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Wonders Nurses find PDAs handy devices in reducing errors, streamlining access to information and alleviating paperwork headaches. Reading illegible handwriting. Walking to another hospital wing to enter notes. Lugging heavy books around. Re-entering information again and again. Technology that fits in the palm of your hand is rendering such ordeals things of the past. Arlene Keeling, director of the acute care nurse practitioner program at the University of Virginia School of Nursing, noted her students’ lab coats bulging with pocket-sized textbooks on pharmacology, diagnosis and treatment. But a friend using a personal digital assistant inspired her to find a better way to tote around information. “This was 1997,” Keeling says. “I contacted Palm Computing and asked if they would supply some of our students with PDAs.” Palm agreed, and the university alumni association supplied matching funds to equip the faculty. By downloading various applications from the Web, students suddenly could have the latest drug information in their hands, instead of heavy textbooks. “In PDAs, you can download yesterday’s New England Journal of Medicine and get abstracts,” Keeling says. Accessing the latest information would be especially important for nurse practitioners in family medicine in rural areas who might not have all the necessary textbooks at their disposal. Information in a digital device is far more malleable than words in a book, and these devices can supply all sorts of useful bits of medical data gathered online. Contraindications, dosages, interactions with other drugs — even herbal ones — are a pen tap away. Load the device with assorted handy software such as a creatinine clearance calculator. Can’t recall something about the new ACLS guidelines? Bring them up with a Pocket PC device or one running the Palm operating system. By “beaming” programs and data between compatible PDAs, Keeling says, nurses share knowledge even more widely. The University of Virginia School of Nursing requires that graduate students purchase one of these devices when they enter the pharmacology course, rather than buy the textbook. “Most of the information they can download for free from the Internet,” Keeling says. Although the pharmacological textbook hasn’t disappeared, students are much more likely to share the textbooks and check them out from the library than buy them, Keeling says. Keeling says that a study the school performed with unboundmedicine.com two years ago found that the longer a PDA was used, the more it was integrated into clinical practice. “The biggest result was [that] the time saved was significantly related to their use of the PDA,” she says. But for nurses, not just any old PDA will do. “The basic PDA doesn’t work,” says Keeling. “You need to pay $200 to $300 to get one with adequate memory, or have the ability to expand memory.” Pilot Program With fewer people going into medicine, the doctor shortage has enhanced the use of physician extenders, such as nurse practitioners. One such NP is Raquel Vaughan at Stern Cardiovascular Center, a group of 14 cardiologists and nine NPs in Memphis, Tenn. Board-certified both as family practice and acute care nurse practitioner, Vaughan now carries her first computer — an HP iPAQ Pocket PC that Stern purchased for her four months ago. “What they have elected to do at this center is to begin slowly purchasing this equipment, identifying NPs and physicians to begin piloting the program to transform our paper records over to electronic records,” Vaughan says. As part of the pilot program, Vaughan has been paired with a physician, an interventional cardiologist who had used electronic medical records in her practice. Allscripts TouchWorks, a suite of software sold by Allscripts Healthcare Solutions of Chicago, is loaded on Vaughan’s Pocket PC. “It allows me to access outpatient information such as prior physician visits, lab results, stress test, electrocardiogram, ultrasound or other test results,” she says. Before this new pilot, most of this information was kept on paper records. With 266 employees in an office setting, finding an available desktop computer to use TouchWorks took up too much time. And worse, “I couldn’t carry that into the room,” Vaughan says. Now, a typical day can quickly illuminate just how much of a time-saver this hardware and software combination is for Vaughan. “There’s not been a day in the clinic I’ve not had a walk-in,” she says. “I remember a day where I literally sat for an hour, ready and available to see a patient. She was ready, but I had no information to see her with.” Staff from another floor at the center had to retrieve paper medical records and charts-a wait that, for Vaughan, averaged 45 minutes. Now, the center’s RF wireless data network retrieves the same records into Vaughan’s iPAQ within