Technical Debt in Long-Term Care

February 22, 2022

The residential long-term care industry has a technical debt problem, which has significantly slowed the adoption of innovations that increase residents' quality of care and quality of life.

Technical debt is a concept borrowed from the programming world– if you’re working with legacy products, chances are you’ve been working against technical debt for years and potentially decades.

Similar to financial debt, technical debt accrues interest– by implementing limited solutions now instead of more robust long-term solutions, the cost of the additional rework required in the future becomes larger.

The price isn’t paid just as a lump sum when replacing old hardware– care facilities pay it every day in the form of caregiver burnout, high industry turnover rates, and a buoyed quality of care.

In other words, technical debt is the result of a bunch of decisions made in isolation without understanding how they affect the broader problem and solution. For example, "we need a call bell system" will focus innovation on iterating on a single product, rather than the underlying workflow, which may even render the proposed iteration superfluous.

As Henry Ford’s famous adage goes, “If I had asked people what they wanted, they would have said faster horses.”

Facilities should view themselves holistically, rather than a cluster of fifty point solutions and niche software products that don't integrate with each other.

We can’t just use old hardware for new software because most legacy solutions don’t have interfaces that can be integrated with.

For example, when Tesla builds a “computer with wheels” Model S, it builds it from the ground up. Tesla isn’t gutting a 2002 Nissan Altima and retrofitting it with a software-friendly operating system; the car is built with its software interface in mind.

Tesla’s cars are meant to become a platform for updates that can change or improve its function over time with updates, rather than having its performance snapshot in place at the moment of purchase.

Care facilities are urged to either buy a new car or bolt on new pieces that may increase performance– and the lack of standardization makes it incredibly confusing to assess the efficacy and ROI of new technology. We can be mindful of any further accumulation of technical debt by creating and tightening the feedback loop that underpins healthy technology progress.

The following guide explores the technical debt in long-term care, and how a software layer can spring the industry forward.

The Cost of Technical Debt in Modern Aging

The barriers to implementing technology in residential long-term care include a unique basket of circumstances:

A lack of information about available technologies. Providers cite difficulty in finding new applicable technologies, evaluating their applicability to their custom setting, assessing their cost-effectiveness, and evaluating the long-term stability of the technology manufacturer.

A failure of the regulatory process to track technological advances. Many states don’t regularly update their regulations pertaining to long-term care facilities, often significantly lagging behind the newest tech innovations. Currently, the regulatory environment prioritizes documentation for code compliance purposes, rather than primarily considering how the tech can immediately improve the quality of care and life for residents.

Technology can make documentation simpler, reducing the lift on the regulators.

There is a regulatory vacuum around senior living software and products due to a lack of standardization. This is a frustration shared by manufacturers, care providers, and regulators alike. The tech stacks for most facilities are a hodgepodge of independent products and services that aren’t meant to be interoperable because there is no software layer that is robust enough to connect them all.

The variety of care facility products don’t play nice (or play at all) because each product was built in isolation, without consideration of how it would interoperate with other solutions.

Many providers find that their technologies would be much more effective if they integrated with each other, but this is hindered by the lack of a simple common API.

The various product creators aren’t incentivized to provide an open API– it just makes their lives harder and yet another product to provide support for. If facilities are buying a bunch of point solutions, the product producers simply must focus on selling and replacing old parts.

If there is no API, humans are forced to be the interface. Rather than our products speaking with each other, caregivers are given yet another task.

Manufacturers, particularly those creating iterations of the hardware-heavy legacy products, need a better and clearer environment and operating system to build for.

Regulators have also expressed a need for a more streamlined evaluation process of new tech.

A perceived lack of financial resources to adopt new technologies.  Most long-term care technologies tend to have a large initial investment; care facilities with minimal budgets (and limited reimbursement from public and private insurances) view each wave of new products as an expensive overhaul.

It’s not a stretch to assume legacy vendors use the confusing intricacies of tech debt as a revenue driver. One hardware vendor, for example, charges upwards of $200 just to clean out a database– a process that should only take a few clicks, but users can’t do this themselves since there’s no user-side access.

Our intention isn’t to strawman products; we want to set the standard for what modern aging technology looks like for vendors, facilities, and regulators alike. The issue is that most legacy products don’t have software interfaces, and if they do, they’re more so built as an afterthought with minimal functionality.

And ultimately, a lack of provider experience in implementing and managing technological changes.

There are many reasons why providers themselves are hesitant to adopt new technology, including motivational issues such as a lack of time, absence of local implementation support, and staff simply stopping use of the new technology because they feel it doesn’t actually address their concerns.

Further, with so many different solutions floating around the market, it can be overwhelming to read between the lines of marketing speak and figure out what would actually help, versus what would just be another expense.

Facilities must avoid the “shiny object syndrome” of chasing the next “10x better camera” or “10x more accurate” sensor, and instead pay attention to the software stack behind the hardware.

Legacy solutions don’t provide feedback to residents and caregivers, and the lack of a feedback loop makes it very difficult to decipher any productive meaning through the course of ordinary business.

All five of these obstacles to tech adoption in modern aging can be solved by addressing technical debt that has accumulated over decades head on.

Paying the Piper

If you’ve been operating a care facility for decades, you’ve likely lost track of the number of salespeople trying to sell you on replacing your facility’s hardware with better and more accurate sensors, cameras, and so on.

Salespeople aren’t necessarily at fault– sensor and camera hardware has evolved by leaps and bounds in the past few decades. However, most products neglect the software side of things.

Facilities don’t need best-in-class hardware as much as they need reasonably good hardware that, more importantly, integrates with software.

Reasonably good hardware still blows most dated legacy equipment out of the water– but the ability for your care facility technologies to communicate with each other is a game-changer.

Facilities have never had the current combination of IoT-friendly technology and software within reach before.

By blending reasonable hardware and best-in-class software, facilities can start generating robust data that can be used to make a wide-spread impact, such as assigning the appropriate classification of care and general workforce management.

Final Thoughts:

Eldertech must reach for a high-quality standardization of products and services to impart meaningful change. We need a standardized bedrock for manufacturers, care providers, and regulators alike.

Doing custom bespoke integration from the ground up will just lead us to yet another iteration of technical debt– the industry needs to scale with a generalized software-first layer where we can implement broad updates.

Sage is a full tech stack for modern aging. Our goal is to usher long-term care facilities into the future, once and for all– software can be updated as needed, whereas hardware gradually outlives its utility and must be replaced. However, if we were just a software layer, we’d be incomplete– we need minimally viable IoT-friendly hardware.

If you keep trying to bolt on things to bad infrastructure, you’re chipping away at your foundation for the future and accumulating tech debt. The next wave of innovation in modern aging shouldn’t just be a replacement of legacy technology with marginally more effective hardware– it needs to be a software-based operating system, which may also require new hardware to best integrate with it.

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