By: Jeneane A. Brian, BSN, MBA, CEO, VNAHHS Jeneane Brian is a nurse executive and creator of a handheld based clinical documentation system in use by VNA Home Health Systems, the industry leader in home health and hospice services for Southern California.

VNA Home Health Systems (VNAHHS) has a synchronization based mobile IT strategy representing an important part of our enterprise-wide solution.

In addition to direct data input via the Internet, The FreeForms System makes it possible for VNAHHS clinicians to document patient care and exchange information with the agency via handheld devices running Palm OS software. The mobile component of the FreeForms System is a local/local or "Fat" model. The handheld processes locally, stores locally, and synchronizes later. Database information is available for internal use as soon as synchronization occurs. The System supports bi-directional information flow, so all data in the patient's digital chart and on the clinician's handheld is updated on each data exchange.

Home health care is particularly well suited to mobile application technology. Home health workers make up a widely dispersed, on-the-road workforce and mobile access is the only interaction mode that can be reliably counted on whenever and wherever clinicians need patient information. Patient information gets stale with time and wireless synchronization offers opportunities for more frequent updates, eliminates barriers that require dependency on home (wired, Internet capable) PCs for data transfer, and adds email/instant messaging to the mix of communication alternatives.

We are already using wireless technology in those areas where it currently makes sense. We have phones, pagers, and wireless pda modems. We have made a purposeful effort to remain unfaithful to one technology, we take every process and evaluate it for how it will best be served. Therefore, we use voicemail for some things, cell phones for other things, email for yet other things- whatever can be exploited for the best advantage.

Since synchronization is the core of our mobile solution, we evaluate all new possibilities with that transaction in mind. "Always on" is a desirable state, but is currently not a reliable reality for our use. We have solved the synchronization needs of those clinicians who do not have wired PC access to the Internet via wired modems. This still requires occasionally connected synchs- but is sufficient for now, is affordable now, and has finally become reliable enough that we are not having troubles with dropped connections and lost data (something we cannot afford to have happen).

VNAHHS's future relies not on a 'thin' model handheld solution that depends upon the Internet for processing power, but on a 'fat' model that allows processing locally, in the handheld. As long as our model is configured in this way, we can wait on 'always on' to be refined and keep on developing. I believe that an investment in 'always on' needs to center on a more robust Internet ISP and a less robust handheld requirement. Since we are developing now and not later, we have taken the fat model as our goal. This buys us time and may just fine for some time to come.

The VNA Home Health Systems Mobile IT Strategy- the FreeForms System

Increasing market pressures and a national nursing shortage prompted VNA Home Health Systems to initiate a mobile computing solution which could be exploited in all possible ways to optimize service levels. We sought the following advantages:

· Improved quality of patient care
· Faster, more decentralized, decision-making in the field
· Improved responsiveness to patients
· Reduced clinical documentation time
· Reduced information flow latency
· Increased staff morale and productivity
· Reduced travel costs
· Decreased facility costs

With almost 70% of our workforce mobile, doing business in busy Southern California counties, on a 7/24 schedule, and dealing with patients from infancy to adult including hospice, we had high hopes for our system's impact. And, we have not been disappointed.

Components of the FreeForms System:

1. Mobile Clinicians- Clinicians have ad hoc connectivity to the enterprise server via forms based clinical documentation software on over-the-counter handheld devices.

2. Mobile Workers and In-house Staff Remote Access- The FreeForms System allows for data input directly into a secure website by all VNAHHS staff who have password access. Internet viewing/editing of synchronized data and other system components occur via wired PC connection. In-house staff utilize the website for time and attendance reporting, human resource forms input, and statistical reporting for other business purposes. Clinicians use the Internet access for viewing and editing patient related information, time and attendance, and staff development post-testing, etc. Clinical documentation editing permission is allowed up to 48 hours after a patient encounter. Once data has been synchronized to the server, it is pushed back out to the providers as part of the patient's digital chart and based upon the clinician's caseload. Data generated by one user cannot be viewed or edited by another except by user permission. Program managers, for example, have access to the data generated by those on their staff.

3. In-house Staff LAN Access- A robust backend viewer system based upon Microsoft Access is used by internal office staff who analyze data for various purposes. The FreeFormsÔ Manager, sorts clinical and other system data according to a variety of requests formulated through query and displayed on the desktop. User access is password and permission based. The viewer has a printing function to generate a paper version of any digital form whenever necessary. Patient charting information is printed only on demand. Managers approve timecards, perform quality assurance audits on clinical documentation, and can review the patient's digital chart via this mechanism. Data can be viewed in aggregate format, by individual clinician, or by patient.

Wired Synchronization

Mobile and wireless are not the same. Wireless is one component of a mobile strategy. Our equipment list includes wireless devices for paging and a variety of cellular phones that are capable of connecting to the Internet and receiving emails.

Currently, the need for mobile clinicians to use a fixed wire system at some point in the process is impacted by important user limitations including:

1. No access to a computer at home
2. Access to a computer at home, but not Internet
3. Limited access to a computer at home, the clinician is/has never been a user

Wireless Synchronization (not yet)

Although real-time connectivity would be a messaging advantage, VNAHHS believes our 'store-forward' synchronization solution is sufficient to meet current needs, given available alternatives. The FreeForms System stores data locally on the device, so users are not required to maintain a constant connection. With either wired or wireless connectivity, clinicians must be guaranteed efficient and reliable synching processes. The FreeForms synchronization process is device agnostic. The software does not 'care' whether it's being synchronized via a wire or wireless method. This means for us, the advantages of going wireless for synchronization must far outweigh the reliability of a wired connection to the Internet. Despite the psychological appeal, wireless synchronization for the transfer of patient care data is currently risky, time consuming and expensive. The current advantages of wireless synchronization do not seem provocative enough for us to make the leap.

Wireless Messaging

Wireless email messaging is a very compelling advantage. However, with an active workforce using a pda for clinical documentation and other purposes, the addition of email introduces a potential and serious confusion. VNAHHS has an internal email system, but we do not currently communicate with field staff via this means. We will add this feature when it is clearly understood which means of communication will be used for what purpose. Middle management takes on a new meaning within an enterprise that is converting to a mobile strategy. Anywhere, anytime access cannot mean anywhere, anytime, anyplace data and information. Chaos results when enterprise managers do not know where to go for necessary information or what form of communication to use. Should time critical messages about a change in physician orders be sent via email, voicemail, or pager? If the method is not consistent, messages will get dropped. We are moving slowly to assure those who need information know where to find it. Each new addition requires thorough training.

Summary

In short, VNA Home Health Systems, as an early adopter of mobile technology for a clinical workforce, is looking forward to including more wireless in our worklife. Our "occasionally connected" system is far superior to the past- and we are still getting used to its new advantages. We have chosen a Local model configuration that is stable and serving our needs. Wireless technology for 'always on' does not offer enough of an improvement to compel us to convert from a system that requires wired connectivity. (see 3G is Not Broadband) However, the eventual introduction of email and messaging outside the walls of our offices will only be useful if we have wireless connectivity during the workday. Messaging will probably be the final driver for us to make the investment in wireless modems for our pdas. However, the cost and data transfer capabilities currently available are too risky. While the dust is settling on arguments of protocols, we are preparing, developing, and getting used to the advantages of today's real world of mobilization.

Jeneane Brian can be reached via email