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Migration to Handhelds: Visiting Nurse Association of Brooklyn
In October 2000, the Visiting Nurse Association of Brooklyn (VNA), like all Certified Home Health Agencies, moved from a cost-based reimbursement system through Medicare to one that reimbursed on a prospective basis (per episode of care). It became imperative to streamline the workload for clinicians in terms of workflow and paperwork. While laptops greatly facilitate clinical documentation, the costs associated with purchasing, maintaining and licensing laptops are often prohibitive. The move to handheld computers achieves a greater economy of scale due to their lower cost. Thomas Gilmartin, Vice President of Finance and Administration for VNA of Brooklyn explains how and why the VNA of Brooklyn is implementing the use of handhelds in the field. What prompted the move to handhelds? Having a resourceful Board is always a benefit. Our Board Members include current and former KeySpan employees. KeySpan's interest in wireless technology prompted our review. We were also fortunate to find an extremely creative Internet Service Provider (ISP), Promenet (which partners with Verizon) to collaborate on this project. And last but not least, we have a tremendous resource in our committed and creative IT staff. Our agency prides itself in serving all populations seeking our services. We reduce the risk of our employees being crime targets if we can provide them with a level of technology that is not easily detected. Handhelds provide us with a more cost-effective solution, being cheaper to maintain and replace. They provide the infrastructure to move towards a wireless environment and by having ownership over the actual application we are able to create competitive differentiation. By streamlining process and cost we are able to divert monies to such critical functions as clinical recruitment, wages and retention. How did you select your handheld system and software provider? We developed an informal Request For Proposal (RFP) that laid out a workflow process and then sent it out for response. As it turns out, several Application Service Providers (ASPs) provided creative and comprehensive solutions. Partnering the ASP with our ISP for connectivity has only enhanced the viability of this project. The one thing that is important to note is you need to spend time doing research both externally (researching prospective vendors) and internally (researching workflow and departmental requirements) prior to making an informed decision. As far as the handheld technology itself, we have yet to make a final decision between a Consumer Electronic (CE) device or a Palm type device. The CE device has a number of functions built in, such as Microsoft Office, while the Palm offers wireless capacity without the addition of modems. This type of decision is dependent upon the design of the application and the needs of the users. How will data be transferred from individual handhelds to your clinical management system? Data will be transmitted and transferred electronically into existing systems eliminating the need for administrative costs associated with data entry. What are the security issues involved with the move to handhelds? Data encryption is essential to ensure the security of the information and access to the unit. What if a unit is lost? How do you monitor access once data has been transmitted? Where does the data ultimately reside? Since we work with the most personal of information - our clients' health records - these questions are critical concerns for us. There are various security schemes, encryption of data, tokens that change passwords, firewalls, etc. but we know there are no guarantees. You need to spend a lot of time up front considering the worst-case scenarios. You need to be prepared. Security is the one place you cannot cut corners. Other Issues? Data validation and synchronization will always be a concern and process to ensure that all data elements are complete and answers are valid. This is obviously dependent upon the amount of validation that is done remotely on the handheld versus on-site after receipt of data. How will training be handled? It takes about three or four training sessions to get staff completely up and running. We prefer a low student-to-teacher ratio so that each staff person receives personalized training. It's important for people who are experienced and understand the system to reside in-house to assure prompt response and problem solving. Training tends to develop a life of its own as staff become motivated and often involve informal resources, like family members, to provide support. It is important to have buy-in at all levels of the staff to ensure understanding of the project and its goals. Before we even developed the RFP we spent an inordinate amount of time assessing workflow. You would be surprised at the tricks, bad habits and shortcuts the staff develop over time that then become an agency's informal policy. This preliminary work took nearly a year but it does yield dividends in the end. Agencies should understand that there is no "magic in a box," no "off-the-shelf" solution that fits all needs. Understanding how work is executed on a daily basis facilitates transition to a responsive system designed to do work in a manner consistent with departmental needs and requirements. When is the VNA likely to implement the technology? We'll be ready to go out into the field with the first handhelds by the end of the summer. We're making a big commitment to parallel testing, maintaining our physical documentation and then comparing results with our automated reporting. Our beta test will run through the fall, evaluate, modify and deploy any necessary changes. We will utilize various levels of staff breaking out the beta groups by low-end users, middle-end users that have demonstrated some confidence and capacity and high-end users that pick it up right away and are more computer savvy. The mix is essential to evaluating the potential for an implementation's success. Any additional words of wisdom for agencies considering the move to handheld systems? It all starts with solid leadership, a committed Board of Directors and CEO. We, like many agencies, are fortunate to have a wealth of experience at our fingertips, we just need to use it. I can't over emphasize the importance of time, patience and due diligence during this process. Understand your work process. Use vendors and providers as a resource for information. Evaluate solutions separately and collectively - often one solution by itself does not provide all the answers. In the case of the VNA of Brooklyn, the dynamics and requirements of Medicare's Prospective Payment System provided the spark. The Board of Directors and CEO provided the leadership, the staff provided the necessary input and our vendors provided creative design and infrastructure that eventually led to the development of a creative solution. That solution will meet the agency's needs today and position it well for the future. You can contact Thomas Gilmartin at Tgilmartin@vnabklyn.org. Tips for Managing Handhelds
2. Determine which employees need access to what data and create user profiles and user access codes based on this determination. Once your systems are in place, these profiles and codes will automatically connect your employees with the appropriate functions, software and access rights. This is critical to maintaining system security. 3. Protect your data with an encryption solution such as SSL (Secure Socket Layer). 4. Create management tools that enable your employees to handle the units and the information with which they are working. Without these, employees are likely to tax the time and energies of your agency's IT department with basic support service requests that are more effectively handled through management solutions provided by such companies as Extended Systems XTNDConnect Server, XcelleNet Afaria, Callisto Orbiter and Mobile Automation Command Server. Your LAN provider may also provide wireless management support services. |
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