Home Healthcare, Hospice, and Information Technology Innovations Conference

Innovations in Home Healthcare, Hospice, and Information Technology

A forum towards achieving evidence-based diffusion and implementation of innovations

Fri, Nov 3, 2017

Friday, Nov 3, 2017, Washington - D.C.

H3IT: Home Healthcare, Hospice, and Information Technology Conference Nashville, TN, 2015

Mobile Application Development in Real Time

Shradha Aiyer, Lead, Mobile Application Development Team – Axxess

he original Axxess company, Axxess Healthcare Consult, began in 2007, as a technology advisor/consultant for

Home Health Agencies in Dallas, TX. The consulting company conducted performance reviews, enabled agen-

cies to operate utilizing seamless pro cesses, advised agencies during their formation, during their compliance

surveys, and, served as an education/training provider as an accreditor for the American Nurses Credentialing

Center (a division of the American Nurses Association), and as such, conducted training events for educational purposes.

Home Health continues to be a business that requires immense learning challenges for its operators from a clinical quality,

operational process and general regulatory standpoint. Axxess throughout its history has sought to address that diﬃcult

challenge with training and education tailored to the needs of home health professionals. In 2009, Axxess, through an in

depth industry analysis, determined that a state-of-the-art Electronic Medical Record system, delivered from “the cloud”,

was unavailable in the home health (Medicare Certiﬁed Home Health) marketplace. Axxess Technology Solutions was formed

to launch the software segment of the business, as a Software-as-a-Service, subscription-based business model, and after a

year-and-a-half long development cycle, began its EMR solution, with a 4/15/2011 “go live” date. The Agencycore platform

was built was built with Scalability, Redundancy, and Availability in mind using the Microsoft Visual Studio development

environment, and operates in the .NET (Active Server Page/Java Script) environment. Scalability, Extensibility, Redun-

dancy, and Availability are characteristics of the .NET development environment, as well as Sustainability into the future.

The .NET Framework is a technology that supports building and running the “next generation” of applications and XML

Web services. The .NET Framework is designed to fulﬁll the following objectives: To provide a consistent object-oriented

programming environment whether object code is stored and executed locally, executed lo cally but Internet-distributed, or

executed remotely. To provide a code-execution environment that minimizes software deployment and versioning conﬂicts.

To provide a code-execution environment that promotes safe execution of code, including code created by an unknown or

semi- trusted third party. To provide a code-execution environment that eliminates the performance problems of scripted

or interpreted environments. To make the developer experience consistent across widely varying types of applications, such

as Windows-based applications and Web-based applications. To build all communication on industry standards to ensure

that code based on the .NET Framework can integrate with any other code. As our Agencycore platform began growing in

number of users and features and functionality, it became obvious that a functional, integrated Mobile Application feature

was necessary in order to facilitate the visiting clinician’s ability to document all aspects of the patient’s condition at the

Point Of Care. Shortly after “go live”, in early 2012, our mobile applications team began its work.

Methods: The Software Engineering team at Axxess evolved their software development process over the years since 2010.

As the team grew so did our processes. Being a SaaS environment, we push enhancements and ﬁxes rapidly, at least bi weekly.

We have always followed the Agile – Scrum process for our development. This ensures rapid delivery to our customers. While

other EMRs update their software platforms once every few months or quarterly, we push out new features at-least once a

week. Initially, our software deployment process was a tedious and manual process. Now, using a continuous delivery process,

we have automated our deployment process, which helps us with shipping more software features. Collaboration was key to

our organic growth within the engineering team. We have reﬁned our development process to enable seamless collaboration.

As we expanded our product suite, we embraced team collaboration tools and moved away from physical scrum boards. Bug

tracking, issue tracking, and project management tools are being employed to manage our work backlog. Although our team

is divided into diﬀerent product teams, everyone follows the same agile principles. This is at the core of our success as a

software team.

Results: Our Axxess Mobile solutions currently focus on point of care. Anything a clinician needs to document at the

patient’s home, they will be able to using our Apps. Access to the software via Smart Phones and Tablets has enabled our

clinicians to work more eﬃciently and spend more time on patient care, not paperwork. Axxess mobile app continues to

be the ﬁrst (and only) native mobile app that works on both platforms (iOS and Android) in home health. The Axxess

Mobile App is unique in that it provides Electronic Visit Veriﬁcation (EVV) - an accountability feature that uses GPS and

automatic time stamps to track location and time of visit to the patient’s home. This tool allows organizations to do cument

proof of their organization’s compliance and eliminate potential fraud charges by recording the date, time, and location

while focusing on patient care. A clinician can collaborate with care-givers within their agency by sending HIPAA-complaint

messages via the App. They can review patient information, and contact their patients ahead of their visits. They are

able to navigate to the patient’s home and plan their day better. While at the patient’s home our clinicians have access

to the patient’s medication proﬁle, Allergy proﬁle, Pharmacies and Physicians associated with their patient. They can also

reach out to emergency contacts and other caregivers actively treating their patient. Clinicians ﬁnd that adding orders and

