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May 12, 2008

Point of No Return?
By Annie Macios
For The Record
Vol. 20 No. 10 P. 14

A pair of studies raises concerns about the viability of implementing mobile, point-of-care solutions.

As healthcare documentation becomes more automated and streamlined, technology enters into the equation across the continuum of care—including at the point of care. Mobile documentation at the point of care can do wonders for workflow and documentation; however, its implementation is not without challenges.

Two recent reports by the Spyglass Consulting Group—“Healthcare Without Bounds: Point of Care Computing for Nursing” and “Healthcare Without Bounds: Point of Care Computing for Physicians”—highlight the current state of mobile computing in hospitals and ambulatory care. They present the findings of an end-user market study focused on the adoption of point-of-care computing by physicians and nurses across the United States.

The reports uncover strong opinions gleaned from more than 200 in-depth interviews regarding the opportunities and challenges for adopting computing solutions at the point of care. It also identifies the market drivers, trends, opportunities, and challenges in using mobile computing devices.

According to the survey, clinicians believe the right point-of-care computing device depends on physical location, urgency of the situation, tasks to be performed, complexity of the required applications, and, most importantly, personal preferences. Gregg Malkary, founder and managing director for Spyglass Consulting Group, says there is really no ideal device for point-of-care computing thanks to these variables.

While viewed by physicians as an ideal device for communicating, managing personal and clinical workflows, and accessing stand-alone, reference-based tools, smartphones are used by fewer than 14% of the physicians interviewed to access single-function clinical applications for managing patient data, prescribing medications electronically, and capturing patient billing charges.

There is a big push for physicians to use smartphones and PDAs for accessing clinical applications, but the study shows that doctors are not using it in this way because screen size presents a problem. “If given a choice between a 2- X 2-inch screen or a full-size terminal, they’ll choose the full-size screen,” says Malkary. For that reason, he says smartphones/PDAs currently have limited clinical utility but great potential.

Tablet PC
Tablet PC use varies based on the environment. “For the hospital-based clinician, it is too heavy and its battery life is only two to three hours for what is often a 10- to 12-hour workday,” says Malkary. Tablet PC applications resemble DOS applications, and with wireless networks there are often dead zones because of poor handoffs within the hospital. According to the report, more than 90% of nurses are reluctant to use the tablet PC for bedside nursing.

In an ambulatory environment, however, tablet PCs are more prevalent and have more widespread adoption because there is limited geography. Malkary says the tablet PC is more convenient in this setting because there are usually no more than 30 steps between offices rather than the five or six miles that hospital-based clinicians may encounter during an average shift. Financials also come into play in ambulatory settings, where doctors are more financially motivated to use tablet PCs because they pay for them themselves, according to Malkary.

Mobile Clinical Carts
Patient safety concerns have driven 56% of the healthcare organizations represented in the Spyglass Consulting survey to implement departmental initiatives that include mobile computer carts. Ideally, these carts enable nurses to generate structured clinical documentation, automate safety checks and procedures through bar code technology, access information on demand, automate the collection of vital sign data, facilitate real-time communication among all care team members, and practice evidence-based nursing.

Mobile clinical carts, also known as computers on wheels (COWs), are the workhorse of hospital-based nursing. Unfortunately, while the cart is mobile, it is usually left in the hallway due to space limitations in hospital rooms. Another reason for COWs’ lack of use at the site of care is that it is not yet required by hospital administration. However, “That will change as medication administration moves to bar coding,” says Malkary.
According to the survey, rather than COWs, nurses prefer to use a fixed station for documentation. “If they can find a terminal every 10 yards, they will use those instead,” says Malkary. He also notes that nurses often do their documentation on paper first and then input the report afterward.

Wall-Mounted PCs
According to the survey, these devices are gradually replacing COWs as a more useful point-of-care computing tool. Ironically, COWs have helped establish wall-mounted PCs. “The good thing about the COWs is that they let you know where to put a fixed station,” says Malkary.

Putting Them Into Practice
While smartphones, tablet PCs, mobile clinical carts, and wall-mounted PCs offer opportunities for point-of-care computing, the pitfalls associated with these devices sometimes overshadow the benefits. Malkary says better communication can help overcome many barriers. “Facilities have to develop a better solution and get the clinicians involved in the process. IT makes recommendations on the technology, but they also need to understand the clinical workflow,” he says.

Malkary says getting clinicians involved in the decision making for such devices will improve the chances of implementing a user-accepted solution and, ultimately, improve workflow, patient care, and patient safety.

The physician survey suggests that widespread adoption of these devices depends on how practitioners perceive their use. When looking to increase the adoption of point-of-care computing technology, Malkary says the investment a facility is able to make, as well as the return on investment, are important factors to consider. “In looking at the investment perspective, you have to ensure the technology will deliver an automated hardware, software, infrastructure, and workflow solution,” he says. “If you only automate the current system that you have, that helps, but you have to automate across the board for the adoption to be more widespread. It all comes down to eliminating inefficient processes.”

