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Point of Care Part I: The Evolution Of Mobile Hardware
Health Data Management Magazine, April 1, 2008
A growing number of health care organizations are making new choices of mobile hardware after getting some experience with point-of-care computing under their belts.
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In 2004, its physicians balked at using the Tablet PCs Alegent Health purchased from Motion Computing Inc., Austin, Texas, because they believed the hardware didn’t have a large enough screen to effectively run computerized physician order entry. And in 2006, its nurses complained that the two brands of mobile carts the delivery system implemented for bedside documentation and medication administration were too heavy and bulky to push, says Michael Westcott, M.D., chief medical information officer.
“We worked with the vendors to make changes and incorporate new designs to improve maneuverability, but we still had issues,” he says. “It got to the point where our nurses were complaining of back and neck problems from pushing the carts and asked if there was something else we could offer them.”
After two disappointing deployments, Alegent Health executives decided to try a new form factor. In April 2007, the med-surg unit of the delivery system’s Lakeside Hospital became a pilot site for the new C5 Mobile Clinical Assistant from Motion Computing. The device, which resembles a tablet but is equipped with a handle, was originally designed by Intel Corp., and released by Motion in February 2007.
While the pilot only lasted a few weeks, it resulted in a 62% increase in nurse satisfaction with the hardware and related clinical workflow changes. Further, the delivery system recorded a 42% improvement in point-of-care documentation when nurses were using the C5 devices, Westcott says.
“When we compiled the results of the pilot, it was amazing,” he says. “Nurses really liked the handle. Now physicians are asking me when they can have the device with a handle that they’ve seen the nurses use.”
Alegent Health has deployed 18 C5 devices in the same department that piloted them. And it plans to buy more of the new hardware to implement in other departments later this year, Westcott says.
Phase Two
Now that many health care organizations have experience with point-of-care computing, they are finding they need different functionalities or different form factors than they originally selected, says Erica Drazen, partner for emerging practices in the global health services group of Computer Sciences Corp., El Segundo, Calif.
“Point-of-care mobile hardware is still a work in progress,” she says. “That’s not surprising though because a lot of hospitals still haven’t enabled access to data at the point of care. But for those that have, there are always mobile hardware issues they didn’t anticipate once they got into it.”
For example, clinicians sometimes don’t realize what they need from a point-of-care device until after they’ve been using one for a while. So just a few months into a deployment, they might complain that the hardware they chose is too heavy or doesn’t have a large enough screen.
Health care organizations also might not realize they don’t have the infrastructure to support the devices they’ve selected until after implementation. In some such cases, a hospital’s original mobile hardware doesn’t get used as intended because there are not enough places to store and recharge the devices or a stable enough wireless network for them to work effectively, Drazen says.
Further, industry practices have changed since some health care organizations began their foray into point-of-care computing. For example, the amount of data that can be used at the point of care has dramatically increased, while some hospitals’ mobile hardware was selected to support only a single, small data application.
“There’s still no one single device for point-of-care computing,” Drazen says. “It’s experimental and even very individual within a hospital or title of caregiver. As a result, everyone offers multiple types of devices for different tasks.”
While Alegent Health plans to deploy more C5 devices, the delivery system currently offers a mix of mobile devices for point-of-care computing. Most nurses still use the original mobile carts to access the documentation and medication administration applications, from Siemens Medical Solutions, Malvern, Pa., at the point of care.
Others, however, are using the Motion Computing Tablet PCs that were originally intended for physicians. The delivery system equipped the devices with a scanner and set up docking stations for them in clinical areas so nurses could get accustomed to a new form factor before the C5 pilot, says Westcott, the CMIO.
Alegent Health worked with the vendor before the pilot to determine what features and functionalities the delivery system now needed from a mobile computing device.
“Nurses thought the mobile carts would work best for them before we implemented the documentation system,” he says. “But when we added medication administration, we were trying to have them do something they weren’t designed to do.”
The pre-pilot analysis found that nurses not only wanted to use a smaller device at the point of care, but also one that offered an integrated scanner so they wouldn’t have to deal with cables and cords as they did with the carts and Tablet PCs.
While the size issue was inherently eliminated with the smaller form factor of the C5, there were other features of the new device that the nurses found appealing during the pilot. For example, instead of scanning bar codes on patient wristbands and medications during administration, nurses can use the C5 to take a photograph of the bar codes to facilitate verification. This feature enables nurses to loosely hold the C5 over the bar code rather than awkwardly turn the patient’s arm or the device to get a direct line of site that’s usually required for scanning, Westcott says.