seconds. Vaughan’s iPAQ’s digital memory stores not just text and numbers, but also her voice, as she can dictate into the device, with TouchWorks embedding these words right into the patient’s electronic record. Previously, Vaughan’s words had to be captured via telephone. And to use the old system, she had to enter a potpourri of identification numbers. With the new system, dictation is a click away. TouchWorks can even act as a coach during dictation of physical histories or, if the narration is preparing a patient for hospital admission, offer a series of hints to the NP. Eliminate error-prone number entry and offer handy checklists to NPs and you reduce error, as well as speed information capture and retrieval, Vaughan says. “We’ll eventually be able to do our prescriptions in the computerized setting,” Vaughan says. “I know without a doubt that there have been pharmaceutical errors because of the difficulty of reading handwriting.” Once prescriptions can be entered in the PDA, Vaughan says, errors in drug, dose, route and frequency will be reduced. Stern’s devices also will offer the same kind of drug interaction and contraindication advice that Keeling and her students enjoy. Although the Stern center’s PDA initiative is still a work in progress, Stern’s wireless network may be the most cutting edge technology in use. In fact, it’s so new, Vaughan says, that “any office that is considering using this — and I think it’s a wonderful system-needs to have good tech support easily accessible. There are times I have to make multiple attempts to upload data.” Vaughan has yet to take her iPAQ into a hospital setting, where further savings await. “I’m in the hospital 75% of the time, making rounds, seeing new consults,” she says. “At admissions, a secretary has to try to locate reports, get them printed, typically faxing them to you. Having the ability of this device to carry that into a hospital setting, or to get a report downloaded, will help with cost-effective and efficient treatment of patients without having to unnecessarily repeat tests — what’s called defensive medicine.” Vaughan adds that PDAs have evoked wows from patients, too, who feel it is improving their quality of care. To Billing and Beyond Can a combination of PDAs and other computing devices free nursing from paperwork? Jeneane Brian says yes. In January 2001, nonprofit VNA Home Health Systems in Santa Ana, Calif., began a special project to determine if it could reduce the paperwork burden for nurses through the use of point-of-care technology. “We decided to try out Palm OS devices for that purpose,” says Brian, CEO of VNA Home Health Systems, which has a mobile workforce that travels from patient to patient. “We found there was 48 minutes of paperwork for every hour of home health care delivered,” Brian says. “Even in the hospital, that’s 30 minutes. If you do the math for all the things that come into play, there is an average of 18 hours of paperwork for every case.” Brian’s vision was a PDA-based point-of-care system that collected and retrieved information faster to reduce the tremendous paperwork burden and increase nurse satisfaction. What started with a group of nurses and two physical therapists is now a full electronic medical record system with 250 users responsible for 10,000 patient visits per month. They all use PDA software that Brian wrote and that uses a customized version of a Palm OS software development kit sold by Pendragon Software. VNA Home Health Systems nurses are assigned patient groups based on where the patients live and where the nurses want to work. “We have these devices in the field,” Brian says. “Nurses synchronize data via the Internet and a Web interface where they can view and edit what they’ve synchronized.” The only ones who keep paper patient records are certain specialists who do not visit patients often enough to justify using the PDAs, Brian says. But if the specialists choose to, they can enter information via any Web browser. The first application Brian wrote for the Palm OS automated the nurses’ most commonly used combination note form and timesheet. By August 2001, she had coded a way to store a complete patient electronic medical record on the device. The next step was to provide a way for clinicians, primary care physicians, and managed care caseworkers to access this data on the Internet. Patient records could then be pushed out via the Net and PDA synchronization to the nurses who would see them. The patient’s record includes all information pertaining to the latest episode of care and allows employees to order supplies, request managed care authorization for visits and generate physicians’ orders for signature. “Physicians are generally not ready to accept electronic versions of orders,” Brian says. “Managed care authorizations are, if the company is equipped to do so, processed via the Internet or electronic