Bedside Manner and Hardware Choices
Health Data Management Magazine, April 1, 2009
This is Part 1 of a three-part series on hardware issues. Part 2, on infrastructure, will appear in the August issue.
When Guthrie Clinic prepared to implement electronic records, it took an informal survey of some patients to help determine what kind of hardware doctors and nurses should use to access the system.
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Most patients said it was more important for them to look at the computer screen with their doctor than to maintain eye contact with the physician, which came as a surprise, says Joseph Scopelliti, M.D., president and CEO.
So the Sayre, Pa.-based group of 25 clinics in two states experimented with various placements for computers within exam rooms at a few pilot sites. "Doctors had been quite anxious about patients feeling disconnected," Scopelliti says. "But we got the opposite response. Patients saw the computer as improving their care."
Guthrie ultimately rolled out thin clients from Hewlett-Packard Co., Palo Alto, Calif., in all 1,000 of its exam rooms, carefully positioning them so that the patient can see the computer screen while the doctor is using the device.
Across the country, clinics and hospitals are considering "bedside manner" issues when equipping their clinicians with hardware to access clinical information systems. And, depending on their circumstances, they're coming to very different conclusions about what kind of device yields the best results in terms of clinician/patient communication. For mobile workers, including nurses who serve the terminally ill in a hospice program, a tablet computer may be the best bet. But at many hospitals, nurses and doctors want to select from several options, including tablets, computers on mobile carts and fixed workstations.
Making a Choice
Guthrie considered and rejected placing PCs in every exam room due to lack of space and concerns about cost, Scopelliti says. Although tablets would have been more convenient for physicians, they would have been far less convenient for patients who want to view the screen, he contends.
Guthrie's 235 physicians now use the thin clients to call up templates and create detailed records in an application from Epic Systems Corp., Verona, Wis. The physicians no longer use dictation, opting instead to grab pre-defined phrases from templates and occasionally type notes, the CEO says.
Now that the hardware and software is rolled out at every site, Guthrie Clinic will hire a training company to provide extra coaching to doctors on maintaining a good relationship with patients while using an electronic record.
Kevin Carr, M.D., associate chief medical officer at BearingPoint Inc., a McLean, Va.-based consulting firm, advised Guthrie on the selection and placement of computers at its clinics. He got a first-hand lesson in the importance of hardware selection in his previous role as assistant clinical professor at Yale University.
"At Yale, we spent a lot of time training residents to really focus on the physician-patient relationship," Carr says. In the paper-chart era, that meant setting the chart to the side, looking the patient in the eye and listening to them talk, he notes.
When a primary care residency clinic phased in tablet computers, the residents struggled, spending too much time staring at the devices and not enough time interacting with their patients, the former teacher recalls. So the clinic changed its procedures, having a nurse interview the patient to gather medical histories. "We had to teach the attendings to teach the residents to put the computer aside" when talking with the patient, Carr recalls.
Inpatient Challenges
The consultant laments that at many hospitals, "People tend to grab blueprints and put them out on a table and start deciding where to put the devices based on the layout." A better approach, he says is to "spend time on the floors and watch the natural migration patterns of nurses and doctors."
At 247-bed Cookeville (Tenn.) Regional Medical Center, a study of workflow led to offering nurses and other clinicians a choice of computers on carts, PCs at workstations and tablets.
"We took a hard look at how we wanted to provide nurses and doctors with the opportunity to document while making it user-friendly," says Amanda Burgess, R.N., clinical informatics manager. The goal was to enable clinicians to document treatment in patient rooms, out in the hall or at the nurse's station, depending on their preference, she adds.
Many nurses use carts from Rubbermaid Medical Solutions, Huntersville, N.C., equipped with laptops from Dell Inc., Round Rock, Texas. In addition to a large monitor, the carts contain medication drawers. Therapists, dieticians, patient care assistants and even some nurses use tablet devices from Motion Computing, Austin, Texas. That's because, in many cases, nurses use a cart throughout their shifts, making it unavailable to others, Burgess says.
At first, many nurses kept their carts in the hallway for fear they might get in the way of communication with patients, she says. But most nurses quickly shifted to taking their cart into patients' rooms to document at the point of care.
Many nurses rejected the tablet computer option because they perceived that the screen size was inadequate for viewing complex information in the hospital's clinical information system, from McKesson Corp., San Francisco, Burgess adds. She acknowledges, however, that the hospital's strategy will change as technology evolves.
Starting from scratch, Adventist Bolingbrook (Ill.) Medical Center reached a similar conclusion about offering clinicians multiple hardware options. The hospital, which opened in January 2008, uses a mix of laptops, tablets, PCs and computers on carts. For example, some nurses and doctors prefer to document care at the patient's bedside, while others prefer to complete records at an office or workstation, says Kathy Mitchell, vice president and chief nursing officer.
Last year, Island Hospital in Anacortes, Wash., added tablet computers from Motion Computing to its mix.
"We discussed mounting computers on a wall in patient's rooms, but no matter where you put it, at some point you have your back to the patient," says Holly Hoskinson, R.N., clinical informatics specialist at Island Hospital.
Instead, nurses now have the option of using computers on carts or the tablet devices, she says.
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