For Community Nurses mobile health data collection wins with mobile devices out-scoring laptops in all aspects: portability, connectivity, and time saving.
DEVICES at “Point of Care”
Nurse in the home
For the nurses that work in the community mobile devices out-score laptops in all aspects: portability, connectivity, versatility and time saving.
Executive Summary
The increased demand of acute secondary services in the region enabled, in 1996, the establishment of a team of specialised paediatric nurses with advanced education in the assessment and treatment of children in the community. The service operates 7 days a week and covers a large geographical area from Otahuhu to port Waikato, with 11.05 Specialty Clinical nurse FTE.
This evaluation assesses the advantages and disadvantages of using paper forms, electronic forms via laptop and electronic forms via tablet. The evaluation has important limitations as it had to be completed in a very short time-frame but produced results that are consistent with existing published evidence.
The evaluation found that the use of laptop was more time consuming than paper forms and mobile devices and the least preferred by the community nurses. Paper was less time consuming overall than the laptop but more than the mobile device. Nurses using mobile devices to assess patients, can have the equivalent of 0.8 nursing FTE/year extra (instead of paper forms) and 1.3 nursing FTE/year extra (instead of laptop).
The evaluation also found evidence, through specific situations experienced by community nurses during their home visits, that mobile technology improves information access and promotes evidence-based practice to make effective decisions at the point of care. In the case of the evaluated community nurse service, mobile devices used for the assessment of patients did improve efficacy and effectiveness of the service.
Background / Justification
The South Auckland District has the highest proportion of urban Māori and Pacific island children, with health disparities caused by low incomes and unemployment that lead to poor health outcomes and causing a disproportionate number of South Auckland children to be high users of the health service.
The increase demand of acute secondary services in the region enabled, in 1996, the establishment of a team of specialised paediatric nurses with advanced education in the assessment and treatment of children in the community. The Kidz First home Care Nursing Service (KFHCN) was formerly known as the Children’s Community Nursing Service until June 2000.
The key functions of the KFHCN service are assessment, case management, patient advocacy, palliative care and referral for four main paediatric patient groups: (i)acute unwell children 0-15 y.o. for up to 72 h. post hospital discharge, (ii)premature neonates, congenital anomalies or requiring tube feeding or home oxygen, (iii)chronic disability for 0-17 y.o., (iv)medically fragile 0-17 y.o.
The service operates 7 days a week and covers a large geographical area from Otahuhu to port Waikato, with 11.05 Specialty Clinical nurse FTE.
Objectives of the Evaluation
This evaluation assesses the advantages and disadvantages of using paper forms (for the assessment of patients in their home), electronic forms via laptop and electronic forms via tablet. It aims to answer the following questions:
- Which one of the devices (paper, laptop, and mobile device) produces most time savings?
- Which one of the devices provides additional benefits for users and patients?
- What are the main technical issues (accessibility, security) regarding each one of the devices?
Methodology
Nurses were divided in three groups of three nurses each, one group used the paper based forms, another used the electronic forms via laptop and the third one used electronic forms via tablet. There were 20 measurements for each one of the nurses in each group (n=60 measurements per each method)
The methodology for each one of the evaluative questions were:
1. Which one of the devices (paper, laptop, and mobile device) produces most time savings?
1.1. Self-reported timing of completion of individual forms
1.2. Analysis and extrapolation of potential savings individually and as a service
2. Which one of the devices provides additional benefits for users and patients?
2.1. Literature review
2.2. Interviews with 3 users per method
2.3. Review of existing reports
3. What are the main technical issues (accessibility, security) regarding each one of the devices?
3.1. Literature review
3.2. Interviews with users
3.3. Interviews with technical staff supporting software, hardware and systems.
– Each nurse timed the completion of each form from the time they started to write the first note (or fill the first field) to the time when they finished writing the last not (or filling the first field). The time was taken using the chronometer personal mobile phones. – Times (one measure per nurse, per form) were logged in an excel file and sent to the evaluator that randomly selected 20 from each nurse and for each option (paper, laptop, mobile device) – Nurses kept a diary and/or notes with their personal observations on positive and negative aspects related to the mode of assessment – Nurses were interviewed by the evaluator – The technician from Kinross software supporting nurses was interviewed by the evaluator
Limitations
The context in which an evaluation takes place is very important. In this case there was an urgency to complete this evaluation before the end of the financial year 2013-2014 as its results will support decision regarding integration of forms and use of mobile devices for community nurses. We decided to use existing operational data that nurses could extract from already collected assessments. During the mobile health data collection phase the operative system in some nurse’s office computers was upgraded and some of the information was lost resulting in having to collect data in new assessments.