H3IT: Home Healthcare, Hospice, and Information Technology Conference Nashville, TN, 2015

communications to the patient proﬁle can be done in a jiﬀy with talk-to-text enabled data ﬁelds. In rural areas, Clinicians

need to visit rural areas, our mobile apps let our users access information oﬄine. To remain HIPAA-compliant and keep data

secure, we use encryption techniques to secure mobile data even before it’s uploaded to the server, ensuring that information

is secure at every point. The code within our apps, itself, is obfuscate, that is, it only communicates with approved Axxess

services (unlike other commercial apps that share data).

Discussion: There are many challenges facing engineers in our mobile app development team, including ongoing mainte-

nance, on a week-to- week, and day-to-day basis. The world of enterprise apps can get extremely complicated with all the data

thrown at the users. Being an Agile team, we continuously deliver useful features hence ensuring customer satisfaction. User

Focused: People and interactions are emphasized rather than process and tools. Customers, developers and testers constantly

interact with each other. User Friendly: Our approach to technology is all about making it user-friendly, helping home health

provider clinicians (nurses, therapists and aids, who are not always comfortable with technology) seamlessly and painlessly

employ technology to work smarter and more eﬃciently. Customer enhanced: To achieve this, we in engineering and other

experts from the industry the sit down with real customers to understand ﬁrsthand what works, what can be improved and

what is the next opportunity for innovation that raises the bar. Real Time Updates: From a business perspective, being

Agile is extremely beneﬁcial. Late changes in requirements are welcomed which ensures the best possible outcome. Working

software is delivered frequently. Being Agile helps both Engineering and Business Development, as internal client focused

partners, be more collaborative, tackling challenges in the ever-changing world of healthcare regulations. When you are agile,

there is continuous attention to technical excellence and good design. We constantly monitor availability and usability of

our software. Every room in Engineering has a screen with our current request ratios, server and database load. Within the

mobile team we use Google, Apple and Fabric – analytics to monitor accessibility as well as our user device demographics.

This helps better cater to our user’s needs while monitoring industry trends within the mobile device space. As the mobile

team develops features to work in unison with our web-based platforms, Agile can prove to be challenging at times. Mobile

is always focused on rapid deliverables where as our web- based application requires maintainability updates as well as large

features. When it comes to large deliverables it becomes diﬃcult to assess eﬀort required, in the beginning. This in turn

can aﬀect the timeline across platforms as they all pass through the same testing environment. Inter-dependencies of deliv-

erables create challenging road blocks for our product managers. In Agile, designing and documentation happens as you go.

This can cause misunderstandings b etween business requirements and implementation. Product Managers need have a clear

understanding of our business as well as understand what technical eﬀort is required to build features. At Axxess, we have

addressed this potential issue of communication by employing Health-Care industry experts as Product Managers. They

work closely with the project team leads to create meaningful sprints for business and engineering. People play an extremely

important part in Agile development, within Axxess we have noticed a productivity decline when we move resources from

one part of our development team to another. This is mainly due to each product being so unique. For example – Billing

and Payroll for Home Healthcare(Medicare Certiﬁed/Clinical) vs. Private Pay. To help reduce these knowledge gaps we have

Role-play sessions once a month, where members of the engineering team act and use our software as real customers would.

Conclusion: The development of native Mobile Apps for both Android and iOS systems is a challenging characteristic

that has not been achieved by any other software company in the Home Health space. Most of our competitor software

companies utilize a third party app development contractor to manage their app development tasks, if they have attempted

to develop an app. This is problematic for them since outsourced developers rarely have an in-depth understanding of the

industry. Our regular updates require our mobile app developers to remain fully utilized. Not only do we have to pay close

attention to features and functionality for our client agencies, we must research our relative compliance with the evolving

standards for Electronic Visit Veriﬁcation across each of the United States. Our in- house counsel is researching the statutory

requirements the states we serve (45 states so far). The key issue is whether the state has recognized GPS as an acceptable

method for Visit Veriﬁcation rather than twenty-year-old- plus CTI telephony integration technology. Looking forward, we

realize the Home health industry is slightly behind the currently available technology but we also see the immense potential

for innovation. With the advent of Wearable and Bluetooth enabled measurement devices for a patient’s vital signs, as well

as various patient movement related apps, Remote Patient Monitoring will become more achievable and cost-eﬀective, from

within the app. Mobile devices bring with them an array of features such as sensors, touch interaction, location awareness.

Many of our future enhancements will take advantage of these features. We want to continue to harness this technology to

provide innovative solutions for patients and Clinical and Functional practitioners in the industry.