Laptops standardize assessment information

Apples-to-apples comparison now possible

Nurse Smith goes to see a patient in rural New Jersey. The female patient is elderly and diabetic and, according to the nurse’s assessment, not able to care for herself well. Because of a lack of communication, two hours later, Nurse Jones goes to see the same patient, but her evaluation of the patient is much more positive.

The lack of consistency in evaluations is something that plagued In Home Health of Sparta, NJ, says Janice Cavanaugh, RN, MPA, CNA, director of quality improvement. The agency operates in a fairly rural area, and makes about 60,000 patient visits annually. To combat the consistency problem, the group decided two years ago to purchase laptop computers for nursing staff, and the results have been remarkable.

"The assessment we have now is standardized and much more detailed than what we had on paper," says Cavanaugh. "The visiting staff all use the same terminology, and documentation and practice have both improved."

Standardized documents, such as advance directives, are never forgotten, she says. "When we did record reviews in the past, they were often missing." There is also less delay in getting out 485s because the nurse completes the form as part of the assessment on the computer. "It is sent right out and returned on a more timely basis. We used to complain all the time that orders are not being sent back and signed, but now it never comes up at all."

The laptops also have fostered greater cooperation between nurses and support staff, says Cavanaugh. They work more closely together, with the support staff taking care of all requests for reports and the printing of all documents. "It gives the nurses more time to see patients."

Creating a program that works

Cavanaugh is quick to admit that the program was not without its problems. When technology first came to In Home Health in late 1993, it was via handheld units that were the size of check books. But within a year, the nurses convinced management that the palmtops were a bad idea. "They were inexpensive and portable, but you could only put in 24 characters. We need more than that. There were also only 10 lines on the screen at a time, so there was a lot of scrolling. Nurses’ notes just didn’t make sense."

By October 1994, the company was willing to spend the $2,500 each on 14 laptops to rectify the problem.

There were also problems with training. While two of the first four nurses had some computer experience, the other two had none, says Cavanaugh. Their participation was based on an acceptance that computers were coming so they had better get on board. For those two nurses, training took more time. For one of them, Cavanaugh says, training had to be repeated.

Initial training was done by the vendor, HCIS of Bloomfield, NJ. That vendor was chosen because In Home Health already used its financial software. "You have to have programs that are compatible with each other. You can’t choose one billing software and one assessment tool and hope they communicate. They won’t."

The first round of training included two days of classroom work and three days in the field. The nurses’ typical six visits per day were cut to two to three, and per diem staff were used to cover the slack.

"Once we got through the initial group, other nurses expressed some fears. They thought it would be hard to learn," says Cavanaugh. However, with the training and support from management, the nursing staff accepted the program. With few exceptions, they have all embraced it. "There have been a few nurses and maybe 1% of patients who think that more time is spent with the computer than with the patients," admits Cavanaugh. "But that will decrease over time. A nurse with good typing skills will be able to maintain eye contact and take notes at the same time."

Advice for the technophobe

Cavanaugh firmly believes an appropriate technology program can help an agency improve quality of data collection, as well as save time and money. But taking certain steps can help ensure a successful transition:

1. Let the nurses nurse.

Cavanaugh says it is important to give nurses the freedom to nurse and leave technical problems to other people. At In Home Health, computer problems are described to support staff, who then spend the required time on the phone with the vendor troubleshooting.

2. Make sure the programs are customized to your needs.

Some things in the initial training were inappropriate for In Home Health’s nursing staff, says Cavanaugh. For example, a lot of training time was spent on how to edit documents and correct errors. "Support staff takes care of those things for us," she says. "Make sure your vendor knows how your agency operates."

3. Get a strong commitment from management.

"This is going to be more expensive than you initially think," warns Cavanaugh. "We had to upgrade our hardware with two new PCs, and upgrade our file server. But it was still worth it." The information on what the upgrades cost In Home Health two years ago was not available, Cavanaugh says. But the price of a new PC can range from $1,500 to $2,500, and file servers can start at $3,000, depending on how much disk space is required.

4. Have technically literate people involved.

You should also make sure you have people on the implementation team who understand technology, says Cavanaugh. "We have a technical project director with a strong information systems background. That meant I didn’t have to learn the technological aspects of the program."

‘System changes affect everyone’

A broad implementation team that includes people from across your agency is a key to success, says Craig Jeffries, president and chief executive officer of Healthspan ServicesTM in Johnson City, TN. "You have to understand that systems changes affect everyone. Make sure you have a team that includes clinical staff, administrators, billing and financial staff, and quality assurance people."

5. Make sure the users are as comfortable with the project as you are.

While appropriate training can help ensure nurses are able to use technology, you also have to be sure that the system change you are considering is one they think is necessary, or one they believe will assist them, says Jeffries. "You have explain to people the benefit of a change."

6. Use the experience of those who have gone before you.

Implementing a program successfully means having as much information on hand as possible, says Richard Davis, RN, clinical systems improvement coordinator at the Visiting Nurse Alliance of Vermont/New Hampshire in White River Junction, VT. "Talk to people at conferences," he says. "Ask your vendors for references you can talk to. Go to other agencies and see how their programs work." Davis, who is in the final stages of developing a laptop program for his nurses, visited In Home Health to learn from its experience. It was one of several such visits he made.

7. Make sure you can integrate information.

Davis says no technology program is worth the time, effort, and money if the information provided cannot be used throughout the agency. "You have to have seamless integration," he explains. "Your RN has to be able to make a visit and have the information go into the 485, go to payroll, and go into their day sheets." Currently, that means using a single system from a single vendor. But Davis says it is only a matter of time before compatible systems are developed.

8. Foster a culture that accepts change.

Perhaps the most important aspect in making any substantial change is having a staff that is accustomed to continuous quality improvement, says Jeffries. Such a staff will recognize that experimentation and change are good things. "We look to our employees to suggest change, and that means resistance to a change that is recognized as beneficial is minimal."