faxing without turning our documents into paper first.” Supply orders are not turned into paper at any point, Brian says. They are processed electronically from field data and e-mailed to the vendor. Supplies are drop-shipped to the patient’s home the next day. Other paper records still in VNA Home Health Systems at this point include lab results that outsiders send to the company, and patient consent forms, which are not electronic. Other devices can be used to complement the PDA. A new serial digital wound care photography system captures pictures nurses take with digital cameras. “We then publish that picture alongside the clinical notes on a secure website for viewing by those in charge of the patient’s care,” Brian says. Wound care specialists don’t have to visit each case, yet can provide effective overnight service. In addition to writing the Palm OS applications with the Pendragon SDK, Brian, with assistance from her son, wrote the server portion of the system with Microsoft Access, Active Server Pages and a Microsoft SQL Server database server. “I’ve become real good friends with the guy who runs [Pendragon] because we’re always bugging him,” Brian says, with a laugh. The result of all this PDA-based automation? “50.3% of our nurses report a reduction in documentation time, which was our very first objective,” Brian says. “So the 18 hours has moved down to 9 or 10 hours for a total episode.” Even more startling, VNA Home Health Systems has enjoyed a fourfold increase in its nurse retention. “I think it’s directly attributable to the technology,” Brian says. “We used to lose nurses. They don’t go anywhere now. They realize we’re solving traditional problems in nontraditional ways. Will we ever have enough nurses? No. But I think it’s been very successful.” According to Brian, PDAs also trump previous efforts to use laptop computers to automate nursing paperwork. “Nurses who used laptops hated lugging them around,” she says. “They would get through with their visits, and then they’d see the welcome screen. The software was complex, and it required a $3,000 IBM ThinkPad to handle it.” The Palm OS PDAs also have been extraordinarily reliable, Brian says. “I’ve had nurses’ kids drop devices into the bathtub,” she says. “That messes them up pretty bad. We’ve had the Internet connection go out. But as far as the Palm OS crashing and failing, that has never once happened.” Protecting Patient Privacy The Health Insurance Portability and Accountability Act of 1996 regulates the use of electronic medical records in the United States. HIPAA requirements include the need for “dual factor” authentication when accessing sensitive patient information. This means that PDA users with patient records must use two of three different approaches to identify themselves to a computer:
“We password protect and do 128-bit encryption and decryption behind the password,” Brian says. “In my view, it’s much more protected than the typical paper records left on the front seat of a car while someone goes in a store. People have kept copies of paper records to verify their timesheets. I’ve seen years of physical records left under the bed of health care workers. You have to look at the technology compared to the previous system.” As another precaution, Brian’s software does not allow anyone to print or save data from the PDA outside of the authorized synchronization processes. VNA Home Health Systems’ technology was the only one uncovered in researching this story that handles what is still on others’ wish lists: it generates the billing right from the PDA. “Our visits are our unit of service,” Brian says. “That’s what we generate our bills from. Those are all uploaded into our financial system. Say we do 300 visits one day. Those are ‘synched’ over, appended, someone makes sure there aren’t two of the same thing, then they’re into the billing and into payroll.” Even at VNA Home Health Systems, the next goal beckons. Brian’s objective is to fully automate quality assurance and process improvement. “For instance, if I give a class to 30 nurses on how to give cardiovascular physical assessments, it would be possible for me to compare their assessments a week before class vs. a week after, to see if their assessments are more sophisticated,” Brian says. Telemonitoring is another strategy to cope with the nursing shortage. If a home care patient can take vital signs, not only can each visit be shortened 20 minutes by doing the test before the nurse arrives, the technology also could replace needless weekly visits, with visits prompted only when telemonitoring equipment readings detect a problem. All these results can be pushed out into the same PDA data system now in use, Brian says. “If I can do that, I can save another 20% on our staffing,” she says.
Scott Mace is a freelance writer. To comment on this story, send an e-mail to editorca@nurseweek.com. |