VNS says write on’ to pen-based computer
Field test yields promising results
The time: 9 AM, one day in June, 1998.
The place: New York City, The Bronx.
The situation: A field nurse working for the Visiting Nurse Service Of New York, one member of a work force numbering more than 2,000, documents the progress of her patient, an 80-year-old widow recuperating from total hip replacement surgery. The patient, who lives alone on the fifth floor of an eight-story walkup, has been complaining of slight pain and stiffness. The nurse prepares to take notes.
This is the first of five stops she will make today. Each will require painstaking, time-consuming documentation, but the nurse, instead of grabbing a stack of forms, pulls from her bag a rather chubby pen and a small rectangular tablet that resembles an Etch-A-Sketch.
With the tablet in her left hand and the pen in the other, she taps the pen lightly against the face of the tablet. Symptoms, changes in the plan of care, and vital signs are being recorded. The 485 is also being completed. The nurse doesn’t need a table, nor a wall outlet for a power cord, nor a telephone jack (which is fortunate, because the patient has no phone). She transmits the updated record to the data center across town in Manhattan using a wireless cellular digital packet data (CDPD) modem. It takes only a few minutes. She is now ready to go to her next patient.
This is not science fiction. The Visiting Nurse Service of New York, which serves an average of 20,000 patients a day in the boroughs of New York City, has been field testing its pen-based mobile computer system for the past eight months. As of late February, 250 nurses were using it. Over the next 18 months, the remainder of the VNSNY’s 1,300 nurses will carry them. Eventually, the rest of the work force, comprising 500 therapists and nearly 400 social workers, will have access to the new technology.
The VNSNY wanted a system to take the home care documentation process out of the Paper Age and into the Information Age. The VNSNY’s goal is not only to save money, but also to compete successfully for managed care contracts.
"Our goal was to capture all our clinical data in one computer system," says Rick Stazesky, director of systems analysis and development for VNSNY. Stazesky estimates that the system, once fully installed, will eliminate between "30 and 40 forms they [nurses] fill out now." Each patient requires two to three forms, he says. "We can eliminate repetitiveness of the process."
The system includes the Fujitsu Stylistic 1000 tablet computer, powered by a 486 DX4-199 microprocessor. It is equipped with a PC Card Modem or Motorola Personal Messenger 100C wireless modem. The computers run Microsoft Windows 3.11, Windows for Pen Computing 1.0, and an application written by Stazesky and his resident team of 15 information services specialists, using Microsoft Visual Basic and Access products. The computer measures about seven inches by 11 inches by 11¼2 inches. The eight-inch screen is available in full color VGA display; transflective mono display for outdoor use; or transmissive mono display for indoor use. The tablet weighs about 4 pounds with the lithium-ion battery pack installed and can be carried easily in a nurse’s knapsack.
"This efficient use of mobile computers streamlines our work processes and is key to our continuing ability to compete effectively in the home care market," Stazesky says. "We’ll have a complete clinical record that provides us data for outcomes for managed care."
The Visiting Nurse Service of New York is the largest voluntary, nonprofit home care agency in the nation, providing skilled nursing care, rehabilitation therapy, mental health services, and supportive care to adults and children, primarily in patient’s homes and community-based facilities.
"The trend now is to cover lives. Home care is part of the continuum of care. Anybody who’s engaged in this area of health care is going to have to find some way to get clinical data in a computer. Pen-based data is one way you can do it," Stazesky says.
Initially, VNSNY equipped nurses with laptops, which demonstrated the nurses’ willingness to use automation, Stazesky says, but to make computers conducive to field work, nurses agreed it was better "to hold the CU in one hand and use a pen with the other. In many of the patients’ homes, it isn’t practical to set up a computer. There’s no chair and table. This would only encourage a nurse to do more documentation at her own home."
System eliminates up to 80% of paperwork
Without computers, Stazesky estimates nurses spend two hours a day filling out forms, in addition to caring for patients. "We want to whittle the time down. This way, a nurse can talk with the patient and document at the same time."
Stazesky says the pen-based system eliminates up to 80% of the paperwork.
"We anticipate saving several million dollars over the next few years," he says, "but we’re also spending several million dollars." Stazesky declined to say what the total bill would be, acknowledging only that the cost will range somewhere between $3 million and $10 million.
"Anybody who is serious about mobile computing it’s going to cost them money. The return will come by being able to compete for the managed care contracts. It’s a strategic step home care companies need to make if they want to stay in business. The savings will be in getting the bill out the door faster, and it will potentially reduce the back-office labor force of nurses doing their own data entry," he says.
Although Stazesky’s system does not yet capture the doctor’s signature on the 485, it does so for the nurse, using individually assigned PIN numbers. "That’s the nurse’s way of authorizing things. New York state recognizes this as legal," Stazesky says.
A long-term goal, he says, is to establish electronic interfaces with doctors, either at the hospital or at their practices so they can receive information from VNSNY and view it on-line over the Internet. The doctors would enter a PIN number for their authorization.
Now nurses print out the 485 and mail it to the doctor for his or her signature. Stazesky says VNSNY is ready to start hooking up with hospitals, but not to do doctors’ orders yet. Hospitals will still have to get the doctors on-line.
Not every agency can afford it
Another advantage of VNSNY’s pen-based system, Stazesky says, is that it can be used to enter patients’ medications into the database. "Patients get overmedicated, and it costs money. Why? A patient sees two or three doctors and one doesn’t know what the other is prescribing. A nurse at the home, however, sees the medications and records them into the system.
"The system also allows critical pathways and care plans to be entered, eliminating the heavy booklets nurses now must carry for each case. The only long-term way to implement care plans is to computerize. That’s what a computer platform gives you," the IS manager says.
Stazesky concedes that his organization is "sort of an anomaly because of its size," and not every hospital-based agency has the IS staff at hand to build its own application. He advises going to one of the handful of companies providing off-the-shelf programs for home care, such as Axiom, based in Chatsworth, CA.
The only major problem encountered during the development of the system, according to Stazesky, was "getting the communications to work correctly all the time. We have to make sure all our products are talking effectively."
The wireless modem has not proved to be as cost-effective as the traditional wire-line, and Stazesky says only 125 nurses use it now during the evaluation phase. It is doubtful that the wireless can compete in costs, he says. Where a wired line call may cost pennies, the wireless call "could be $50 or more a month for a nurse. That will add a little to the cost of the visit. Is the cost justified? Do we benefit? I couldn’t say."
But Stazesky is certain of one thing: Automation is the future of home care. "If you aren’t thinking about it, you’d better start," he advises. "By the end of the decade, mobile computing will be the standard in home care."
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