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Case Study

About CHIME
The College of Healthcare Information
Management Executives (CHIME) is
the professional association for chief
information offcers and other senior
healthcare IT leaders. CHIME enables
its members to collaborate; exchange
ideas; and advocate the effective use
of information management to improve
health and healthcare in the
communities they serve.
When IT Matters:
Improving Care Delivery and
Patient Outcomes through
Technology
April 2014
Philip Chuang
Chief Strategy Executive
(Former Director of Information Services)
Sutter Care at Home
Tablets Improve Access to Information,
Care Coordination for Home Care Nurses
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Home care nurse Victoria Conneely covered a wide range of topics and duties in her one-
hour patient visit with Robert, a 90-year-old San Francisco resident who just returned home
after a recent hospital stay.
Like many home care nurses, Conneely performed a range of functions essential to improv-
ing Roberts health. Taking vital signs; organizing drugs into a pill box; showing the full-
time caregiver how to best use remote telehealth devices to report Bobs weight and blood
pressure; reviewing canned food in the kitchen to ensure high-sodium products wouldnt be
consumed.
During her visit, Conneely would reach instinctively for an electronic tablet at certain mo-
ments; to record information, fnd Bobs previous medical information, coordinate care with
a therapist, and order supplies. After a few fnger taps, the tablet was down on the table,
and she again could focus her attention on the patient visit.
Key Terms
Mobile device: A small form factor device (such as a smartphone or 10 or smaller
tablet, weighing less than one pound). In general, these devices have built-in wireless
Internet connectivity; a lightweight operating system, such as Apple iOS or Google
Android; and media features, such as digital camera and/or video capability.
Mobile device management (MDM): Software installed on a mobile device that helps IT
departments manage large groups of mobile devices. MDM software features include
the ability to apply security policies and controls; to track device inventory and usage;
to manage software distribution; and to remotely wipe (erase all data) from a lost or
stolen device.

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Youre getting better Bob, she said. Your blood pressure is much better, and I cant hear
any rattling in your lungs when you breathe. Bob smiled in response; just the news he was
hoping to hear.
Its no surprise that Conneely, a nurse for Sutter Care at Home, is a strong proponent of the
way the tablet technology helps her do her job.
Its so important just to be really prepared for a patient visit and having the patients medi-
cal record available, she said. Im better informed about whats been going on with them,
what occurred in the hospital, and what medications theyre on.
During her visit, Conneely reaches instinctively for an electronic tablet at certain moments; to
record information, fnd Bobs previous medical information, coordinate care with a therapist,
and order supplies.
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Mobile Staff Need Mobile Solutions
Healthcare providers are facing increased pressures to minimize patients treatment costs,
and thats typically best accomplished by moving patients to the least expensive and most
appropriate care setting. For many patients, that venue is their own homes.
However, incorporating information technology with home care has been challenging. Home
care clinicians have worked with paper records, and all the inherent limitations, for years.
Onsite device choices have limitations laptops are often diffcult to use in patients homes,
and syncing them up afterwards to organizational records can interrupt clinicians workfow.
Smartphones provide more portability and connectivity, but are limited by small screens and
minimal computing capabilities.
These kinds of technology issues had perplexed Sutter Care at Home, a large home care
agency whose 1,300 caregivers now make home visits in 23 counties, serving nearly
100,000 patients. In addition to home care, Sutter Care at Home provides hospice services,
home medical equipment, home infusion therapy and respiratory care. A subsidiary of Sut-
ter Health, Sutter Care at Home advances Sutters efforts to coordinate and increase the
value of care for patients living at home.
About 10 years ago, Sutter Care at Home attempted to bring computers into the care de-
livery process for home staff, said Phil Chuang, chief strategy offcer and former director of
information services. The laptop-based system ran into diffculties that Sutter Care at Home
was still attempting to resolve four years later, in 2008. The application was not optimized;
training users was diffcult; and the laptops themselves, as a form factor, were diffcult for
home care staff to use effectively, Chuang said.
We still hadnt fnished the rollout, he said. There were many reasons why Sutter Care at
Home was challenging. We got to a breaking point and we had to decide, Do we try to fx
all the issues with the existing system? We could have done that, gone back to square one
and do it all over again. But we decided that if were going to spend millions doing that, we
better make sure we pick the right horse.
