A Tablet a Day
Lightweight PCs boost efficiency and productivity for visiting nurses

By Scott Mace
September 15, 2003

If nursing's embrace of computer technology can be compared to a hurricane, the Visiting Nurse Service of New York could be considered its eye.

Nearly 2,300 nurses and therapists are being issued Fujitsu Tablet PCs this year, for a workforce fanning out into the five boroughs of the city, like a paperless tornado.

The organization's point-of-care application, written in-house, replaces 95 percent of the paper it uses with a highly structured set of software that automates almost all nurse recordkeeping. VNS is no stranger to pen computing, but the new Tablet PC allows the nation's largest nonprofit home care organization to automate 100 percent of the point-of-care tasks, instead of the 50 percent achieved in the past round of automation.

"It was very cumbersome to carry around all the paperwork we had," said Lisa Felszer, RN, a per diem coordinator of care at VNS. "I would guess it doesn't really support decision-making the way the Tablet does. Every diagnosis generates certain problem areas. Each of these problem areas gives us a critical pathway that has a lot to do with what we're taught about medications."

For instance, a patient with congestive heart failure could be put on a low-sodium diet. As a visiting nurse, Felszer said home care "is really all about teaching in general." The Tablet lets Felszer and her nursing colleagues focus on patient education and just about eliminate the time spent and delay involved with doing paperwork.

Small wonder

The device powering this improvement in productivity is powerful and lightweight. Various manufacturers make Tablet PCs. VNS uses Fujitsu's Stylistic ST4000 Tablet PC, which weighs a little more than 3 pounds, is less than 1 inch thick and provides a 10.4-inch display. Storage of 40 to 60 gigabytes per Tablet is built in. That's easily enough for each clinician to carry around an entire caseload, which at VNS is 25 to 30 patients per clinician, along with their complete demographics. Password protection means that a Tablet accidentally left behind on a table at a diner, while regrettable, won't yield its secrets the way a briefcase of papers would.

The Tablet PC is the latest generation of Microsoft Windows devices that users interact with via a pen, although each unit at VNS also includes a separate keyboard, linked to the Tablet by an infrared signal, whenever needed. Other features include a pop-up on-screen keyboard and handwriting recognition. Drop-down boxes reduce choices between options to little more than pointing and clicking at them.

"When we were using paper, every diagnosis had a different paper form to fill out," Felszer said. "If you didn't go to the office, you didn't have the right form."

Paper-buried visiting nurses also had to practice the art of total recall: Who did I see today? How were they doing? What was my diagnosis? Nurses had 48 hours to get their paperwork into the VNS headquarters in Manhattan-relatively easy for Felszer, but daunting for other nurses living in the outer boroughs. Now, Felszer can complete her notes in the patient's home, even as she's talking to the patient, and upload that information to VNS's servers that night or the next morning. "I can't tell you what a world of difference that makes," she said.

Under the old system, Felszer had to conjure up even deeper memories. Every two weeks, there was a "route sheet" to fill out, requiring nurses sometimes to think back as far as 10 working days and document each patient they saw during that period.

Now, Felszer's routine is considerably smoothed. Each morning, she commands her Tablet PC to connect to the VNS servers via phone lines. Without leaving her house, she can file reports, receive new patient charts and access the latest company news via e-mail.

Profit sharing

Because per diem visiting nurses are paid according to how many patients they see in a day, reducing the time needed to complete paperwork results in more money in their pockets. These nurses can even file their reports by 10 p.m. on a pay-period-ending Thursday and get paid in full the next day.

Felszer also can connect to VNS servers during the day to receive more frequent updates, if need be. It helps, she said, to identify those patients on her regular rounds who have an "RJ11" phone jack that can be easily plugged into the Tablet PC, just in case.

Not only is the information being uploaded from these Tablet PCs more accurate than past reports at VNS, communication between nurses is better. For example, Felszer will file a final report Friday night, and any nurses who are in touch with her patients during the weekend can refer to the most up-to-date information and treatment plans.

"Nurses who have been used to paperwork for a long time probably took a little longer to get used to it," Felszer said. "Computers do have problems, and it's frustrating at times. I've never had it completely go down on me. But everybody at the office is so helpful. The help desk is wonderful."

In the VNS offices, the Tablets also get the benefit of a high-speed connection thanks to a Wi-Fi network.

Despite the dramatically more automated job that the Tablet enables, Felszer retains the human touch that distinguishes nursing. "I maintain eye contact," she said. "It's very easy to just use the pen and tap."

As with smaller devices, the Tablet PC can contain a full database of drug contraindications that VNS nurses can consult on the fly. This process is known as the Drug Utilization Review. "After I input all the medications into the tablet, I tap the 'DUR' button," Felszer said. "It runs through every medicine."

Software sorts drug interactions into four categories, ranging from "don't ever use these together" to "no interaction at all" between the drugs. At Level 2 and above, the nurse must notify a physician and document the DUR. "

A lot of times, it really helps with patients who go to clinics," Felszer said. "Physicians don't always know what other medications they're taking."

Back in the office, a nurse can tap a button and generate a printout about a new medication's side effects, then hand this printout to the patient at the next visit-all of which is a whole lot easier to lug around than the old drug book, not to mention more up to date.

VNS has not encountered any of the problems that plagued earlier laptop computers, Rick Stazesky, director of information systems, said.

"We've been active users of pen computing since 1995," Stazesky said. "We're a fairly seasoned organization, experienced in what this does for us. Laptops are not meant to be lugged around all day and open and closed constantly. Our applications require more storage space than is available on PDAs and Pocket PCs. Over the years, we've progressively enhanced the mobile computing application that runs on the pen computers, now called Tablet PCs. We've gotten excellent life out of them."

Nurses traveling by car can recharge the Tablet during the day by attaching to a charger that fits into the vehicle's cigarette lighter. Nurses on foot or on public transit can swap in a second charged battery without losing any work.

On the same page

Stazesky doesn't have any hard figures on what the Tablet PC's return on investment has been for VNS, but he notes that fewer back-office staff are needed now to handle data entry functions. "We just believe it really has improved our documentation standards, and cut down on errors," he said. "Clinicians can see what the other clinicians document."

As VNS's critical-path knowledge bases accumulate in each Tablet PC, there's also a greater standardization of the quality of nursing care, Stazesky said. "The way a nurse in the Bronx is treating a diabetes 1 patient is now essentially the same as how a nurse in Staten Island does it," he said. "Before, every nurse had it in their head. Now, it's more consistent."

Fresh analyses of treatment plans can be input into the VNS servers, and IT staff can distribute updated plans online via the nightly data swap between the servers and the Tablets.

Within the next year, Stazesky foresees using the powerful graphics engine in the Tablet PC to make video training for nurses and patients available right on the Tablet. Other handy databases, such as the guide to ICD-9 diagnosis codes, help drive reimbursements VNS receives from other payers, particularly Medicare.

As in other cases, this nursing informatics push is leading the way for initiatives elsewhere in health care. "Other providers in the health care network have the same patients as us," Stazesky said. "The next step is we hope to electronically share with them any important data we're picking up about their patients. At the point where insurance companies, hospitals and physicians are ready to receive this data, we're ready to share that information."

Point-of-care computing is where such broader automation starts, he said.

Felszer has only one request of the hardware wizards who made this latest generation of mobile device possible. "Our old tablets had a small handle on the outside casing, kind of like a briefcase handle," she said. "I miss that," she said with a chuckle.