Nurses Without Wires

Wireless tablets streamline referrals, and let nurses better serve patients.

by / July 6, 2006

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 or educators.

"The CAO chose our nurses because, in part, there are great community demands for this classification of workers and a national crisis in nurse recruitment. This presented a perfect choice to improve our productivity without more staffing."

In specific terms, the HHSA was expected to produce a 25 percent increase in the numbers of clients served and a 25 percent reduction in time needed to serve clients. These initial goals seemed unrealistic to Macchione and "knocked us off our chairs," he said.

To address wasted travel and office time issues, the county invested in wireless, electronic tablets for the public-health nurses. The tablets contain each nurse's client database, which provides patients' vital statistics and medical histories. The tablets' portability allows nurses to schedule appointments, fill out forms, record pertinent follow-up information for later retrieval, and perform other administrative tasks remotely. This convenience not only saves time, but also promotes enhanced care to appropriate individuals.

Project participants said the pilot succeeded because line employees were involved from the outset. In the first operational phase, the agency asked the public-health nurses how the county could improve and streamline their administrative tasks.

"The thing that was really positive from the very beginning was the line nurses were in on the design and implementation," said Kitty Roche, public-health nursing supervisor in the North Inland Region. "The people who were using it in the field had as much input as those overseeing it, and we felt very much a part of it. We were all asked to express what we thought the barriers and problems were in the process. I have an incredible team of nurses, who from the very start were very positive about the project."

The second phase of process enhancement started in July 2005 and lasted three months.

"This is where we did our workflow redesign," said Macchione. "We looked at all the steps, identified the 18 paper steps, and discovered it was a cumbersome, highly frustrating system for the referral agencies, staff and clients. We then began to enact organizational change. Although nurses were concerned this would mean losing jobs, we made it clear we were looking to gain efficiencies to gain more clients. Less paper, more clients served."

Macchione and his colleagues gathered a core design team of nurses and clients. A process engineer consultant guided them through the process of eliminating steps and reducing time. Macchione said that during the process of shortening travel and administrative time, the idea developed for a Web-based referral system.

"We did not start out with the idea, but through the process, we discovered it," he said. "We then realized we also needed a database to manage cases. This led us to the next step of dispatching referrals to the nurses in the field, and we thought it would be great to have a desktop in the hands of the nurses, along with clinical information to educate clients, do notation, client input, time recording and mileage tracking."

Use of tablets at the point of service was the logical next step, he said.

The Results
San Diego County public-health nurses will get to see 2,400 more clients each year thanks to the new referral system and electronic tablets. Without this new technology, it would require 23 additional staff members to achieve such an increase, according to Macchione.

Now the average amount of time it takes to make contact with clients is around 13 days.

"We are still not satisfied with that number," said Macchione, adding that this is a reduction of 75 percent, and 11 percent of the time, clients are seen on the same day.

Over the long term, more clients will see public-health nurses, so fewer San Diego residents will need to rely on the health-care system, generating savings for county government. Also, in helping a pregnant woman ensure her baby is delivered at full term, the baby is less likely to suffer any preterm problems.

The 10-month pilot started in February 2005 and extended its December 2005 deadline to June 2006 to work out the bugs in the document conversions to the tablets, Macchione said.

A Web-based rollout of the online referral system, to be accessible to all public-health nurses in the county, is scheduled for Sept. 1, 2006. Costs will be recouped in the next fiscal year, and the agency expects to save $2 million a year thereafter.

Macchione said the pilot program will later be expanded to widespread tablet use and the county will look into deploying similar applications in other departments.

"We are still working on them," Roche said of the inevitable bugs. "But with technology, there is always something that comes up."