Applications, Cambridge, MA: Ballinger Publishing Company 1974.

St. Clair, C.H., Siegel, J .M., Caruso, R., and Spivack, G. Allocating time and manpower to computerize a community mental health center information system. Administration in Mental Health, 4:10-18, 1976.

Walton, R.E. and Dutton, J.P. The management of interdepartmental conflict: A model and review. Administrative Science Quarterly, 14:73-84, 1969.

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