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For other articles and previous issues click here. April 8, 2002 BEDSIDE
MATTERS: NEW APPLICATIONS FOR WIRELESS PDAs In response to this problem and as a means to increase efficiency and maximize the potential of medical personnel, healthcare providers have begun exploring and developing new applications for wireless technologies, including handheld personal digital assistants (PDAs). Once merely a high-tech replacement for the ubiquitous Filofax, PDAs have become an integral part of our increasingly wireless culture, allowing users to download information from the Internet, read e-mail, and store reference material. Recent innovations have also brought handheld technology to the forefront of medical error solutions, as new drug administration applications are implemented in hospitals across the country. “Several issues are converging on the healthcare industry right now,” says Jeff Schou, director of World Wide Healthcare Markets for Symbol Technologies, Inc., in Holtsville, N.Y. Among these are the IOM report, the Health Information Portability and Accountability Act (HIPAA), and a continuing and critical shortage of nurses, which, he explains, is projected to grow significantly over the next six years. “Many hospitals are feeling like they have three different guns aimed at them,” Schou adds. “They are scrambling to figure out how to reduce errors and be HIPAA compliant, while enabling their existing clinical staff to be more productive.” These concerns led hospitals and other medical providers to adopt technologies that other markets adopted years ago, Schou says. For example, implementing mobile and wireless technologies allows clinical staff to be more productive at the bedside, instead of handwriting notes and entering them into a computer system later in a shift. “Wireless PDAs eliminate that middle work,” Schou explains. “They can also reduce errors because clinical staff don’t need to decipher their handwriting at a later time.” Using PDAs also allows clinicians to make information immediately available to medical staff throughout the hospital. “A doctor doing telemedicine can access the most recent set of biosigns,” Schou adds, “and radiology staff can access up-to-date information as they need it.” In many ways, wireless PDAs may present a near-perfect solution to issues and concerns facing physicians, nurses, and other hospital staff, but they also have limitations that have many physicians continuing to reach for pen and paper, according to Jerrold Young, MD, chief of general surgery and cochairman of the Physician Net Access Team at Baptist Health Systems, in Miami, Fla. Of the 1,400 physicians on staff at the hospital, he estimates that nearly 70% use PDAs in their daily routine, but only approximately 10% to 20% use them with true electronic connectivity. “The use of PDAs depends not only on the doctors’ expertise with Graffiti [the system of letters and numbers used to write on a PDA] and inputting information, but also on how comfortable they are with technology and on that technology’s efficiency,” he notes. An important factor in determining how a PDA can benefit a physician is analyzing what the physician does on a daily basis, focusing on areas where he may be able to work more efficiently, Young says. Dermatologists, primary care physicians, and pediatricians may do most of their work in their offices, compared to surgeons who work mostly in hospital settings, he explains. “As a surgeon, if I’m in the hospital every single day, working from my office three or four half-days a week, the questions would be ‘What kinds of communications might I need to use the PDA for?’” he says. “You also have to consider how many patients a doctor sees each day. There are many ways a PDA can be helpful, but first you have to determine how to make it efficient.” One problem, Young believes, may be the time-consuming nature of most PDA applications, making them impractical for those who have a busy schedule. While he uses his PDA as a personal calendar and address book, he often finds it easier to pick up a paper-based schedule from his office and jot notes on it throughout the day, rather than take the time to manually enter information into his PDA. “It is much easier for doctors to function in real time and be finished with a particular task,” explains Young. “When I am writing a prescription, it takes me 10 or 15 seconds to write it out by hand, and when I give it to the patient, I know it’s done.” While the technology and applications necessary to write electronic prescriptions are available, Young explains that use of these systems is still limited. “Electronic prescribing is a technology that we will continue to see more of,” he predicts. “Currently, though, many doctors are finding that approximately 5% to 10% of electronic prescriptions don’t go through to pharmacies for various reasons, which creates more work.” At the end of a workday, he explains, the last thing a physician wants to do is find out that two or three prescriptions were not received, forcing him or her to go back and pull patient records. Other issues of concern to physicians include the current difficulty of syncing PDA applications with systems in use at the various locations where they work and the limited memory capacity of the device when storing the data from hospital or office. Although university- and hospital-based physicians typically employ technology that is provided by the facility, community-based physicians function independently and need to interact with multiple hospitals, laboratories, and pharmacies. Many physicians are also anticipating the day when they are able to efficiently integrate charge-capture information into their daily schedules on PDAs; however, the programs that allow for this are few, and the links to the office system are expensive, Young explains. “In the end, no matter how amazing a technology is, what is vital is how it helps me with my day-to-day work flow.” Ultimately, the implementation of wireless technologies in hospital settings provides the opportunity to improve work flow efficiencies and to potentially eliminate a significant amount of paperwork, according to Tova Manett, director of communications for the AUTROS System, Baxter Corporation, in Toronto, Ontario. “Patient information can be entered in real time at the bedside,” she explains, “so at the end of their rounds, nurses and physicians no longer have to do the amount of paperwork that has been required of them.” The AUTROS System, recently acquired by Baxter, is a wireless point-of-care medication management system designed to prevent medical errors. “We found that real-time connectivity among various departments in a hospital can help prevent medication errors, beginning with transcribing the actual ordering and moving through dispensing and administering,” she explains. According to the IOM report, medication errors can be broken down into several categories, including ordering (which accounts for 55% of medication errors), administering (35%), dispensing (5%), and transcribing (5%). Wireless solutions need to be designed to address each of those areas where potential for errors exists, according to Manett. “The elements must be in place to ensure that the right patient is given the right dose of the right medication at the right time via the right route,” she explains. “These five ‘rights’ of patient safety cover all of the key aspects of medication errors.” Historically, when nurses approached patients’ bedsides, they were not certain of having the most up-to-date orders and instructions, Manett says. A handheld device