My first day in Healthcare at Home was in early November, 1993. A software salesman, I believe it was Terry Bryant of Patient Care Technologies, had scheduled a visit with my COO but she begged off, saying, "Give him to the new IT guy." With the ink still moist on my W-4 form, I sat down to a demonstration of state of the art, 1993, clinical point-of-care software, running on what looked like a 1980's GameBoy device. I admit, on day one I had no idea what Terry was talking about, something about standard clinical phrases and up and down arrows navigating a 3-line green screen, but I was polite and I filed the education away for later.
Since that day 22 years ago, I have come to understand home health point-of-care systems better and watched them evolve through the PDA and 10-lb. laptop eras, through smart phones large and small, and finally onto iPads and other tablets. Software has evolved at the same pace, piggybacking on enhancements to operating systems and communications as well as hardware. With the possible exception of the leap from the early "GameBoy" to devices with keyboards, however, never has point-of-care software evolved so suddenly as it has in 2015.
Last month, we were treated to demonstrations of three point-of-care software systems that signify the dawn of a new generation, a new way of thinking about the function of such software in healthcare at home. Igea, a recent Procura acquisition, Brightree, and HEALTHCAREfirst have all freed their software designers and developers from the burden of point-of-care tradition and re-written the textbook on what field clinicians need.
We detailed the genesis of HEALTHCAREfirst's Mobile Solution for Android Devices in our September 30 issue (Elite Team Builds Point-of-Care System for HEALTHCAREfirst), describing how it was designed by Mary St. Pierre, Tina Marrelli, and Suzanne Sblendorio, under the direction of Stan Bell.
The company calls it "Radically Awesome," which is of course pure marketing hype but there is a grain of truth behind it. What Stan Bell showed us in the HEALTHCAREfirst exhibit hall booth is radical in the sense that it breaks with traditions while being rooted in a clinician's real experience in the presence of the patient. ("Radical" shares the same Latin source as "radish," a root plant.) In addition to the software, what Stan Bell showed us was the kind of pride one typically detects in the presence of new mothers or owners of a new Tesla.
He explained, with gusto, that the goal from the start was to increase the likelihood that assessments and other charting would be completed in the presence of the patient. To test usability, the team submitted its design to the human experience lab at the University of Missouri. There, the UI was critiqued, tested with focus groups, torn apart and rebuilt. Every detail from the placement and size (sometimes quibbling over millimeters) of icons to the suggestion to place a large 911 button at the top of every page was reworked, retested, and tweaked again.
The important basics are all there. Nurses can skip quickly from one OASIS section to another in order to follow a patient's unorganized flow of information. An assessment can be "put on hold" if an urgent phone call requires looking up information about another patient. An integrated drug database checks for interactions. Quick access to personal and patient schedules support efficiency while automatic time-in and time-out monitoring eliminates paper and sends payroll and billing data directly to the office. And the tablet-based system is entirely self-contained so that clinicians can work offline and synchronize when the next connection becomes available.
Improvements on PoC traditions are also present. Little or no typing is required. Checking a box can select pre-written phrases for visit notes but measures are in place to prevent the same exact sentences from appearing in note after note, which attracts unwanted attention from audit contractors. Restrictions that force clinicians to be more compliant can be found throughout the application, especially with regard to care planning, another area MACs and ZPICs look at, hoping to find disconnects between assessments, plans, and treatments so visits can be declared medically unnecessary.
Care planning is built upon the 5th edition Tina Marrelli's Handbook of Home Health Standards: Quality, Documentation, and Reimbursement. Nurses are guided through plan design in such a way that it must be based on the assessment. Similarly, treatment and educational activities conducted during every follow-up visit must be based on the care plan. Goals, interventions, and expected outcomes are positioned prominently on the screen where nurses and therapists cannot inadvertently deviate from them.
The software makes full use of Android tablet cameras and microphones, cellular and Wi-Fi connectivity, and electronic signature capture. Mr. Bell affirmed that early users have indeed seen an increase in assessments and notes being completed in the patient's home.
Founded in 2003 by Pablo Buki, Indura Systems changed its name to Igea in 2013. (In Greek and Roman Mythology, "Hygieia" was the personification of health, cleanliness and sanitation.) Buki started with a point-of-care system and added full EMR and financial capabilities later. Procura found the system interesting, came on as an investor, and then acquired Igea last March.