The evaluator decided that the quality and consistency of data was adequate for the purpose of informing management decisions around this issue but the following limitations should be taken into consideration when reading this evaluation:
- Time for three categories (paper, laptop, and mobile device) was measured in a consistent way, using a chronometer on a mobile phone but there was no rule regarding rounding when timing was in between minutes. – Laptop measurements were only 20 (not the expected 60) due to lack of time (evaluation deadline) – We did not control for the type of patients, neither for first or follow-up visits, although almost most of them were acute patients; the cases measured reflect the normal case mix of the community nurses
Findings and Discussion
1. Which one of the devices (paper, laptop, and mobile device) produces most time savings?
The “Acute referral assessment and GP handover form” has 58 potential data fields and is used in every visit for the first visit and for follow-up ones. The standard for the study was the paper form which was adapted in 2013. The laptop version is a replica of the form with some fields that can be populated choosing from a drop-down menu. For the mobile devices all fields were replicated using “Kinross” software provided free of charge by AMS in NZ. This software allows the creation of template forms in mobile devices, sending and storing them, allowing access to all stored information and complementing forms with additional information such as clinicians’ contacts, pharmacies and other community services in the area.
A group of nurses at KFHCN were offered the opportunity to use Kinross software and mobile devices for their home visits. There is evidence in the literature that mobile technology can improve the health workers experience and provide better services to patients. In a review1 of published literature (48 articles analysed from the 900 originally selected) Lindquist and colleagues found that “…there is some evidence that the use of a PDA in health care settings might improve decision making, reduce the number of medical errors and enhance learning, but the evidence is not strong …”
In another large review of published literature2 (138 primary studies from five systematic reviews) Mickan and colleagues found evidence that handheld computers allow health professional to be more efficient in their work practices “handheld computers provide easy and timely access to information and enable accurate and complete documentation. Further, they can give health care professionals instant access to evidence-based decision support and patient management systems to improve clinical decision making”.
There is also evidence that nurses spend a considerable amount of their working day on administrative tasks3. It obviously depends on the role and service where the nurse work but it could be as significant3,4 as 30% in some hospital-based studies.
There are different studies that found that electronic forms allow nurses to increase the time spent in direct patient care rather than in documentation activities5,6. Some studies7 quantified the time spent by nurses in electronic versus paper forms and always found important time savings when using electronic forms and those savings could be as important as the equivalent of 50% of time that nurses dedicate to fill in forms . In another study8 also in a hospital with portable devices (PDAs ) researchers found that the time needed for nursing documentation could be reduced by 60% (a 10% saving of a nurses’s total working time).
The evaluation found that the use of laptop was more time consuming than paper forms and mobile devices and the least preferred by the community nurses. Paper was less time consuming than the laptop but more than the mobile device. Data regarding the three methods used to fill the patient assessment form are presented in table 1.
Table 1. Time expressed in minutes employed in filling in the assessment form using three different methods. Number of assessments made Paper Laptop Mobile device 60 20 60 Maximum value 40 60 43 Minimum value 6 17 2 Mean 23.65 29.85 13.96 Median 27 11 Standard deviation 7.14 10.4 10.7
The KFHCN has 11.05 clinical nurses FTE and on average they filled 9,680 assessment forms every year for the past five years (2009-2013). Using the average time needed for each one of the three methods, we can estimate the average time that nurses need to fill the assessment forms in a given year (see table 2).
Table2. Nurses time expressed in hours to complete a year’s patient assessment forms Time in hours based on 9,680 assessments per year Paper Laptop Mobile device 3,815.5 4,815.8 2,252.2
Time savings in hours
Laptop instead of paper +1,000.3 Tablet instead of paper -1,563.3 Tablet instead of laptop -2,563.3
When comparing laptop with paper, an excess of 1,000 hours will be needed to complete the same amount of assessments. The best results in terms of time efficacy were achieved by using the mobile devices, an excess of 1,500 hours when compared with paper forms and an excess of 2,500 hours when compared to laptop.
In other words by using mobile devices to assess patients the service can save the equivalent of 0.8 nursing FTE/year (instead of paper forms) and 1.3 nursing FTE/year (instead of laptop).
2. Which one of the devices provides additional benefits for users and patients?
Mobile technology can improve information access, enhance workflow and promote evidence-based practice to make effective decisions at the point of care9. It is useful in areas: documentation, medical reference, access to patient data. In this evaluation we found that, in addition to portability and connectivity, this is the aspect that nurses value more when choosing the type of device that is more helpful for their work. Some of the uses of the mobile devices were (in the words of the nurses):
- Downloaded anaphylaxis and St Johns ambulance forms and sent to parent for medic alert documents negating need for second visit.
- Organised mobility taxi to avoid clinic DNA
- Documentation complete during visit, only GP form to write post visit.
- Emails sent to my work address whilst waiting for appointment reducing wasted time.
