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"We found there was 48 minutes of paperwork for
every hour of home health care delivered," Brian
said. "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
said. "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 said. 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 said. "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 said. 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 Web site for viewing by those in charge
of the patient's care," Brian said. 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 said, with a laugh.
The result of all this PDA-based automation? "50.3
percent of our nurses report a reduction in documentation
time, which was our very first objective," Brian
said. "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 said. "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."
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