City and county governments countrywide laud wireless networks and wireless handheld devices as key to greater efficiency, cost savings and improved customer service for mobile work forces.

In northern San Diego County, Calif., 24 public nurses employed by the county's Health and Human Services Agency (HHSA) participated in a pilot that tested using wireless tablets and a Web-based referral system to improve health services for HHSA clients.

The Problem

Before the pilot, public-health nurses faced many obstacles, such as erroneous or incomplete referral information, in attempting to contact clients. The nurses dealt with an 18-step, paper-based process; it sometimes took months to process referrals and reach people in need.

Time was spent retracing steps and making phone calls to get the right information; traveling from client homes to the office was time consuming, and administrative tasks required office time and often created duplicate entries.

"It was startling to find that 98 percent of our referrals before the pilot were inaccurate and incomplete," said Nick Macchione, deputy director of the HHSA. "That meant 98 percent of the time, we had to get on the phone and track people down to get the info."

The agency serves many pregnant and post-delivery mothers who often have high-risk pregnancies due to a lack of prenatal care. Although such patients needed timely care, the referral process was typically slow and inaccurate. For example, Macchione said, it was common for a public-health nurse to receive a referral from a clinic or hospital with incomplete information.

In a typical scenario, a nurse would arrive at a specified address -- an eight-story apartment complex. The next two hours might be spent interviewing residents and the apartment manager to track down a pregnant woman whose visit to the clinic initiated the referral process. This time spent searching would be better spent counseling.

"We found out time was wasted tracking down information from incomplete referrals, which delayed assignments," said Macchione, noting that an average of 54 days elapsed from the opening of the case to the first client contact.

The Plan

The concept behind the business process re-engineering project dates back 11 years to the birth of the e-government model in San Diego, said Macchione, explaining that the new tablet pilot project is a natural extension of the transition toward e-government that began back then.

To address the incomplete referrals problem, the county partnered with referring agencies and discussed agencies filling out the referral forms online.

"When we started, 18 steps were needed to process referrals and serve clients, and those steps took roughly two to three hours per referral," Macchione said. "As a result of the pilot, the same tasks take five electronic steps in less than three minutes. We no longer needed a supervisor to decipher the clinical information since it was all there for the nurses to use in the field. The Web-based tablet made sure the forms were accurate and complete along the way."

The North Inland public-health region of San Diego County, where the pilot project was tested, covers a land area close to the size of Rhode Island. San Diego County is divided into administrative regions, with respective divisions of Public Health Services. The HHSA's Public Health Services division employs about 150 public-health nurses divided among those regions.

Macchione was asked by the board and the county chief administrative officer to oversee one of the business process reengineering projects being tested countywide.

"Ours was truly the service personnel piece: to test the concept of a truly mobile and remote work force that could be replicated beyond the walls of our agency," Macchione said, adding that the HHSA was chosen for this experiment because approximately one-third of its employees work in the field as social workers, nurses