VNAs make the leap to new technology
VNAs make the leap to new technology
Laptops, PDAs now used on nursing visits
Two visiting nurse associations (VNAs) undertook massive technology upgrades over the past year, despite the already daunting challenge of simultaneously weathering the new Medicare prospective payment system (PPS).
At the VNA of Hudson Valley, in Mount Kisco, NY, staff switched to a new computer system in July 2000, in part to prepare for the move to PPS. Since then, the agency has begun issuing laptop computers to its nursing staff.
In Santa Ana, CA, VNA Home Health Systems undertook an even greater leap. This year, clinical staff began switching from paper documentation to using personal digital assistants (PDAs) — small, hand-held devices on which nurses complete forms, schedule visits, and even research drug interactions.
Administrators in both organizations say any agency contemplating such an upgrade should be prepared for a lot of hard work.
"It invades every single inch of your organization to do something like this," says Jeneane Brian, BSN, MBA, president and CEO of VNA Home Health Systems, who wrote the software for the PDA-based system her nurses use. "It’s going to take a lot of time and attention and people are going to have to be willing to do more than the normal stuff to get it done."
New system saves time
As the VNA of Hudson Valley prepared to cope with PPS, it had to deal with a time-consuming dual computer setup, says Susan Tucker, RN, BSN, director of quality improvement.
OASIS data were being entered into one computer system, and the rest of the agency’s information, including billing and visits, being entered into a separate system.
In addition, the VNA wanted a system that would coordinate with other organizations in its health care network. And Tucker says the agency wanted eventually to incorporate laptop computers into nursing visits.
The rollout of the new system last summer, with an initial focus on the agency’s financial operations, turned out to be a blessing during the PPS transition. "We’ve been very lucky; we didn’t have problems dropping RAPS [requests for anticipated payment] that some other vendors have had," Tucker says.
A key factor in the technology upgrade has been the new clinical information systems department, led by Joyce Galuppo, RN, MS, a former clinical manager with 25 years of home care experience. She and another clinical information services staffer work with two nonclinical employees who specialize in the system’s hardware and software.
The group serves as a liaison among all the departments, and between the departments and the new computer vendor. Galuppo and her associate helped train different departments in how to use the system, and keep staff on top of upgrades as the company sends them.
Assessing nurses’ computer skills
To train the nurses, the agency began by assessing their computer skills, Tucker says. Groups with more experience moved through the training process more quickly and in larger groups. Nurses who were computer novices were given more training time and smaller groups to work in.
Forms are filled out on the laptops using a stylus, so there’s little typing involved.
"We rolled them out at first doing admissions," Tucker says. "Then they started doing recerts on them, then resumptions." She says the agency hasn’t yet started doing discharges on the computers because of all the complex issues involved. The agency plans to be doing discharges on computer by early next year.
She says nurses tend to follow the same work patterns they did when filling out forms on paper. Those who did the paperwork while in the home do so on computers now. Those who simply took notes and filled out their paperwork later now use their notes to complete forms on computer.
As the nurses have become more proficient with the laptops, the agency has been able to process cases more quickly. Tucker says that at first, it was taking 17 days to produce a Centers for Medicare and Medicare Services (formerly the Health Care Financing Administration) 485 form. Now it takes four to five days.
As the quality improvement (QI) department tracks the process, it looks for areas that are slowing things down and addresses them. QI staff review all the computerized records to be sure OASIS questions are being answered properly and that ICD-9 codes are correct.
Galuppo says that as nurses raise usability issues, her department helps devise work-arounds, which are short-cuts that can solve the problems.
Some of the limitations of the new system, such as an inadequate care-planning component, are being addressed by the vendor in upgrades. Others, such as reporting limitations, are addressed by a separate ORYX vendor whose reports meet the agency’s needs, Tucker says.
In the end, she says, initial concerns that the new system wasn’t clinically friendly turned out to be mistaken.
"They thought it wasn’t going to help nursing in any way, that it was going to be a nightmare to work with, and I think, after six or eight months, that people saw this wasn’t quite so," she says.
When Brian came to VNA Home Health Systems last September, the agency was not automated on the clinical side, except for the inputting of data from paper records for Medicare reimbursement.
She says that arrangement makes it hard to fully monitor the effectiveness of care, since retrieving data from paper records is so laborious.
"What you see happening in most cases is that there are assumptions made from very small sample sizes," she says. "This agency is generally known throughout the community to be providing excellent care. I just don’t know that we had the data analysis function to prove that."
