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Contents 
Introduction
Nurses streamline with tablets
Picking up tips from from NYK
Fighting fire with wireless
Eight points for wireless success |
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Victoria's Royal District Nursing Service (VDNS) is the largest and oldest provider of home nursing and healthcare services in Australia. It is a company limited by guarantee with consolidated revenues of more than AU$72 million for 2003-04. It employs nearly 1000 district nurses.
More than 800 of the nurses employed work in the field and are equipped with a tablet PC. A district nurse starts the working day by connecting to the RDNS's host system via GPRS to download information about the patients they will visit. This allows nurses to drive directly to the first patient without first travelling to the RDNS base centre.
Payments from the Victorian Department of Human Services are based on the number of direct care hours delivered, so this may have a significant effect on revenue. Other financing comes from donors and patient fees.
When nurses do visit a RDNS centre, a wireless LAN provides faster and cheaper communication with the host. If additional information is required, the nurse can reconnect at any time. For example, if a patient needs an urgent visit, a nurse can attend without having to return to the centre or take detailed notes over the phone. Any new data collected (such as the date the next visit will be required) can be sent back to the host immediately or cached until the next connection is made. Case notes are still recorded on paper and remain at the patient's home.
This tablet-based system was awarded the inaugural City of Melbourne celebrating Melbourne' award for digital innovation. Information stored in the host system includes patient details, demographics, appointments and financial records. "As soon as you put in place the ability to [remotely] access the main system, it opens up other possibilities," Ian Cash, general manager or information services at the Royal District Nursing Service, says.
Take the changes to occupational health and safety legislation which mandated site inspections of patients' homes -- a task that was previously performed informally. A new module was added to the tablet software to collect the required information. "It's fairly quick to implement some new aspect of data collection," says Cash, but people realise this so they are also quick to request additions. Such requests are vetted carefully, as RDNS is concerned that non-treatment activities should not eat into the time nurses spend with their patients."
The GPRS-enabled tablets also provide nurses with on-the-spot access to Internet or intranet-based resources such as drug databases or policies and procedures manuals. This real-time access to information makes nurses more autonomous, Cash says, as they can collect information and make decisions on the spot.
Sydney-based Pen Computing developed the tablet software. RDNS has a long relationship with this company, dating back to an early trial using Newton MessagePads and more recently with Sharp handhelds.
Jade Software Corporation of New Zealand developed the host software, which runs on Windows Server. "We had a significant partnership in both development efforts," Cash says, explaining that the Jade software is now sold commercially and is used by other organisations in the health sector. "The partnerships have been very successful."
The programs running on the host tablets are independent systems that exchange data in the form of messages complying with the Health Level 7 (HL7) standard widely used for clinical and administrative data. This architecture avoids problems with communications black spots, and ensures essential data is available when it is needed. "Keeping systems online for a mobile user where there are dropouts ... does play havoc in terms of maintaining data integrity," Cash says.
GPRS is typically associated with full-time connections, but the RDNS system was originally designed around GSM links that are charged by time rather than data volume. The message-passing architecture means very little data is transferred over the air, so running costs are low.
The Jade software incorporates its own store-and-forward message gateway for communication with external software such as that running on the tablets. The ability to deal with peak loads was essential as everyone at RDNS starts at 7.30 in the morning. This was also seen as a high-risk area for the project. Middleware was thin on the ground at the time of the original development, hence the decision to build a messaging system from scratch. "We needed to put a lot of work in," Cash says, but these days off-the-shelf middleware is up to the job.
The combined system also provides better co-ordination with other organisations, such as referrals to Meals on Wheels or planning other activities around the district nurse's visits. PKI technology is used for encryption when exchanging data with other organisations. RDNS is about to start a formal evaluation of the system, but some of the benefits are already apparent. Data is checked for consistency as it is entered, and there is no need for rekeying. "There's been a huge improvement in the quality of the data," Cash says, and this has led to improved administrative decisions.
The information is also available to other people at a much faster rate. The tablet application is designed with simplicity in mind, and more than 80 percent of data entry is achieved by "point and click". For example, instead of writing down visit start and end times, nurses simply click an icon to record that data.
Cash notes that the increasingly complex care required by patients may absorb the time saved by the system, so the number of visits per day might not have increased. Avoiding the traditional visit to a centre at the start of the day clearly frees more time for patient care, but some contact with colleagues is important and even vital for some roles including mentoring.
Nurses' grades and the particular type of work they're doing may affect the best practice in each case. One centre recently went 100 percent mobile for about a month during a sudden move to new premises. "They just didn't look back," Cash says.
