Mobile Tech for Homecare Paperwork

Tablet PCs help Boston’s VNA maximize care by minimizing paperwork.

Keeping pace with the growing paperwork demands of the Federal Government’s Medicare and Medicaid programs is a formidable task. For Boston’s Visiting Nurses Association (VNA), getting that paperwork under control was imperative for the organization’s continued success.

Tablet PCs help Boston’s VNA maximize care by minimizing paperwork.

The not-for-profit VNA of Boston is one of the largest providers of comprehensive home healthcare and hospice services in greater Boston. Every day, the organization’s experienced clinicians care for thousands of patients and families in their homes, providing more than 250,000 home care visits to over 14,000 patients in 2005 alone. Established in 1886, VNA of Boston is the oldest and one of the largest VNAs in the country. Our more than 500 employees serve patients ranging from infants to elders, including more than 1,000 individuals who would otherwise not receive care.

The VNA’s mission to bring compassionate, high quality and cost effective home care to individuals in their respective communities has not changed in more than 120 years. What has changed is the inordinate amount of paperwork and record keeping now required for the organization to do its work. It became necessary to further analyze the problem in order to find a solution that could reduce the paperwork and maximize our effectiveness as caregivers.

VNA of Boston receives the majority of its operating income from the Federal Government’s Medicare and Medicaid programs. To qualify a new patient for coverage, the government requires a substantial amount of documentation, primarily through forms that need to be filed on behalf of the patient. Many of the home care episodes for the organization run for a fixed period of time, such as 60 days. In addition to the paperwork needed to initiate and conclude each home care episode, the government demands that comprehensive records be kept for each and every patient encounter within that episode.

Getting Paperwork Under Control
With many patients receiving care three or four times per week, the documentation burden is potentially disruptive. The inordinate amount of each nurse’s time spent documenting things for the government often worked against their productivity.

A first step toward controlling the paperwork was taken six years ago when the VNA implemented a comprehensive computer system from McKesson Corp. While the new system handled much of the billing and scheduling in the back office, it wasn’t being used to automate the growing mounds of clinical observation data collected daily by the visiting nurses. As a result, a comprehensive analysis of clinical findings was impossible to create without reviewing scores of paper-based medical folders by hand.

Meanwhile, automating the back office created its own set of data challenges. Clinicians, for example, still had to fill out paper forms before and after every visit. Most would begin their day in a VNA office by collecting stacks of patient folders from medical records. Then, after making their rounds by car, they would fill in the paperwork before returning the next day with the most important forms needed for data entry and billing. Consequently it became increasingly difficult for clinicians to handle the paperwork.

Better Care Through Portable Technology
It soon became obvious that as government red tape increased, the quality of our reports would decrease. The solution to this challenge came in the form of a business plan penned by Kate O’Neil, our vice president of operations and myself in 2003. The plan detailed the use of convertible tablet PCs to allow clinicians to create forms and update patient records themselves. This would greatly streamline data collection on the front end and nearly eliminate data entry on the back end, so the plan was adopted and deployment began in early 2004.

Based on an initial recommendation by McKesson, and their own market research, the VNA of Boston selected the Fujitsu LifeBook T4000 series convertible tablet PC. The result of partnering with Fujitsu was the rollout of approximately 285 of the units to our mobile nursing staff. In conventional mode, the LifeBook T4000 has a keyboard for typing. But if you rotate and fold down the screen, it transforms into a tablet for pen-driven navigation through forms or jotting down notes using the stylus. Both were invaluable options to our clinicians in the field.

We had four main goals in the business plan that ultimately sold the VNA on an integrated system that utilized tablet PCs:

• Improve the quality of the patient documentation;
• Improve the timeliness of reports and billing cycles;
• Improve communications between the clinicians in the field, office staff and physicians; and,
• Establish a strong technical foundation to build upon in the future.

Once implemented, we saw dramatic changes in the following areas of the comprehensive plan.

Patient documentation. With McKesson’s help, VNA of Boston has converted over 40 forms from paper to electronic format. With so many forms and patient records now in place that offer drop-down menus and built-in error checking, we’ve seen major improvements in the accuracy of the documentation. And, with more complete and extensive patient records being collected, the result is better patient care.

Clinicians must still spend time with patients collecting and entering the information required for government payment and reporting. However, the clinical quality reports now have greater detail and are much easier to generate, thereby facilitating reports on previously impossible business aspects. Consequently, the LifeBook tablet PCs help us support a new level of standardization that didn’t exist before.

Timeliness of reports. Billing information is also more accurate and timely. For example, the turnaround time previously needed to issue government invoices has been reduced significantly, thereby increasing cash flow. Moreover, many of the clerical staff previously needed for billing and data entry have been redeployed elsewhere in the organization.

Another major improvement is the travel time saved by clinicians who previously made separate trips to the office simply to drop off and pick up patient folders. Now, the nurses just download whatever patient information they need rather than going through the medical records department as before. Fifty percent of clinicians no longer have to make a daily trip to headquarters, and a substantial number have reduced office visits to just once a week. The most important result is that the timesavings gives all nurses more time to care for patients in their homes.

Improved communications. With Microsoft Office installed on all of the tablet PCs, an added benefit is better and more frequent e-mail communication between clinicians, physicians and staff. Secure e-mails often are exchanged throughout the day when users connect remotely to the network to upload or download patient information. Meanwhile, many clinicians are leveraging the Internet to research medical best practices and collaborate with one another on projects, while others are testing new e-learning software solutions aimed at professional development.

A strong technical foundation. Early in the project’s history, my team enhanced its internal network infrastructure to optimize performance and to make document uploads as convenient as possible. The improvements included upgrading servers and disk storage space, adding wireless routers to leverage the built-in WiFi found in the latest Fujitsu LifeBooks, and deploying a RAS server for dial-in user access. I wanted to make certain that when we went live with the tablet PCs, the technology would not become an inhibitor to using the system.

Bottom Line
Making Fujitsu’s LifeBook T4000 tablet PC an integral part of the VNA’s home healthcare documentation has helped us to improve the quality of our business reports, redeploy clerical workers once dedicated to data entry, enhance communication among staff, and increase cash flow through improved billing. Most importantly, the VNA’s home care system has helped to improve the quality of care it provides to patients.

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Fran Lorion is Chief Information Officer at VNA of Boston. Contact him at florion @vnab.org.