Sutter Care at Home assessed EHR systems from scratch, bringing in clinicians to let them
experience different systems and devices. As a result of clinician input, it decided to go with
a system based on mobile technology, specifcally the smartphone, Chuang said. At that
time, tablets were just coming on the scene, but were nowhere near ready to support an
enterprise application.
However, Chuang acknowledged that the smartphone-based system had technological
and user limitations that brought new challenges to mobile home care staff. For example,
phones had limited usefulness if staff used them outside of cellular service areas, couldnt
effciently access Sutters EHR system and were unable to allow users to see faxed docu-
ments, among other limitations.
After a couple of years on the smartphone-based system, Sutter Care at Home reassessed
technology again, this time looking to tablets as the form factor of choice.
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Benefts of Tablet Computing
Technology Requirements (used in support of the project)
. Mobile Android tablets
. Mobile tablet ergonomic equipment keyboards (Bluetooth, docking stations),
styli, cases, stands
. Mobile device management (MDM) software
. Electronic health record
. Secure email/messaging software
As mobile tablets became more sophisticated and robust, advantages of the platform be-
came apparent to Sutter Care at Home executives. For example, devices equipped with 4G
mobile broadband access to the Internet enables users to have access to email communica-
tion. Tablets enabled multi-tasking and better teamwork, facilitating effective communication
between mobile caregivers.
Tablets have sped up the fow of the process, said Jennifer Brecher, project manager for
the mobile device project. In the past, if one of the clinicians went to see the patient on
Monday and the physical therapist would go on Tuesday, the therapist would not have the
information about the Monday visit available. This is better from a productivity perspective
and better for the patient.
Before use of the tablets, clinicians could not access a new patients full records in the feld;
instead, they had to visit an offce to pick up faxes that documented the referral, history and
other records to prepare for accepting a home care patient. Now, productivity is enhanced
because scanned copies of faxed referral documents are sent to a clinicians tablet, and the
worker also can access the mobile version of the Epic Systems software that Sutter uses
to provide read-only data from prior hospitalizations, physician offce visits, and laboratory
results.
The turnaround time for documentation also has improved by use of the tablets, Chuang
said. Our prior standard was to have documentation completed within 72 hours of the visit;
now, our clinicians complete documentation with 24 hours, he said. Visits on subsequent
days now have up-to-date data for review and necessary follow-up.
Some processes dont show any gain in speed on tablets, such as the admissions visit for
new patients, which still takes about two hours, Chuang says. However, the digital forms on
the tablets can incorporate logic, enabling some questions to be skipped if they are not ap-
plicable to the patient. But on subsequent visits, patient documentation is streamlined and
patient data is much easier to locate than it was on paper forms, he added.
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The tablets also enable time savings and care improvement in wound care. Home care nurs-
es are able to use a tablets built-in camera and send the photos securely to the offce for
inclusion in the patients electronic medical record, where it can be reviewed by a specialist.
Previously, wounds were documented by clinicians using digital cameras, often causing time
delays in uploading images, as well as security and patient privacy concerns, because of the
risk that the cameras could be lost or stolen.
Team Players
Project manager
Technical analyst
EHR trainer
EHR feld support analyst
Field clinician as testers/
early adopters
Ergonomics analyst
Accelerating and Standardizing
Supply Ordering
Sutter Care at Home clinicians use the tablets to directly
order medical supplies. The process is easier, because
the tablets contain a standardized formulary of supplies.
Previously, clinicians ordered supplies by calling the
agencys medical supply vendor, a time-consuming
process that introduced the potential for error.
The technology, coupled with the formulary, cut medical
supply costs by 20 percent per visit in the frst year that
the tablets were used, Chuang said. In addition, tablet-
enabled ordering reinforced Sutter Care at Homes ef-
forts to ensure best practices in the care it provides to
its patients.
Finally, tablet-based supply ordering improved the timeliness of order delivery to patients,
he said, through the use of direct linkages between orders in the feld and the supplies dis-
tributor, who ships supplies the same day directly to patients homes.
If we want to achieve better outcomes for care, we need to be sure that we are staying on
top of best clinical care practices, Chuang said. Its unfair to expect a feld nurse to keep
up on what is best practice in all areas. This system helps drive best practice; a wound care
nurse manager determines what supplies should be on the formulary and keeps it updated
as improved supplies become available on the market.