As she considered computerizing the clinical operations, she looked at a system that would have included laptops in the field. But she was unimpressed with the company’s response to the PPS conversion.
At Christmas, she discussed the matter with her grown children, some of whom are in health care and all of whom are computer-savvy.
They were the first to suggest to her that the Palm Pilot she used every day to stay organized might be the right choice for nurses in the field.
"My daughter, who is a nurse, said she uses hers at work, and my son went and found some development software that we could use to make a little program on," she says.
Brian already had given the devices to her executive team as Christmas gifts. Soon after, she offered to buy PDAs for the management staff. She told them: Try one for 30 days, and then decide whether to stay with the automated planner or go back to a paper organizer. All but one remained with the PDA.
As she explored the idea of a system based on Palms or similar devices, she used a software development program to create forms that could be filled out using the PDA’s small screen.
A nurse can attach the device to a special keyboard, or use her own home PC. The data then are sent in an encrypted form to the main office to insure confidentiality.
One benefit from the new system will be to clear out a stockpile of old and useless forms that the VNA now stores. Brian says her agency has 9,000 such forms, each costing about 25 cents, that were discontinued because of outdated information or other problems.
Because she can edit the computerized forms herself, making changes is relatively simple. Brian recently appointed a nurse informaticist who will be taking over that job.
There still is one major form that nurses haven’t gotten yet on the hand-held devices. Because of the complexity of the OASIS assessment — "it would take 100 screens to get through it" — Brian decided to work with an outside vendor for that form. Two companies she’s reviewed already have developed OASIS forms for PDAs and a third wants to work with the agency to develop one.
She says that for agencies that don’t want to try to develop forms in-house, PDA-based software for home health should be available in the next few years.
Brian also has made contacts outside the agency to make the best quality assurance use of all the new data.
She says she hopes to get graduate informatics students from San Diego State University to help create the necessary queries and analytical tools needed to make sense of all the computerized information.
Brian admits that her problem now is the opposite of when she started — instead of too little data to work with, she now has almost more than she knows what to do with.
"We’re almost into a tsunami of data and we have to figure out how to make the most of it," Brian says.
Tucker and Brian suggest several strategies for smoothing the transition to new technology:
• Plan to hold on to your old systems. It’s impossible for an agency to simply switch off one computer system and turn on another. Tucker says that for the first year, an agency needs to maintain the old system on at least a few computers to provide access to records and statistics.
And don’t be too quick to throw away all the old paper forms once nurses have been switched to laptops or hand-helds. Brian says there will always be those at VNA Home Health Systems who work on paper, primarily nurses who work infrequently and don’t spend enough time at the agency to become proficient on the computerized forms.
• Look for added features to help clinical staff. While an agency may switch to portable computer technology for financial or operational reasons, the devices can actually help nurses in the field deliver better care.
Brian says the biggest surprise with the introduction of hand-helds in her agency has been how nurses use them to help support clinical decisions.
VNA Home Health System’s PDAs include pharmaceutical software that allows nurses to research drug interactions and contraindications.
"A nurse can look up all the drugs a patient is on, right there in the home," Brian says. "I think that is one of the most powerful things that I have ever been able to put in a nurse’s hand."
Don’t rush the introductions
Other programs can help with infection control and calculating IV drips.
• Introduce staff to the technology gradually. Brian says she introduces nurses to their new PDAs over a six-week period to help them get used to them. She starts with a 90-minute overview of the device.
"We show them how to physically turn them on, then we walk through some introductory information on how they navigate around. I let them have them for a couple of weeks, just to play with it."
A few weeks later, nurses learn how to fill out their first form, then another form, and eventually, must begin filing forms by computer.
"We’re not giving them an option but we’re giving them time," she says. "Altogether, it takes about six weeks to roll out that first form. And then after that, I don’t have any problem because all I get then is pressure about where’s the rest of [the forms]."
Sources
• Jeneane Brian, President and CEO, VNA Home Health Systems, 2500 Red Hill Ave., Suite 105, Santa Ana, CA 92705. Telephone: (949) 263-4700. E-mail: [email protected].
• Susan Tucker, Director of Quality Improvement, and Joyce Galuppo, Director of Clinical Information Systems, Visiting Nurse Association of Hudson Valley, 100 S. Bedford Road, Mount Kisco, NY 10549. Telephone: (914) 666-7616. Fax: (914) 666-0145. E-mail: [email protected], [email protected].
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