Electronic supportive documentation: welcome to the future; touch screens feeding information-hungry computers--Star Trek technology comes to the nursing home. (Feature Article).

Sally touches a picture of a bed on a wall-mounted touch-screen device to record Mr. Smith's bed mobility. Then she touches a picture of a helping hand labeled Independent to record the resident's self-performance.

Sally, a nursing assistant at Hennis Care Centre in Dover, Ohio, doesn't think of herself as a computer user, but with the help of a new electronic documentation system, she quickly and easily enters assessment information into one of several wall-mounted touch-screen computers located throughout the building.

Meanwhile, back at the MDS office, Robin Miller, RN, can retrieve this information, including mood/behavior, restorative, intake/output, bowel/bladder, skin assessments, pain, activities, and all other forms of supportive documentation on her computer. Miller remembers when she had to sift through paper documentation forms to gather this information, and recalls her uneasiness when it was obvious that each shift had copied its entries from the prior shift's reports.

Anita Peffer, director of resident services, analyzes an acuity report generated from this same electronic supportive documentation; allowing her to make staffing assignments based on the residents' level of acuity as of the last shift. While she is reviewing this, an alert is displayed showing two residents who haven't had enough fluid in the last 24 hours and one who hasn't had a bowel movement within a prescribed time frame.

Traditionally, paper forms are used by nursing assistants to record ADLs, mood/behavior, restorative, intake/output, weights, bowel/bladder, activities, pain, vitals, and much more data. Because paper forms allow staff members to see prior assessments, staff members tend to copy from shift to shift, making each resident's condition appear to be exactly the same for every shift of the observation period. These inaccuracies are then carried on to the MDS, the care plans, and determination of staffing patterns, which can have a major impact on revenue, quality of care, and staffing.

Paper forms are difficult for care planners to read, and they make it difficult to compile information in various ways. Many facilities also struggle with compliance issues because of the many problems created by a paper system. Electronic documentation systems are designed to address these problems. While licensed staff might use such systems, nursing assistants are the intended primary users, since they have the firsthand knowledge from frequency-based observations.

The touch-screen devices are mounted on the walls, usually one per wing/unit, and connected to the facility's computer network, where the information is stored in a large database. Management can retrieve information as needed from any computer workstation on the network. This includes supporting documentation for MDS completion, care-related information for care planning, acuity levels for staff assignments, alerts, and more.

Nursing assistants record information throughout their shift instead of charting at the end of the shift, when things tend to be forgotten. Because these supportive documentation systems are primarily for the nursing assistants, they must be easily taught to people with a wide variety of education and comprehension levels. Indeed, these systems must require almost no training, much as is the case with an ATM. This means that the program must use an intuitive approach, including visual associations, to reduce comprehension errors, as well as sophisticated programming to guide the caregiver through the process.

With this system, caregivers are encouraged to record observations multiple times per shift, if applicable. "Most paper forms don't allow this, which is a big cause for concern when it comes to accurate reimbursement," says Andrea Platt, a consultant with Thomas Healthcare and Consulting in Indianapolis. "The MDS is looking for three or more times that you assist a resident, not three or more shifts. So, if a resident was having a bad day and you had to provide variable amounts of assistance throughout the shift, it is important to record each occurrence," Platt continues. "This can mean a lot of money for a facility for assistance the staff is already providing but may not be recording."

"Accurate assessment information translates into accurate reimbursement," adds John Austin, administrator at Briarwood Care Center in Coldwater, Ohio. "This technology has helped our case-mix index increase substantially." Moreover, Dock Terrace, a 72-bed facility in Lansdale, Pennsylvania, reports a 78% increase in ADL scores since it started using this technology.

In addition to enhanced reimbursement, MDS coordinators find these systems helpful because the information recorded is much more accurate than that found on paper forms. Carla Tuisl, MDS coordinator at The Alverno, a 135-bed facility in Clinton, Iowa, says, "We have a much higher level of confidence in the information coming from the floors, especially for the afternoon and night shifts."

"Using paper documentation, the MDS might remain open for several days while we track that person down," adds Tom Durst, director of quality assurance at Echo Manor, Pickerington, Ohio. "This technology knocks days off of the process because the information is there instantly and we can count on it." Also, since these systems automatically cue caregivers for assessments during the observation window, MDS coordinators don't need to place assessment sheets on the floors to correspond with the residents' observation windows.

Directors of nursing are seeing the benefits, as well. Not only is the information more accurate, but it can be retrieved easily and presented in ways that help measure outcomes, show trends, and identify problems. Electronic supportive documentation systems can immediately warn care planners and floor supervisors of problems such as residents who are experiencing low meal and fluid intake, constipation, fails, and other incidents. "With paper forms we really didn't get a good picture ofthe resident's needs. Now we have a much better picture of the resident," says Ellen Corbin, director of nursing at Locust Grove Care Center in Mifflin, Pennsylvania. "If your assessment documentation is inaccurate or missing, your care planning is affected, and you might not have a good handle on what the resident needs."

In a multifacility environment, these systems allow corporate and regional clinicians to see trends, quality-assurance alerts, and acuity information through the Internet (or corporate intranet). Proactive measures can be taken while this information is still "hot."

Finally, many facilities have noticed improvements in staff morale with the use of such systems. Peffer of Hennis Care Centre explains, "It allows the nursing assistants to feel more involved in the care-planning process and in having the correct staffing levels."

These systems can include the use of portable personal data assistant (PDA) devices, which adds portability to the process. With the current state of the art, however, some facilities have expressed concerns about these devices being too small, too easily dropped, misplaced, or stolen.

Electronic supportive documentation may soon include shift-to-shift communications, voice input, and on-demand ADL/assessment training. In sum, electronic supportive documentation will likely become an increasingly important tool for facilities, as demands posed by quality measures, insurance rates, and regulations increase.

Larry Triplett is president of Resource Systems, New Concord, Ohio, developer of data collection systems for the Long-term care environment. For more information, phone [phone]. To comment an this article, e-mail [e-mail].