- Address not on paper map. Google maps had street facilitating visit I would otherwise have abandoned.
- Google maps worked out how to get to unknown destination and time to destination allowing me to better organise appointment times with other families.
- Camera used to capture image of equipment needed that I was unfamiliar with allowing for right resource to be delivered in timely manner.
- Equipment photo taken as supplies delivered incorrectly and matter resolved immediately with new and correct supplies delivered to family
- Acute patient, mom asking re dose of antibiotics, able to check on line at visit to advice if within correct range. We currently do not have a medication handbook we use out on the roads.
- One of our patients requires YouTube videos for distraction during infusion, no other distraction works. Starship had advised us of this previously and they have tablets they use for distraction therapy. Using YouTube videos on phone have enabled us to comfort the child and provide care.
- Telephone contacts available at all times.
- Play distraction as our service does not have play specialist services.
- Nurse can adjust document in a timely manner to enable use within the community. Not having to wait for long periods of time to do this.
- Nurse is able to develop document that is easy to use and relevant to service, rather than outside people creating.
- Checked pharmacy ability to fill dietician prescription and organised home delivery by local outlet Enteral feeding YouTube video for family teaching.
- Used heart circulation video to reinforce information previously offered by cardiologist.
- Internet search for obesity support for children
- Vector power site search for funding for support for child using oxygen concentrator who cannot afford power bills.
- Search for unknown syndrome amongst others whilst with parent to aid assessment and familial understanding.
- Frank Schann paediatric drug dosages app to check prescriptions
- Conversion table, and calculator apps used daily with premature infants.
- Translator app used for acute assessments negating need for translation services personnel.
- Nutricia site used to problem solve in the home when pump failed during child’s feed.
- Notebook app used as reminder pad.
- Voice app used to record stridor and determine development necessitating hospital admission as stridor increasing and affecting feeding ability.
3. What are the main technical issues (accessibility, security) regarding each one of the devices?
The nurses using the different options to fill the assessment forms had strong opinions regarding the pros and cons of each one. For nurses using the paper forms, they found them convenient to transport and access and easy to fill; they report an improvement regarding previous versions, the actual one being easier to fill and requiring lesser writing.
The main problems are the inconvenience in storage and accessibility if they are not in the office where they are kept. It is impossible to consult previous assessments if the file has not been sought in advance and taken at the time of the visit. They also require some duplication of tasks such as rewriting the information in the referral form when one is needed, it does not include reminders and useful tools such as the Glamorgan score (assessment of pressure ulcers in children). The paper form does not have a question/field for ethnicity.
Nurses using laptops had no major issues in filling in the form but laptops are quite heavy to carry around and requiring some time to start functioning and logging into the system. It was felt by the nurse that quite a bit of time was lost in each visit. There is also an issue of privacy and security of laptops as some of the homes visited are quite crowded.
Mobile devices were very appreciated by the nurses that have been using them for the past months, especially when they compared their experience with the previous use of paper or laptops. The main advantages noted were (see also examples in point 2 of the discussion section “additional benefits”): easy to transport and handle, great connectivity in almost all geographical areas, intuitive way of filling the form, can perform different tasks all in one device, access to extra information and tools needed during the assessment and for education of the patient and whanau.
Table 3. Main differences in functionality between laptops and mobile devices
Mobile Health Data Collection Conclusions
Though the three ways of using the patient assessment forms were effective for the community nurses the use of mobile devices offers a number of advantages that laptops and paper forms do not.
In the past years health systems in developed countries have moved from paper-based to electronic based record systems; it has been recognised that they improve the health workers experience, quality of patient care and decrease medical errors. The question in this case will be which electronic support will offer the best results, laptops or mobile devices. The answer for the nurses that work in the community is clearly mobile devices; they out-score laptops in all aspects: portability, connectivity, versatility and time saving.
Although the limitations of this evaluation are considerable, the findings are in line with existing published evidence. Our evaluation suggests that by using mobile devices the group of community nurses (11.05 FTE) at KFHCN could save, in their assessment of patients, as much as 2,563 hours/year, the equivalent of a 1.3FTE. This increase of effectiveness could have an increase in efficacy as mobile devices allowed nurses to seek additional information needed for the assessment of patients and the information/education of whanau.
Mobile Health Data Collection Recommendations
CMDHB should consider the use of mobile Health Data Collection devices for community nurses and other community health workers and electronic-supported assessment forms as it will make community services more effective and efficient.
Further evaluation can be undertaken to more accurately assess efficacy and effectiveness in the use of mobile devices at point of care although there is enough evidence to support the above recommendation.
The KFHCN Experience
A Report by Ko Awatea Health Innovation Centre, Middlemore, Auckland, NZ
Final report 3/07/2014
