Hot Technologies: Bridging the Voice Communication Gap-Without a Wire

Adherence President and CEO Alan Letzt, with his wife Stephanie, founded the company in the early 1990s. Around that time the couple had been dealing with their own major roles as caregivers for debilitated family members. “We had to perform every ADL for one family member at home, essentially doing everything that a nursing assistant is responsible for in a nursing home,” explains Letzt. “A second family member was actually admitted into a long-term care facility, and we had to check to ensure she was being cared for properly. Those two seminal experiences changed our viewpoint on life. We learned what the 22 million caregivers around the country already know-that being a caregiver is a time-consuming and emotionally draining experience, but also that it requires lots of information and communication with healthcare professionals. That process, especially if the situation is changing fairly frequently, is very demanding and difficult.

“We also discovered that there were deficiencies in the long-term care being provided,” Letzt continues. “Our conclusion was that the combination of high turnover and a lack of sufficient communication, documentation, and education tools for the nursing assistants and supervising nurses were the main obstacles to providing the desired high-quality care.”

Armed with this new perspective, Letzt and the Adherence team began to develop the technology that is now known as AccuNurse in 1999. “The idea was to have a technology that could essentially be a mentor to the CNA,” explains Letzt. “We wanted it to be designed so CNAs could document and communicate at the point of care or wherever they were on the unit, without having to run around and find a nurse, without having to go back to the nurses’ station to look at charts, without having to ask 15 people different questions-they could get the information they needed immediately.”

The first step in implementing the AccuNurse system is entering the CNA’s care plan information into the system, primarily by pointing and clicking through various menus, such as different days of the week for bathing, or whether a resident has glasses or a hearing aid, with the data ending up on a computer at the nurses’ station. (The facility doesn’t have to buy a special computer for the nurse-they can use their current computers on their own network.) Each care plan takes about 15 minutes to enter. The AccuNurse software then converts the information into voice messages, spoken by a natural-sounding human voice, not a robotic one.

When the CNAs and nurses want to access the stored information about the care plan, they simply ask questions and AccuNurse provides accurate answers. For example, CNAs can ask which residents are assigned to them, or what tasks remain to be completed for specific residents. Not only does it tell them at the beginning of a shift what to do, AccuNurse serves as an automated checklist to ensure that all tasks are completed.

One of the key design elements of AccuNurse is that the CNA and the nurse don’t have to memorize special commands. The CNA can document by speaking in simple terms like, “Bathing done.” When the CNA says that an ADL is completed, AccuNurse will then prompt him or her with several specific questions so detailed charting can be done by voice. For example, if the CNA reports “Toileting done,” AccuNurse would then ask, “What was the level of assistance?”

“We provide a small cue card with the key verbal prompts when training staff,” says Letzt. “We are finding that after about a week or two, they throw the card away because the words are easy and intuitive.”

After the ADLs are documented by voice, they are automatically converted into text by AccuNurse and placed into a database on the AccuNurse Web site. This is done in real time so that if a nurse pulls up a report, it reflects what is going on at that time during the shift. AccuNurse reports include information on each individual resident, each unit as a whole, and what Letzt calls “exception” reports. “AccuNurse will report to the CNA what tasks remain to be completed during the shift,” says Letzt. “Likewise, on the nurses’ station computer, the charge nurse can see what work is left for each CNA by resident. Consequently, if the nurse sees that one of the CNAs is falling behind, he or she can talk to the CNA or adjust assignments so the work flows better.”

Letzt also points out that the system has other important staffing implications beyond making work easier: “The traditional nursing home has this mystical period known as change of shift. With AccuNurse, the charge nurse for the outgoing shift records the end-of-shift report by speaking into his or her headset. When that next shift comes on, rather than meeting in a room for half an hour or longer, all staff can put on their headsets and start their rounds immediately, listening to the end of shift report as they walk down the corridor. If a staff member forgets something in the report, he or she can replay it with ease rather than relying on memory or trying to find someone else who remembers the information.”

With AccuNurse, CNAs do not actually use a computer, and no extensive training is necessary. “It is really a hands-free system-and as you know, CNAs never can have enough hands,” says Letzt. Because CNAs are in constant communication with the nurses’ station through their headset, they can call for help with an incident without leaving the resident’s side.

AccuNurse also helps with some staffing issues that many in the long-term care industry don’t consider-or perhaps don’t like to admit. “For CNAs with low literacy, AccuNurse is perfect because it is a totally speech-based system,” Letzt points out. “The other thing you don’t hear about is how much information the average CNA is expected to know. When you print out the typical CNA care plan on the day shift, you find that the average CNA has to commit about 40 pages of information to memory. That’s a huge amount of information for anybody if the residents’ conditions were static. However, since care plans change frequently, keeping up with the changes poses an additional challenge to quality care. AccuNurse relieves the CNA’s memory burden and also keeps a record of those care plan changes.”

Another important point, says Letzt, is that AccuNurse handles accents well. The basic rule of thumb is that if you speak to a nurse or CNA in person and can understand them, then AccuNurse can understand them, too. “If you can’t understand what they are saying in person, that isn’t a technology problem, that’s a communication problem that needs to be addressed by any community,” says Letzt.

As with any new technology, there will be skeptics. “In the beginning, some people were concerned that AccuNurse would reduce communication among staff. Our experience is just the opposite-AccuNurse actually improves the quality of staff communication. For example, with AccuNurse, the DON starts the day with a quick overview of the unit at the AccuNurse Web site. She then approaches the charge nurse with specific information and questions instead of asking, ‘Hey, how are things going?’ Now she can ask, ‘What is being done to fix this situation?'”

The next updated version of AccuNurse, to be rolled out in the fourth quarter of 2005, will feature another new wrinkle: automated communication between AccuNurse and family members based on information selected by the nursing home staff.

Time will tell whether AccuNurse-or other programs and systems like it-will catch on in a big way. For his part, Letzt sums up AccuNurse’s appeal this way: “AccuNurse is ‘transformational technology,’ which means it empowers all staff and it encourages important and fundamental process and behavioral changes that enable nurses and CNAs to complete their jobs more accurately and efficiently with less stress. Most important, the residents are the winners.”

Who wouldn’t want to have that in their facility?