The Importance of Training
As Sutter Care at Home moved to the tablet-based system, it developed a more extensive
training approach for new users. Just because tablets offer touch-based selection doesnt
mean they are easy for clinicians to use, Chuang said.
Because its mobile, most people think you just throw it out there and it sticks, he said.
First, its still a project, its technically complex, and change management still is crucial. To
teach people how to use the technology and use it in the right way takes context. Now, we
train a new nurse for 18 hours on how to use the tablet to do their jobs.
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Nurses who are new to tablet technology are encouraged to take the tablet home and
become familiar with the interface, said Julia Berger, the education specialist who is the
training lead for the mobile device project. Training itself involves classroom experience
(often at branch sites for Sutter Care at Home), support from subject matter experts, and
responsive help desk support for questions coming from the feld.
The nature of home care, and the dispersed coverage area for Sutter Care at Home,
makes training and support crucial to the success of the tablet-based system, Chuang said.
When you deploy Epic in a hospital, you have all those super-users running around with
different colored vests answering questions, he said. In home care, you cant do that.
Not only do we have to buy the devices but we have to fgure out how to supply all this
remote support. If you go with a mobile solution as the core computing platform, this is
really important.
To fully support its 1,300 users, Sutter Care at Home must be ready to help users who have
a wide range of comfort levels with technology, Berger said. Theres a whole spectrum of
needs, so its a joint effort between us and the clinical staff, she said. We ask them what
their needs are; we talk to clinical educators, preceptors and experienced nurses who are
mentors. They get the hardware and learn to use the documentation software. Then they
come back to us and have more questions.
Nurses who are new to tablet tech-
nology are encouraged to take the
tablet home and become familiar with
the interface. Julia Berger, edu-
cation specialist, training lead for
the mobile device project
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The process can be iterative. For example, clinicians using the tablets in the feld suggested
that an app that provided stopwatch functions would be helpful, for example, in assessing
patients pulse rates or respiration rates.
However, other suggestions for apps cant be granted, and explanations are given. For ex-
ample, a suggestion to use a voice dictation system was vetoed because it worked by using
the Internet to turn voice comments into text. We cant allow that, because it sends pro-
tected health information over the open Internet, Berger said, citing privacy concerns.
Tablet Benefts and Challenges
Mobile clinicians from Sutter Care at Home eventually settled on tablets with a 7-inch diago-
nal screen, Chuang said. A tablet with that size of screen can be held in one hand, or can
be slipped into a coat pocket. Users also receive a wireless keyboard and stylus to facilitate
data input.
Sutter Care at Homes EHR vendor decided to design their software for the Android oper-
ating system, because multiple tablet manufacturers adopted Android and stimulated in-
novation and choice in device size and design. Android also enabled better technical man-
agement options needed for a corporate-based program, said Frank Carter, Sutters lead
technical analyst for mobile devices.
Tablet procurement is a challenge. Sutter Care at Home purchases tablets commonly avail-
able to consumers, and currently is supporting four different types of tablets. Because con-
sumer tablets evolve rapidly, they are often not on the market for a long period of time,
requiring Sutter Care at Home to be fexible in its acquisition strategies.
Technology Challenges
Staying nimble when it comes to devices: The organization needs to be
fexible enough to go with the fow, facing rapid changes in mobile technology
market both hardware and software.
Consumer-based devices and device companies: Mobile devices primarily
have been designed for the consumer market and are still evolving to meet
enterprise market needs.
Whos responsible for that? Its hard to tell: Vendor accountability is not
always clear with complex relationships between wireless carriers and device
manufacturers
Many perceptions about the best approach: Organizations will face individual
preferences for each clinician about what works/doesnt work with a mobile device.
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Tablets have disadvantages and benefts when compared to a traditional laptop computing
system, Carter said. With laptops, a corporate entity has more control of when updates or
patches are installed. With tablets, system updates are handled by wireless telecommuni-
cations carriers, and Sutter Care at Home often has no advanced warning. Installing large
updates at random times can be disruptive to clinicians who are treating patients in homes
over limited periods of time.