is valuable, then, because it communicates in real time with electronic patient records and the hospital pharmacy to provide nurses with critical and accurate up-to-the-minute information. By scanning bar codes on patients’ wristbands and medication packaging with a scanner built into the PDA, nurses can ensure that medication is being administered to the correct patient. The system also provides information about potential allergic reactions or drug interactions and alerts nurses if medication is being given too soon or too late, Manett explains. Additionally, a significant percentage of drug orders are changed or modified in a hospital’s pharmacy system throughout the day; by alerting nurses that, for example, a dose was discontinued, PDAs will allow nurses to make the appropriate corrections before starting a new dose. When the technology was first introduced, there was some concern that using wireless PDAs at patient bedsides would result in increased work for nurses with the potential for decreased efficiency. However, as the systems are implemented in more hospitals across the nation, feedback has been positive. “Hospitals are extremely busy and short-staffed, and medication errors are a fact,” Manett says. “This technology can improve caregivers’ work flow and gives them peace of mind in knowing additional security measures have been provided for their patients.” Wireless PDAs and medication management applications are tools that allow caregivers to provide improved patient care while freeing them to spend more time with patients, she says, “which, opposed to administrative work, is what they really want to do in the first place.” Patient safety and error prevention have stimulated the development of another application for wireless technology in hospital settings known as computerized physician order entry (CPOE). It is an integral component of a complete electronic medical records system. At Baptist Health Systems, a team of physicians, information technologists, and administrators is currently exploring methods of meeting HIPAA privacy requirements “to make sure we are in compliance, while giving doctors access to the records they need,” Young explains. The team is also trying to determine how best to apply wireless technology when various methods of communication are used inside or outside the hospital. As an example, he describes a scenario in which a doctor is eating in a restaurant and receives a call from a nurse at the hospital. “At that point, the physician could give error-prone verbal orders,” he continues, “but someday soon, he or she might be able to use a wireless PDA to receive the nurses request with some information on the patient, such as allergies, and forward orders electronically.” Manett agrees that widespread implementation of CPOE systems could have a positive impact on patient care and the prevention of medication errors. “It’s the hottest topic in the industry right now,” she says. “Also, hospitals with this type of system in place often feel they have an advantage as far as attracting highly qualified professionals.” In fact, in a recent job posting, a hospital in the process of implementing the AUTROS CPOE system mentioned the fact that the hospital uses cutting-edge technology to attract applicants, she recalls. Over the next decade, Schou believes an increasing number of applications for wireless technology will be developed, including controlling infusion pumps and real-time location systems using wireless tags that allow staff to quickly find a pump or respirator. “For many hospitals, locating equipment is a big problem,” he explains. He also predicts improvement in existing applications, including methods of positive patient identification and the management of materials, where wireless applications will assist in replenishing and restocking supplies as they are used. Administrators considering the cost of implementing wireless PDA technology will need to account for equipment—the PDAs themselves—as well as software applications, Manett advises. “We generally conduct a comprehensive site assessment to determine the wireless requirements for a facility,” she explains. The number of handhelds needed for nurses, physicians, and other caregivers are determined based on the size and needs of the hospital. In many cases, hospitals are already incorporating some form of wireless technology, she adds, and already have preexisting access points. “Overall,” she continues, “the price of wireless technology and applications is low in comparison with the benefits it provides.” Among these benefits, Manett adds, is the potential for improved patient outcome and reduced length of stays because of fewer complications due to preventable medical errors. Because an automated system provides the opportunity for reduced paperwork, work flow efficiency may also improve. “Scheduling and charting are also automated, and management reports are automatically provided,” she remarks. By reducing the need for physicians and nurses to decipher their handwritten notes at the end of a shift, wireless technology could have a positive impact on preventable medical errors, Schou agrees. It also addresses the needs of hospitals seeking to improve workflow by eliminating time-consuming duplicate entries—first on paper and later on a computer. Additionally, in hospital settings where the pharmacy controls all of a patient’s medications, electronic prescribing could also impact the occurrence of medical errors, he adds. “An electronic prescribing system allows the pharmacy to monitor drug-food, drug-drug, and drug-disease interactions, and also checks to ensure that dosing is correct,” he explains. Electronic prescribing systems can be more difficult to use in an outpatient setting, he notes, since clinical and pharmaceutical staff in various locations may not utilize the same system. With so much information available electronically via wireless PDAs and tablets, many managers may be concerned about patient privacy issues in light of impending HIPAA deadlines. “HIPAA has everyone concerned about making sure that wireless installs are secure,” Schou says, “but there are many ways to deploy technology to ensure security.” Many companies, for example, have developed sync-line solutions to ensure that no data are ever stored on a wireless mobile device. “The data are, in effect, only painting the screen,” he explains. “Because no data are ever posted locally, it is easier to control who is accessing those data.” “Unlike the PDAs many people use as address books, in this case they function as browsers, connected to a server that is installed somewhere in the hospital,” adds Jim Martucci, director of engineering, Strategic Technology, for the infusion systems business of Baxter Healthcare Corp., in Round Lake, Ill. “That way, if a PDA goes missing, there is no private patient information stored on it.” In fact, there have not been any reported problems regarding theft of equipment, Manett adds. Although less than 10% of hospitals have gone completely wireless, approximately one-half currently use some form of wireless technology, according to Schou. “Many have gone selectively wireless, from admitting a patient wirelessly in the emergency department to providing a handheld wireless application for their cardiology or radiology department,” he explains. “New applications are gaining acceptance, however,” he adds, “because of their ability to reduce medical errors by bringing information systems from behind the nurses’ station to the patient’s bedside.” — Hannah Fiske is a staff writer at For the Record. |
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