In team sports, if one's goal is to win regardless of cost, the logical strategy is to assemble a team made up entirely of All-Stars. It worked for George Steinbrenner and the Yankees in the 90's and several teams have tried out the method since. The most recent organization to do so is not a sports team at all but the Steinbrenner strategy seems to apply in the competitive world of healthcare at home software.
We spoke this week with some of the members of an ad hoc software design team assembled by HEALTHCAREfirst CEO Bobby Robertson. His All-Star team is made up of former NAHC regulatory consultant Mary St. Pierre, former agency owner and Home HealthCare Nurse editor Tina Marrelli, home health IT consultant Suzanne Sblendorio, and Neeley Current, Director of the University of Missouri User Experience Lab. They teamed with 25-year home health software engineer and architect Stan Bell, HEALTHCAREfirst's VP of Product Management.
IDENTIFYING THE NEED
After listening to his customers, Robertson decided it was time to modernize his clinical point-of-care product with the latest connectivity tools and updated clinical protocols. Influencing factors in his decision to revise an already successful and popular software module included:
What the All-Stars came up with may very well be a leap forward in technology and ease of use but this is not a product review. The new point-of-care application will not be unveiled until the NAHC meeting at the end of October and released to HEALTHCAREfirst customers shortly after. Rather, this is a study of how some top industry experts collaborated to come up with something potentially newsworthy.
Mary St. Pierre
"My goal was to design a clinical application that would be easy to use by people like me, who are totally inept with technology."
"I have seen too many devices that have been cumbersome to use so I wanted a tablet that could be easily held in your hand while doing patient assessments. I have seen to many care plans that were not aligned with diagnoses so I wanted the software to analyze the assessment and suggest interventions, while still leaving the clinician in charge of selecting appropriate interventions from our list of suggestions. I wanted medications to be entered once and automatically populate the plan of care.
Neeley and Stan started us off with the basic framework, so we knew what is feasible or not from a technology perspective. Stan had already included the checks and balances to make sure assessments and care plans do not have contradictory information. Tina brought in standards for care and in-depth guidance for developing goals and selecting the right care plans to apply to each patient's specific condition. We used her Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (known familiarly as "The Little Red Book”) as our basis for identifying patient care goals.
"My role was to look at Conditions of Participation, making sure that what the software was guiding clinicians to do was in compliance. I also made sure they considered coverage rules, the so-called Conditions of Payment. Medicare healthcare at home providers always seem to get those two things confused. Conditions of Participation deal with plan of care requirements and the like. Coverage rules, on the other hand, lay out what Medicare does and does not pay for. They are two different things but equally important.
"In addition to helping the rest of the team keep Medicare regulations front and center, I also introduced guidance to clinicians based on the same manuals that surveyors use. We didn't insert the manuals themselves into the software but based reminders to nurses on the guidance the manuals offer. This way, nurses do not have to remember every interventions for every single problem a patient might have. Plus, it helps them to cover in their finished documentation all the bases MAC and ZPIC surveyors are taught to look for when trying to find excuses to deny payments.
"After assessments and care plans are done and regular visits begin, we inserted reminders based on the Medicare benefit policy manual, home health chapter. Surveyors examine visit notes today with a fine toothed comb, looking for failure to document homebound status and medical necessity for each intervention performed. So we force nurses to reflect on all three criteria that have to be met: leaving home must be taxing, infrequent, and require an assistive device. Then we added numerous other cues to make sure they don't forget anything. Essentially, when they say they are finished, the software asks, 'What did you forget to do?'
"Since 1988, I have been teaching nurses that goals, interventions, and outcomes are integrated."
The president of Marrelli and Associates, Inc. and former editor of Home HealthCare Nurse started out as a home healthcare nurse and an agency administrator. She first wrote her "Little Red Book" just for her own agency's clinical staff. It started out as a 100-page simplification of Medicare's complex rules. "I thought there had to be a better way to hold my team accountable so I wrote a simple manual to help them do things right."
Now in its 5th revision and widely used nationwide, the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement provides assessment guidance to nurses to ensure that patient goals, interventions and expected outcomes are integrated.
"We wanted the new software to be innovative but fundamental. By incorporating the philosophy and instructions from my book, we are making it easy for nurses to guarantee that orders are entirely consistent with their plan of care, which is consistent in turn with their patient assessment. Compliance is built in to the way they are guided through the evidence-based practices.
"For example, they might be presented with the question, 'If I see that my patient has pain, how can I manage that so there is less pain?' We also designed the system to give extra guidance to less-experience clinicians. This high level of care coordination is more critical now than ever before. As home healthcare becomes more and more integrated into the overall healthcare system, nurses must grow more attuned to the requirements that hospitals and physicians fall under. It is in this way that healthcare at home is subject to the mandate known as the Triple Aim: improve patient outcomes, improve the patient's experience, control costs.
"I wanted the new product to facilitate communication and care coordination, in order to achieve standardization and commonality of clinical practice. We got the programmers to automate the synchronization task. When a tablet is connected, clinical notes are immediately available to the rest of a patient's care team. When notes are taken on a tablet that is not connected, it automatically syncs the next time a connection is restored. Everybody is on the same page.
"I have seen just about every point-of-care system ever made. I knew how not to build one."
"There were already clinicians and technicians on this team so my role was to be a bridge between them. Stan did an excellent job of building a software architecture around Mary's compliance expertise and Tina's brilliant clinical design. When we brought a prototype to the user experience lab at the University of Missouri, they provided great feedback about best device size, intuitiveness of the user interface, and overall ease of use. What was left for me to do was explain features I have seen over the years that are helpful and those that are not.
"Bobby (Robertson) told us that he wanted his new product to be easy to use, first and foremost. The number one problem with clinical documentation in home health is that it is too often done from memory, not in real-time with the patient. Inaccuracy is rampant and payment denials and ADRs are the result. What is the reason nurses don't document in the home? The software slows them down or the device forms a barrier between them and the patient, or both. We had to overcome those objections.
"Some of the things that helped us were advances in tablets and in network technology. We tested 10" screens and 7" screens. We tested them with Wi-Fi and with cellular connectivity. Perhaps the best convenience we developed is the system's automatic synchronization. With the emphasis today on care coordination, it is important that a patient's entire team is aware of the results of every intervention. At the same time, clinicians have always told me that stopping to find a connection and manually initiate a data synchronization gets in the way of their day. So what we did is design automatic synchronization. If a visit is recorded while the device is out of range, it will initiate its own synchronization as soon as it reconnects with a cell tower or a Wi-Fi hub."
Bobby Robertson told us that the new system will be demonstrated at the HEALTHCAREfirst booth at the NAHC Annual Meeting in Nashville. It will be distributed at no additional charge to customers starting in November.
©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. email@example.com