Also, Alegent Health worked with Siemens to enhance the documentation software to work with the C5 to offer nurses more areas within the application where they can use the device’s pen functionality.
“There are certain things that you can’t just use point and click for like we had to do with the old hardware,” says Deborah Storlie, clinical informatics specialist.
As Alegent Health gets more experience with the C5, it wants to experiment with other features embedded in the device. For example, it hopes to find applications for its integrated biometric security or radio frequency identification technology, says Westcott, the CMIO. Or it may use the camera function to take pictures of patient wounds to measure how they are healing, he adds.
“As we get more experience under our belt with the device and our other departments begin deploying it, we’ll get some more ideas on how we can use it effectively in clinical care.”
Many health care organizations jumpstart their second-generation mobile hardware purchases to appease nurses’ requests for a different type of device. But others try to placate clinicians by continuing to maintain an original form factor for them even after offering a new one.
Mobile Highway Not One Way
San Diego Hospice & Pallative Care, for one, is offering its home care nurses, social workers and spiritual counselors the choice of using conventional notebook computers or new Lifebook convertible Tablet PCs from Fujitsu Computer Systems Corp., Sunnyvale, Calif., which can be used as tablets or notebooks.
“We would lose folks if we said they had to do things one way,” says Marc Hahn, I.T. director. “So we introduce ideas to them and later on find out if they are using them.”
The provider organization, which also runs a 24-bed hospital, originally deployed notebook PCs from the vendor in 2003 to offer mobile a ccess to home care software from Misys Healthcare Systems, Raleigh, N.C. Back then, its executives determined that using the Tablet PC form factor was a bit premature. So they chose the notebooks after considering the price and durability of three different devices the vendor recommended, Hahn says.
While San Diego Hospice & Pallative Care staff were satisfied with the devices, in 2005, the vendor inquired whether they would want to swap them out for some Tablet PCs it was developing. Hahn wanted to try the new form factor, but also polled caregivers to gauge their interest.
“Part of the feedback we got was that they would want something that would enable more pen functionality,” he says. “They didn’t want to keep switching back from the touchscreen stylus on the notebook PCs and the keyboard. They also said they would be interested in a device with a larger screen.”
The organization piloted the devices for about three months with a group of 20 caregivers to ensure they could integrate them into their workflow. But after full implementation began, some staff members were a little intimidated by all the new functionality of the Tablet PCs.
So to help appease all staff, San Diego Hospice & Pallative Care continued training some of them to use the devices’ tablet features while allowing the more apprehensive staff members to continue using the original notebook PCs or use the new convertible devices as notebooks, Hahn says.
“Our organization made the decision to not push the tablet features on our staff,” he says. “But if they want to learn, we will teach them and let them use the hardware that way.”
So far, San Diego Hospice & Pallative Care has purchased 223 of the convertible devices but hasn’t yet introduced them to all staff members.
Despite an early mixed reception, the provider wants to continue offering the Tablet PC functionality because it hopes to use the devices for other applications, such as to enable patients to sign care authorizations, Hahn says.
This also could help reduce paper across the organization, he adds.
But caregivers still like having the option of using the devices as either a notebook or Tablet PC. When San Diego Hospice & Pallative Care asked staff members if they wanted to try an updated version of the vendor’s notebook PCs, their overwhelming answer was that they wanted to stay with the convertible hardware, Hahn says.
“That’s when we knew the tablet route was where we were going for now,” he adds.
Multiple Pilots
One way health care organizations can avoid problems with clinician acceptance of mobile hardware mid-deployment is to pilot multiple devices, says Drazen, the consultant. They also should purchase point-of-care hardware as late as possible to ensure they are getting the most up-to-date technology on the market, she adds.
“The good news is that mobile devices have a certain lifecycle, so organizations can easily experiment with them,” Drazen says. “It’s a moving field.”
Before deploying its first generation mobile hardware, Boston Children’s Hospital held a device fair where it enabled clinicians to test various types of mobile carts. But it still ended up switching hardware midstream—and offering clinicians a second form factor as an alternative.
After the device fair two years ago, the provider organization began piloting mobile carts from InfoLogix Inc., Hatboro, Pa., for nurses to use to access a clinical charting system from Cerner Corp., Kansas City, Mo., at the point of care. Clinicians chose the hardware because it had the smallest wheel base of any of the other mobile carts they viewed, says Gary Smith, supervisor of desktop services. The feature was important because they thought it would enable better maneuverability, he adds.
