• Taking Care to the Cloud


    Cloud-based Computing Changes the Home Health Point-of-Care Paradigm

    How do clouds, the Google Effect, the FDA, and technology impact the homecare nurse?

    They are all elements that lead to a paradigm shift in point-of-care electronic visit documentation (EVD). EVD is at the intersection of technology and healthcare. This article will help identify the benefits of “taking care to the cloud”.

    Device-heavy EVD - It used to be that home care nurses had to “make do” with difficult approaches to point-of-care EVD that involved synchronizing loads of data from agency databases to applications running on mobile devices such as laptops or tablets. Often times, this process was so cumbersome that nurses would simply avoid using the technology in the home, during the visit, and would instead “document their day” on their own time at night. This certainly wasn’t the intent of device-based EVD technology but unfortunately an all too common occurrence.

    In the rare cases when the point-of-care device was used during the patient encounter, the information which the nurse may have been basing decisions on was only as current as the last time they synchronized or updated their local EVD application. In the dynamic home health environment, information may have changed since the last “sync”, creating decision support concerns. As evidenced later in this piece, the Google Effect indicates that people are placing more reliance on computer information, so the accuracy of this information is critical to homecare professionals.

    Because of “after the fact” documentation and data integrity issues, the “device-heavy” approach did not maximize the potential benefits of EVD to any stakeholder involved, including the patient, the nurse, or the home care agency.

    Two driving factors have now created a paradigm shift and enable agencies to minimize the technical hurdles which prohibited the effective use of EVD in the past:

    1. Internet Ubiquity, and

    2. Cloud-based EMR Systems

    Internet Ubiquity – The growth and maturation of Internet connectivity has reached a tipping point and today you can get Internet access nearly anywhere, even on a plane. Broadband accessibility and reasonable price points make mobile health effectiveness more attainable than ever before. Because cloud-based EMR systems are securely accessible from the field, the vast amounts of EMR data that used to be sent down to the device can now simply stay in the cloud and be accessed as needed. This “device-light” EVD approach significantly reduces the technical barriers to adoption and has proven to be used in the home, during the visit, more often than “device-heavy” applications which required lots of synchronization and updating.

    Cloud-based EMR Systems – When combined with a cloud-based EMR system, the nurse is able to “go to the cloud” when extensive decision support is needed at the point-of-care, knowing that the information in the patient’s live EMR is accurate. With a cloud-based EMR, everyone in the agency, including all field staff, schedulers, billers and clinical management, is making decisions based on the exact same version of the data.

    Because EVD can be completed at the point-of-care and uploaded to the cloud-based EMR in near real-time, QA and downstream operational processes can be centralized and more effectively managed. Nurses can get their private lives back and do away with the need to document their day after the fact, and documenting at the point-of-care improves the relevancy and timeliness of patient encounter data.

    Device-light EVD and Cloud-based EMR

    Device-light EVD – Effective EVD technology should facilitate electronically documenting a comprehensive, accurate account of the patient encounter and provide a balanced amount of guidance that enables the nurse to primarily rely on their professional training. It should be quick and simple enough to encourage use at the point-of-care, work both online and offline, and ultimately enable the nurse to keep the focus on the patient, not the technology. The technology itself should allow the healthcare professional to naturally perform their assessment, or intervention, and be able to pull any reference information that would help improve care delivery. A balanced combination of human and computer assisted decision making can be achieved with a “device-light” EVD approach and a “cloud-based” EMR.

    The device-light EVD model also limits the need to distribute ePHI (electronic Protected Health Information) to multiple devices, which substantially mitigates HIPAA risk for homecare agencies.

    The Google Effect – In four cleverly designed experiments, psychologists explored how the Internet may be changing the way people handle information. Recently termed “the Google Effect” in the July 15, 2011 edition of Science Magazine, people are beginning to rely more and more on the ability to “find” information by searching online, resulting in lower rates of recall. Knowing “where” to get the answer is becoming more important than knowing the answer itself. This may not be a bad thing, but is an alarming cognitive consequence and raises a number of questions when applied to the nursing professional and the use of information in decision-making at the point-of-care.

    The Google Effect - Image Courtesy AndroidAuthority.com

    How does the Google Effect impact nurses and their point-of-care decision making? Is an experienced nurse better off relying on their judgment, education, and intuition when making care decisions, or relying on computer generated information to guide them? Are point-of-care decision support tools becoming a nurse’s “external brain”? What happens when the “external brain” is not available or is inaccurate?

    US FDA Proposes Health APP Guidelines – In a related development, the United States Food and Drug Administration (FDA) announced that it is proposing guidelines for certain medical health apps, its first move into the mHealth space. In the July 19, 2011 press release, the FDA is proposing to oversee mobile medical apps that could present a risk to patients if the apps don’t work as intended.

    It is rather interesting that the Science Journal’s report on the Google Effect and the FDA’s announcement on medical app guidelines both came out within 4 days of each other. The dynamics are clear, we are relying more on computer information and the stakes are getting higher as to how we are relying on computer information.

    A Balanced Approach – It makes sense that the FDA would want to ensure these “external brains” are accurate and used in a balanced approach. It also makes sense that computer information does not get in the way, or lead the professional home health nurse too much in their patient assessments and interventions.

    FDA policy advisor Bakul Patel provided a pragmatic statement, citing the need for balance, “There are advantages to using medical apps, but consumers and health care professionals should have a balanced awareness of the benefits and risks.”

    How true!

    In the context of the home care nurse in the field, a device-light EVD solution combined with a cloud-based EMR system provides this balance by enabling electronic documentation at the point-of-care and offering decision support as needed to complment their professional judgment.