It began at a national home care meeting, Director of Clinical Services Denise Shaffer remembers. “I heard two conflicting messages that sent me home to Toledo shaking my head. One speaker was firmly convinced that mobile computers – laptops, notebooks or Tablet PCs running Windows – are the only solution to the paperwork burden imposed on visiting nurses in a Medicare agency. Another group, by no coincidence the audience of the presenter with the other opinion, responded with stories about how many nurses they lost after imposing laptop PCs on them.”
They were both right, she decided. At least they both possessed a piece of the truth. Shaffer was determined to put the pieces together and come out with a whole solution for her staff.
On the one hand, it is true that nurses are asked to do too much in a Medicare agency, Shaffer realized. Too few nurses are required to care for growing patient case loads and complete a mountain of paperwork for each patient. She also knew that completing OASIS assessments on paper forms contributes to the workload and that excessive workload is thought to be the reason clinical documentation quality is a perennial problem.
Converting from paper to an electronic system, given the right electronic system, streamlines a nurse’s task load and puts more patient information at his or her fingertips. Electronic patient records frequently improve inter-disciplinary communications and result in better patient outcomes.
If you can convince them to accept technology, that is.
On the other hand, those colleagues who had lost staff after introducing computers must be telling true stories as well, Shaffer further reasoned. With the nursing shortage severe in northwest Ohio, she did not want to propose a move to management that would make it worse. Still, something had to be done to reduce paper and increase efficiency.
“Nurses carry too many things already,” she firmly believed. “Adding one more three-to-five pound device is likely at least part of the reason some nurses resist. Add to that a laptop’s typical short battery life and small screen size, factor in the average nurse’s aging eyesight, and you can understand why people in that audience said what they did. Some admitted that most of their nurses who did accept the computers do not complete their charting in the patient’s home but in their own home at night. Some do not even take the laptop into the patient’s home.”
If only there were an in-between solution,” she found herself wishing, “something like a telephone that they already know how to use and are comfortable using. Everyone agrees that a cell phone is most unsuited to filling out an OASIS assessment but that is only if you try to use the phone as if it were a computer, she continued to reason, typing paragraphs on the tiny keypad or touch screen.”
Why not use the phone as a phone?
With company owner Ritch Adams’ encouragement and a minimum of outside help, Denise Shaffer devised her own OASIS call-in reporting system, based on one she had seen working at another agency. From simple, somewhat awkward beginnings, it passed through three generations to reach full 24/7 automation and integration with Heritage’s back office software system.
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Technology not the only way in which Heritage innovates Faced with lackluster productivity and a competitive community, Heritage president Ritch Adams figured out a way to create incentives for regional managers. It is the Heritage “Grade Card” system as much as its technological innovations that made the agency a model of efficiency, reducing managerial staff while increasing agency offices. Briefly described, office teams are given written goals. At the same time, a small percentage of company revenue is set aside into a kitty. Each month, teams are graded according to a complex but understood set of guidelines. Branch office teams scoring an A receive 100% of their region’s apportioned share of the kitty. A grade of B earns 75%; a C is 50%. D’s and F’s are not rewarded. “When we started the Grade Card system, everyone got D’s and F’s,” Denise Shaffer remembers with a laugh. “Not any more.” |
1) Person to Person
For the first year, nurses called the office and dictated their OASIS answers to a live typist. Shaffer was surprised to learn each clinician/typist pair could complete an OASIS assessment in less time than a clinician on her own, including the time to enter the data into an electronic system after the paper had been delivered. Assessments were entered into Heritage’s back office system the day they were done instead of three to seven days later, as was the case under a paper system.
This innovation’s advantages were outweighed, however, by the necessity to restrict dictation to office hours. “Monday mornings were overwhelming,” Shaffer says. “We had three full-time typists and three more cross-trained from other positions but all six were not enough to handle the weekend backup.” They tried bringing a person in on Sunday afternoons for a while but that turned out to be a very unpopular solution.
2) Person to Software
The second year saw the introduction of an IVR system from Heritage’s telephone service provider, VorTalk, which was negotiated by Adams but evolved into a full “TeleOASIS” system following Shaffer’s urging and guidance. Now, clinicians were able to dictate OASIS assessments over the phone at all hours, including weekends, as no attendant was required. The system read each OASIS question and waited for a numeric response, delivered by voice or touchtone. Data was still entered manually from the new system into Heritage’s clinical and billing software.
Though this version was a giant step forward, it had disadvantages of its own. To get OASIS data into their back office system, a transcriptionist had to sit in front of two monitors, one with the VorTalk system and the other running the back office software. Data entry was still manual but now typed into one system by reading from another rather than by listening to a live voice.
3) Person to Software to Software
Finally, Heritage arrived at its fully-developed system, TeleOASIS, in mid-2009. They supplemented the IVR system with another application developed to serve virtually any business arena, including healthcare and banking, from a company called HTECH. Known as Cascader, the application converts data automatically and seamlessly exchanges it between TeleOASIS and the Heritage back office system.
“I am not sure exactly how HTECH’s Cascader TeleOASIS works,” Shaffer admits. “I have a feeling there is some magic involved. It can convert data between and among almost any number of applications, no matter what language they were each written in or what operating system they run on. I just know it works and works fast.”
She offers two examples of what the Cascader system has done for Heritage’s office productivity. All positions related to entering OASIS data have been eliminated. Also, the process of calculating grade card scores (see Sidebar), which used to involve combining several reports from different sources, a full-day task, is now completed in 20 minutes.
Laptop computers and handheld PDAs may never appear at Toledo’s Heritage Health Care Services, Inc. Ask Denise Shaffer whether her staff uses an electronic point-of-care system, however, and she will answer that they most certainly do.
Editor’s note: Cascader TeleOASIS has completed beta testing and is just now becoming commercially available through HTECH. Cascader also powers Heritage’s Grade Card Scoring system (see sidebar). www.TeleOASIS.com