Since its founding, Igea has been an anomaly. Though it is designed to be affordable in order to meet the budgetary needs of small and startup agencies, it offers most of the features of more expensive systems. Eileen Casellas, one of Buki's original employees, told us that they also have some large, multiple-location HHA clients and that the system can scale to meet their needs. They also seem to have grown to 300 customers at 400 sites by word of mouth, eschewing major advertising campaigns.
One of the more popular PoC features, Ms. Casellas reports, is embedded Medicare eligibility checking. By next year, that service will expand to include private insurance companies. Procura and ContinuLink users can expect to see this code ported over to their software sometime next year. The point-of-care system also includes Electronic Visit Verification with a feature than can be set to force home health aides to complete end-of-visit notes of tasks performed before signing out via the EVV system.
Schedulers and administrators appreciate the feature that monitors license renewals, sends reminders, and automatically removes a person from the list of clinicians eligible to be selected for a new patient or assigned to a visit if their renewal has not been recorded.
From the beginning, founder Pablo Buki has remained committed to live support services. All 60 Igea employees are based in the U.S. and the technical support team responds to phone calls or a chat help system that is accessed from within desktops and mobile devices.
An area we hope Procura developers will help Igea to improve soon is the embedded database of clinical phrases. They are easily inserted into OASIS assessments, plans of care and visit notes but they consist mostly of abbreviations, which each clinician has to manually edit after inserting them, to be sure to keep auditors happy. System administrators can go through the master database of phrases and edit them once for all but that tedious task would be eliminated if Igea did it once for all its customers.
Next on our tour we met two extremely satisfied customers of the new iPad point-of-care system from Brightree. Since acquiring CareAnyware, the HME software leader has invested millions into its home health and hospice application. We described the system a year ago when it was first released (Brightree Unveils Next Generation iPad App for Field Clinicians, HCTR, 10/29/14) and now had a chance to learn about any gains that customers may have measured.
Wendy Cofran is the CIO for Natick VNA in Massachusetts and was an early adopter of the new iPad point-of-care system. "Our nurses tell me that this software and the iPad platform actually encourage patient engagement," she told us. "Unlike a laptop-based system, it not only does not create a physical barrier between them and their patients but they have also begun to show the screen and talk to patients about what information they are recording about them."
She added that Natick has measured shortened documentation times and improved documentation accuracy with the Brightree iPad system. "They genuinely like to use it," she continued. "Clinicians can find where they need to go quickly, they can complete an assessment even if the patient's conversation is jumping around, and they can tell at a glance which assessment segments still need to be completed. It guides them through charting to the care plan so their visit notes always reference medically necessary treatments."
She concluded by admitting that she was a little apprehensive after the Brightree acquisition of CareAnyware. As one of CareAnyware's first customers, she was a little wary about the newcomer and its promises. "They have lived up to those promises though," she said. "This is a product that will keep us ahead of the curve; we can evolve as it evolves."
At the other end of the spectrum, Melinda Moore manages one of Brightree's newest customers. After years as a data analyst for OCS and Homecare Homebase, Ms. Moore recently returned to the provider side when she was appointed as Executive Director of Community Health Systems at Wesley Homes in Des Moines, Washington, a faith-based, not-for-profit CCRC. She took the reins in the midst of a Brightree implementation.
"Most of our visits are conducted within one of our assisted living or retirement centers," she began. "So our clinicians drive less than most do and can complete more visits in a day. If they were using a cumbersome piece of software that forced them to take notes and complete their electronic documentation at the end of the day, they would not get it done without staying up all night. The Brightree iPad makes it easier for them to get all their documentation done during or immediately after each visit so they don't have to do it at home."
She added that her people especially like the way the system allows them to start their day with all the information they need at a glance. They tap to look at three pages, "My Day," "My Patients," and "My Calendar," and then they are off to their first visit. "They have to do minimal typing, if any, and they make good use of the 'Smart Jump' system that lets them divert to a different patient record -- as often happens when they might get a phone call with a patient question in the middle of a visit -- and then tap their way right back to the current patient's page."
Point-of-care software applications have evolved many generations since the first one was introduced by Patient Care Technologies in the early 90's. These three profiled products may not be the only ones to deserve the title of "next generation;" certainly Delta's Crescendo and Thornberry's NDoc, and perhaps a handful of other industry veterans, boast the same clinical design philosophy and many of the same features. But these three certainly signaled at this year's NAHC Annual Meeting what the rest of the field needs to do to compete in this market. Give clinicians intuitive software on small devices, keep them compliant while making it easy for them to document in the patient's home.
©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. firstname.lastname@example.org