Malkary says the point-of-care device selected at a particular facility depends on the investment an organization can make. With IT investments, facilities usually start with an electronic medical record (EMR) and a digital infrastructure. EMR deployment usually takes a significant amount of capital and includes many subsystems, leaving little left in the budget for items such as point-of-care computing technology. “But the requirements of doing documentation at the point of care need to be automated, and it takes a lot of deployments and experimentation to get to a point where it works most efficiently,” says Malkary. By coming up with standardized solutions that work facilitywide, the adoption of these devices can potentially increase, he adds.

Communication overload can interfere with practitioners’ ability to get the clinical information they want when they want it. “The devices offer a lot of support tools for doctors, but they [physicians] also get flooded with a lot of alerts and reminders to respond to. If physicians click off an alert in an effort to go straight to the clinical data, then they have added liability should some medical situation arise from that alert,” says Malkary.

Citing inefficient processes as a common difficulty of effectively employing mobile computing, Malkary finds that a facility’s technical infrastructure is often inadequate to support work from point-of-care devices. “Security is a big impediment, especially when a physician might need to know 10 or more user names and passwords because security is made so stringent. A doctor might have to log in 80 to 90 times a day, which is an unrealistic expectation,” he says.

Infection Risk
According to the survey, 65% of physicians say they fear infection if they use mobile computing devices at the point of care, a 160% increase from 2005.

“Point-of-care computing devices are a large vector of contamination, and hand washing is the key to reducing the risk of infection. It’s a real infection control risk, but it’s not always been seen as a risk,” says Malkary. He notes that perceptions are changing now that Medicare is no longer paying for medical mistakes such as infection caused within the hospital.

Success Stories
While the news from the Spyglass surveys is not encouraging, the deployment of mobile computing technology is working at some facilities. Medstar Health in the Baltimore/Washington, D.C., region and Camden-Clark Memorial Hospital in Parkersburg, W.Va., are examples of how point-of-care computing devices can be successfully deployed in healthcare facilities big and small.

MedStar Health, the largest healthcare system in its region, introduced mobile devices to its physicians in 1998 and has experienced success with the technology since then. Included on Hospitals & Health Networks’ list of the top 100 most wired hospitals for four consecutive years, MedStar is a nonprofit, integrated system that includes a community-based network of eight hospitals with more than 5,000 physicians.

Used at five of the system’s eight hospitals, PatientKeeper, which is deployed on Palm Treo smartphones, helps physicians collect and input charges at the point of care. As any healthcare administrator knows, being paid appropriately and in a timely manner is an integral part of keeping a healthcare facility running smoothly—a fact that physicians are also keenly aware of. “We are able to provide the hospitalist physicians with patient billing demographics through an interface, and it provides a much more efficient and effective way of capturing inpatient charges,” says Suzanne Carter, Medstar’s vice president of information systems customer service.

Staci Parks, the project leader for the PatientKeeper initiative, says physicians responded positively to the technology, which allows them to view and act on information. Its applications give physicians the power to access patients’ electronic records, write prescriptions, enter charges for services, document patient encounters, and send messages securely to other caregivers in a single, integrated environment available at the point of care.

The most noticeable benefit has been capturing a more effective charge cost, mitigating the problems associated with misplaced paperwork, and the lapse in time between the point of care and documentation. Benefits are also realized on the administrative side, where the practice management staff know instantly which patients the doctors have seen. “The entire process has been sped up,” says Parks, who adds that the initiative will expand to additional facilities within the system and into surgical specialty areas.

Camden-Clark Memorial Hospital, a 375-bed facility that is also listed among the top 100 most wired hospitals, as well as one of the top 25 most wireless facilities, adopted mobile computing carts approximately six years ago. Within the last 16 months, after a long discovery process and a one-month trial with multiple carts, Camden-Clark adopted Artromick mobile computing carts to replace more bulky, cumbersome equipment that wasn’t being used as much as it otherwise might be.

Nursing informatics analyst Kerry Cottrell works with the nursing staff on a daily basis and has seen firsthand the improved workflow and time savings the new mobile computing carts have offered the hospital. Among the benefits Cottrell reports are the ability to use the carts at the bedside, the additional area for charting that is decentralized from the nursing station, and the capability to provide readily accessible information in a timely manner.

“It improves efficiency by allowing one-time documentation at bedside rather than once at bedside then again at the nursing station. The nurses are using them pretty extensively—a lot more than ever before,” says Cottrell, adding that it saves time for nurses, who can quickly access information over the wireless network and no longer have to save their charting until a computer is available at the nursing station. The new mobile computing carts are so efficient, in fact, that the old ones are no longer at the facility, says Cottrell.

Besides being easy to use, Cottrell says the carts are ergonomically efficient and adjustable, easy to move and control, and have a better, more easily rechargeable battery life than those on previous carts, all adding to the overall acceptance and successful implementation of the technology.

— Annie Macios is a freelance writer based in Doylestown, Pa.