But shortly after implementing the mobile carts, Boston Children’s Hospital began having some usability issues with them. For example, their battery life wasn’t as l ng as experienced during the pilot. And because they were configured with a PC monitor, the carts were top-heavy and nurses said they were worried they would fall over during rounding.
“Because we were so new at this, we picked one we thought everyone would want,” Smith says. “We knew we had to come up with another solution. Soon after we went through it, we ended up modifying the cart.”
Boston Children’s Hospital worked with the vendor to configure a new mobile cart with a 17-inch screen laptop rather than a PC monitor so it would be considerably less top-heavy.
Though the provider has deployed about 550 of the second-generation mobile carts, it also enables nurses to do their charting on Tablet PCs from Hewlett-Packard Co., Palo Alto, Calif. It offers the two form factors because of the difference in preferences among its nurses in various departments, Smith says.
For example, its pre-op department nurses prefer to use the Tablet PCs to handwrite notes in their surgical system, also from Cerner. And others like the enhanced mobility they get with the smaller form factor.
Different Needs
But some clinicians, however, prefer the mobile carts because the computers mounted on them have a larger screen than the Tablet PCs."
We will purchase more Tablet PCs, but the majority of charting is done on the mobile carts,” Smith says. “It’s not always going to work with one device. So you have to offer multiple types.”
Although its clinicians seem to be content with the two point-of-care form factors, Boston Children’s Hospital, however, isn’t finished experimenting with mobile hardware.
This spring, the organization plans to implement a medication administration system from Cerner. Smith wants to pilot the next generation of mobile carts from InfoLogix with the system to see if the new devices would support the application better than the hardware the hospital currently uses.
“Our second-generation mobile cart has worked well,” he says. “But we can still probably have the vendor modify any of its carts to fit what we need. That kind of service is huge when you need new things from your mobile hardware.”
This story is the first in an in-depth, three-part series Health Data Management will publish this year about point-of-care technologies. We’ll also be running three other series of feature-length articles on revenue cycle, EHRs/EMRs/PHRs and CIO issues. These series represent our effort to provide insightful, concise and timely information to our readers on the technologies and business issues that shape their strategic initiatives. -Greg Gillespie, Publisher"
Multiple devices offer better data access
I.T. staff at St. John’s Hospital in Springfield, Ill., never had an issue with enabling physicians to use multiple mobile devices to access data from its hospital information system, from SoftMed, Silver Spring, Md. Supporting a variety of hardware, they anticipated, would enable physicians to use their own PDAs and smart phones for the new point-of-care initiative.
But before they began evaluating mobile hardware that physicians could use to access the system through the Clinical Xpert Navigator application from Stamford, Conn.-based Thomson Healthcare, they wanted to ensure they also could use it to access clinical data at a nearby hospital at which many St. John’s physicians also worked, says Lori Carroll, physician informatics specialist.
“We wanted to purchase a device that was compatible with systems at both hospitals but also had a large enough hard drive to store drug database software and other clinical reference applications,” she says.
I.T. staff didn’t consider Tablet PCs for the initiative because they believed they were too expensive, and physicians really didn’t need the pen functionality of the devices, says Amy Nell, also a physician informatics specialist. But when they asked physicians what features they wanted from a PDA they would use for point-of-care computing, their answers varied. Some wanted a device that was lightweight, but others preferred one with a larger screen, she adds.
In October 2006, after reviewing a multitude of compatibility issues and physician desires, St. John’s purchased the 2495B model of PDA from Hewlett-Packard Co. and embedded the devices with the Thomson Healthcare software. The PDA features a 3.5-inch screen and has 256K MB memory.
Secure And Destroy
Now physicians can use the HP device or other approved PDAs to access rounding data, inpatient lists, lab data, EKG results, medication data and other information at the point of care. I.T. staff secures the information on all the devices by using functions within the Thomson Healthcare software that encrypts data on the mobile hardware and destroys it if it isn’t synched with the hospital’s HIS within 10 days, Carroll says.
The hospital enables attending and resident physicians to sign a one-year contract to use one of the HP PDAs. No payment is required unless they break or lose the device. Physicians can use the PDA outside the hospital and even load other personal information on it. I.T. staff takes care of the maintenance and updates to the devices, Carroll says.
Despite the deal, some physicians chose to use their own devices to access clinical data at the point of care. But they often come back for a rental when they discover they don’t have enough memory left on their own devices to run software required to access information from both hospitals and the reference applications, she adds.
“We purchased the devices because we didn’t want physicians to purchase one that wouldn’t work at both hospitals. There’s only a limited amount that will,” she says. “But sometimes physicians want the latest and greatest hardware, so they can still purchase their own device and we will try to work with it.”
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