VITAS hospice patients self-report pain in an automated record keeping system that clocks patient visits made by nurses, physicians, home health aides, and social workers. Each employee must phone in data about the visit, or enter it by keyboard. Phone-in reports are usually done on the day of a visit, and track actual visits and certain clinical data, such as pain severity. Others, such as detailed bereavement visits, are entered into the computer within a week of the visit. By using this phone-in system, an employee’s time sheet is effectively done, because managers know when, where and how long employees saw patients. The computerized system does not replace hardcopy medical records, but serves as a real-time tool for managers to track patients and their care.
The most exciting element of the management system, according to Richard Williams, M.D., VITAS' executive vice president and chief patient care officer, is that VITAS not only collects information on employee travel time and length of visits, but allows patients to categorize the pain they are experiencing.
"VITAS team members ask patients to self-report pain by categorizing their pain on a visual analog scale of 1 to 10. Severe pain is in the 7-10 range; moderate pain is 4-6; mild pain is 1-3; and no pain is 0," he said.
Williams described how a patient benefits from self-reporting pain. Imagine a patient who generally reports pain in the range of one to three, a low level. After being turned and bathed during hospice visits, the patient begins to rate pain at 6 or 7, which is very high. This patient can be helped with medication. "After recording such data, team members would instruct the patient to take a pain pill one hour before each scheduled visit to relieve the pain associated with being turned and bathed," he said.
Each team of hospice healthcare professionals has virtually immediate access to patient records. With these computerized records, staff can analyze visit data and discuss questions or concerns with other staff. A VITAS hospice care team of 12 people usually provides the 40 to 60 patients in its care with nursing, physician, home health aide, and medical-social work service.
Melanie Merriman, Ph.D., former VITAS director of quality and compliance, explains that a clinical nurse specialist manages each team, and reviews patient data reported to the system. If a patient appears to be in pain, the team manager can review visits made, contact the lead nurse or physician, and suggest when additional treatment might be needed. This management tool monitors the clinical activity of patient visits and improves the team's capacity to deliver care, according to Williams.
The system also permits rapid response to patient and family needs. If, for instance, a patient requires a wheelchair, that information can be automatically entered, a vendor located, and an order faxed. After death, faxes are immediately sent to all vendors, requesting that they pick up any equipment, and to physicians involved in the patient's care.
Merriman says the system contributes to continuity of patient care by "getting the right information to the right people at the right time." The system can automatically generate information such as a medication list, assessments done, staff who have visited the patient, pain severity, and quality of life measures.
This software program was implemented completely in April 1998. Merriman says that at any given time, approximately 4600 patient records are active in the system, which includes some 100,000 records. The system relies on integrated, relational databases to report staffing and billing information, automating these administrative functions. When asked how the system is performing, Williams acknowledged that it still has some kinks. "One flaw is that when a nurse pool is used for staffing, sometimes patient data are not always captured. We're working on it."
Another problem occurs when the entire hospice team is monopolized with patients who are in the program only one to two days. Williams said to receive the full scope of hospice benefits, patients should be enrolled in the program for at least two months. The median length of stay for VITAS patients is 16 days.
"Hospice resources are used by rapidly dying patients. This tool gives us the opportunity to monitor the disciplines being used in a patient’s care, and how, at the team level, VITAS is responding to patients. Our expectation is that patients will get really good service and care in just a few days," Williams said.
"I am encouraged by the power of these data because they allow us to know what is going on in the field by assessing the amount of care a patient is receiving and the duration of patient visits. In 30 years of practice, nothing compares to this clinical management tool," Williams said.
VITAS has developed a system that makes it easy to look at patient care on simple charts which track patient status for different factors, such as pain and family involvement.
"We can look at acuity, admissions and deaths, geographic distribution of patient population, staff turnover rates, staffing ratios, length of patient visits, the diagnostic mix of the team, and continuity of care. For example, we can know whether a patient has been visited by one nurse the last 10 times or had three different nurses in the last 10 visits. This affects continuity of care."
"What it means to team managers is that they can look at the pain data in graphic form and consider visit activity on a 40-inch screen. This is patient-centered outcomes management. Patient visit data and feedback from team members lets VITAS know what works," Williams said.
Franklin Health has also developed a computerized system for tracking care. William Thar, M.D., Franklin’s medical director, says his company uses the Internet to update patient records during late disease management. Any member of the management team has access to patient data whenever a question arises.
Case managers use the software to track patient home visits, and hospital or nursing home stays. According to the company, only employees with the appropriate web browser and pass code can have access to patient information and only for those in their care.
Franklin has worked with versions of this program for the last five years. "By year’s end, the network will provide Franklin’s 60 case managers with on-line access at home. What Franklin is doing is documenting communications with our patients and providing a resource for families," Thar said.
"We are looking at the pain and anxiety levels of our patients. We bring together data and organize it descriptively. This allows us to improve quality of care and finances," he said.
Hospice care, a federal entitlement, since 1983, is estimated to serve nearly half a million patients. Many researchers believe better information systems and tools that measuring outcomes and evaluate care are essential to systems of care that work, and systems such as those developed by Franklin and VITAS may eventually aid in measuring outcomes.
Donna Horton frequently writes about public health issues and managed care.