Tablet procurement is a challenge. Sutter
Care at Home purchases tablets common-
ly available to consumers, and currently
is supporting several different types of
tablets. Pictured: Frank Carter, Sutters
lead technical analyst for mobile devices.
With tablets, its a consumer device, Carter said. Theyre not thinking about managing
1,000 devices, like we are. There are many sources for potential change when the device is
made by Samsung, the operating system comes from Google and 4G service is provided by
Verizon, Sprint or AT&T, Carter said.
On the plus side, the IT department is able to exert a greater level of control over the tab-
lets than it would with laptops, Carter said. For example, tablets are password protected and
encrypted, and if a tablet is lost or stolen, Sutter Care at Home can wipe the device clean of
information remotely, in a matter of seconds.
Mobile device management is a way to bring consistency to the devices out there, Chuang
said. The system allows us to know where a device is, to wipe a device, to push out new
policies. Our level of control is far more powerful than anything we had with laptops. We
know the status of every device, without any user intervention.
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There are always issues with security compliance with any device, he added. If someone
loses a laptop, how do you know if it was encrypted? The last time it was on the network
is the last time we can tell. When our security offce wants to know whether a device was
encrypted, we can tell them exactly when, and we can issue a wipe command and erase the
device immediately. We have a level of security that we never had with laptops.
The tablets enable Sutter Care at Home to standardize the apps that appear on the screen
and their placement, so that even though devices may be different models, the layout of the
apps is exactly the same on each one, Carter said. The system alerts the IT department if
any unauthorized app is downloaded by a user, and the device repeatedly prompts the user
to delete the app until it is removed.
A Better Tool to Improve Care Delivery
The small form factor of the tablet, and its ability to be the intelligent note pad for the clini-
cian, support the idea that its intended to help the clinician give the best possible care to
the patient and not become the focal point of the patient encounter.
Home care nurses have tons of documentation, Berger said. Thats the way its always
been in home care, and some people leave the profession because of it. We tried to antici-
pate their needs and wants in using this device in the home.
Its easy to get caught up in the device, and weve focused some of our education on that,
Chuang added. The pushback we sometimes get from some staff is they say they lose their
focus on the patient with the device. My response to that is that you can ignore the patient
if you put all your focus during a visit into documentation, whether on paper or in electronic
format. We try to integrate the documentation, which isnt optional anyway, and better co-
ordinate care with the tablet. No one likes documentation but they like the results of having
better documentation at their fngertips. Its about delivering better care as a team.
Chuang expects the tablet will play an even more important role as accountable care initia-
tives put a premium on care coordination, prevention of hospital readmissions, and seamless
sharing of patient data. Other technology advances promise to make the tablet more inter-
active; for example video capabilities might enable a feld nurse to do a quick teleconference
with a wound care specialist to have an impromptu consultation. Thats the power from a
patient care perspective, that we can communicate with you and the patient wherever you
are, Chuang said. Thats what the mobile technology gets us.
Tablets also offer ways to engage and educate patients, Berger said, with the range of edu-
cational material that can be accessed via the Internet.
For Conneely, use of the tablet has come naturally, and it has improved her ability to access
information and coordinate with other care team members by email.
Its defnitely beneftting us and making it easier for us to do our jobs, she says. In the
end, it helps the patients. Its defnitely the way to go. I hope something like this would be
available to every home care nurse or therapist.
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Lessons Learned
Mobile is rapidly evolving: Tapping into the power of mobile technology
requires staying on top of a still maturing technology. MDM solutions are still
evolving, and there are short product lifecycles for tablets and smartphones.
Team up with clinicians to fnd out what works for them: A strong
partnership with clinicians is required to test devices and new apps to ensure
usability and achieve productivity gains. They have insight to help you learn about
ergonomic issues and getting accessories to help, and then you can gather
feedback to handle glitches together.
Theres no such thing as too much training: Even with simple mobile devices
and a mobile EHR, clinical documentation is complicated, and good training is still
needed (i.e. this isnt Angry Birds).
This is a big technology project that needs to be managed: Mobile is no
different than any other tech project just because clinicians use mobile technol-
ogy in their personal lives doesnt mean theyre ready to use a mobile EHR. You
need a methodical, well-planned, well-executed, well-communicated project to
make it happen.

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