Wireless by design: three separate and dramatically different organizations made the decision to shed hard wires—and, in some cases, paper. All are at various stages in their wireless evolution, and all have been challenged to get their arms around a range of devices, individual work styles, implementations and platforms

Health Management Technology, Jan, 2005 by Richard R. Rogoski

While many healthcare organizations are still debating the pros and cons of Web-based networks or whether they should convert their paper charts to electronic medical records, other organizations have already upgraded to wireless networks or are planning to do so. Getting there isn't without challenges.

Increased mobility and the ability to access and transmit patient data at the point of care are often cited as reasons for going wireless. But rationale isn't enough. Clinicians' work habits and the kinds of wireless devices that best match their needs have become major factors in the decision-making process, and also in determining the success or failure of a wireless initiative.

Most physicians at Duke University Health System (DUHS) in Durham, N.C., already have and use personal digital assistants (PDAs). When DUHS began rolling out a wireless application specifically designed for clinicians with PDAs, the project's success was almost guaranteed.

In contrast, public health nurses employed by San Diego County often find PDAs intrusive when visiting clients' homes, and the size of the screens makes them inadequate for using many standard clinical forms.

Tablet PCs, however, were incorporated into the wireless strategy of the Lexington Clinic in Lexington, Ky., enabling this organization to begin phasing in an enterprisewide electronic medical record (EMR).

Early Steps

John Oliveria, automation coordinator for San Diego County Public Health Services, says that when the adoption of PDAs began in 2002, going fully wireless was not an option because the County's network didn't support wireless. The County is now at work developing wireless access to its network, and this will now make it possible for Oliveria to develop a wireless strategy of his own for supporting public health issues.

Prior to using PDAs, the 120 nurses working out of six facilities relied on paper forms that were completed manually, then scanned into a decentralized system. The majority of entered data is required for filing Medi-CAL claim forms and includes information such as how long the nurse spent with the client, the kind of case management activity involved, the nature of the home visit, which tasks were related to this visit and the level of case acuity involved.

Oliveria says each nurse typically visits four families a day, which translates into approximately 40,000 clients per year. But collecting and organizing this much data requires more sophisticated technology. "The PDAs have been successful because they got the entry of data out to the source," he says, but they do have limitations.

The County runs a version of the Avatar PM application from Great River, N.Y.-based Creative Socio-Medics, which has been customized for use on a PDA. Avatar PM manages client and episodic encounter data capturing, scheduling, billing, remittance and reporting functions. The public health nurses are able to download from their desktops each day's client list along with the appropriate demographics. During their visits, they can input their claim encounter data, perform assessments and enter progress notes. When they return to the office, they simply cradle their PDAs and upload the data to a central database.

Acceptance Is Critical

However, Oliveria admits that "more than half" of the nurses aren't using the PDAs the way we intended. They'll come back to the office and input the data on their desk-top computers."

Compounding the issue is the very nature of the work they do--and this is where matching the wireless device to the end-user's work style and to the job's utilization requirements comes in. "Many of the clients are referred by clinics that identified a need," he says. "But the clients, in some cases, may feel they don't need help" and, in fact, may not want assistance.

About half of all visits are done as cold calls, he adds, even though these clients, most of whom are single mothers with children, are referred by a community clinic or private healthcare provider. "In some cases, it's difficult for a nurse to use the PDA in a client's home because the client may not want her there in the first place." Since the nurse may not feel comfortable inputting data when her first goal is to establish a connection with the client that will sustain beyond the initial visit, she may enter data into the PDA before arriving at her next client visit, Oliveria says.

Adding clinical data--even something as simple as a client's height and weight--will require using standardized forms, and this makes use of PDAs more of a challenge. "We don't feel that the PDA is the right instrument for clinical data capture," he says. "It's good for swift data collection, but the screen isn't big enough and it isn't the right device for more complex clinical data."

As a result, San Diego County Public Health Services is now contemplating trading in their PDAs for tablet PCs. "With a tablet, you can see a whole page at once. The whole form is visible," says Oliveria.