Mobile Computing at the Point of Care is Getting Wheels

They’re everywhere. Mobile computers are on the move in the ER and OR, atop carts as physicians make rounds, and in the hands of nurses logging vital signs at the bedside or dispensing meds. With the growing adoption of EMRs, mobile computing use among hospital-based clinicians has moved beyond standalone, knowledge-based applications such as drug reference databases and medical calculators to systems that can increase clinician productivity, reduce errors and eliminate inefficient processes.

The integration of wireless networks into hospital information systems, mobile workstations and handheld computers provides the basis for a pervasive computing environment offering information ubiquity—allowing all parties who need critical information to have it, regardless of location and with full security—plus bedside bar-code scanning for drug dosage verification, and direct data input into the EMR.

Mobile computers, in the form of laptops, personal digital assistants (PDAs), mobile carts, pen tablets and netbooks, are becoming the stethoscope of point-of-care clinical documentation and decision-making.

Can you hear me now?

Only now will do in clinical computing—real-time, fully secure data, 24/7. That means rock-solid support from a wireless infrastructure that maintains constant connectivity from one Wi-Fi zone to another as computers are moved about. “Highly reliable wireless high-speed connections were critical to enable the clinical areas,” says Michael Blum, MD, CMIO at University of California at San Francisco Medical Center (UCSF), a 600-plus-bed academic medical/research center that instituted computers on wheels (COWs) in 2005. “We validated all of these connections in advance, because you absolutely cannot have application ‘drops.’”

Besides tight integration among devices, policies and workflow processes must be established to achieve maximum efficiency of clinical care. “Having a balance with workflow is extremely important,” says Barry Cannon, RN, clinical applications manager at Children’s Hospital Central California (CHCC), a 300-bed facility in Madera, Calif. “Your hardware and software are only as good as the policy and workflow processes you put in place. You may have to make adjustments based on how often nurses need to have the device in their hands (e.g., much more frequently in critical care).”

In the healthcare environment, space concerns and the constant movement of clinical activities also present special challenges. At UCSF, the physical plant was relatively old, with small rooms, narrow hallways, and fairly limited space for fixed devices. Likewise, at CHCC, moving clinical documentation closer to the point of care required a mobile solution; squeezing fixed devices into patient rooms would have created fire code issues.

PinnacleHealth, a non-profit, community-based healthcare system in Harrisburg, Pa., dealt with similar issues, says Director of Clinical Informatics Cindy Brown. “Aside from the reality of physicians and nurses who are always on the go, we found that it was often too crowded in the nurses’ station for them to enter data on a fixed device. Clinicians need a place to document at any point, anytime, for the system to work effectively,” she says. “That’s why we put laptops on carts for the nurses, and are now beginning to introduce tablets for the physicians.”

COWs & tablets

At many facilities, it was patient safety concerns that drove the introduction of computers on wheels in the early 2000s. Small footprints allow easy maneuverability into patient rooms and around obstacles like beds and equipment stands. They enabled nurses to automate safety checks and procedures via bar-code technology at the bedside. Vital sign data also could be collected and entered, rather than written on the fly and taken back to the nursing station. In fact, many facilities have mandated nurse in-room documentation to guarantee accuracy. “Before we introduced a tablet computing solution, we saw transcription errors from nurses writing notes on scraps of paper, Post-Its, or even their scrubs and transferring them to the record later,” Blum says.

Early on, mobile workstations were relatively cumbersome, had short battery life, and required a lot of maintenance. Then came tablet computers tailored for the healthcare user. For example, at CHCC, bar-code scanning for medication administration flows into an EMR application from Meditech via Motion Computing’s wireless Mobile Clinical Assistant C5 tablet PCs with attached bar-code readers.

PinnacleHealth is currently expanding its use of mobile devices beyond its case managers, therapists and educators, adding pen tablets for a small group of physicians to complete progress notes online. “These doctors specifically requested the application so they could pull information into their documents from the EMR, reducing their need to copy or rewrite,” Brown says.

Research & training pay off

Testing and research are critical to selecting progressive mobile devices, experts agree. “At CHCC, we did a pilot to figure out workflow, and in 2007, we held a ‘device fair’ for users to examine and question different options. Ultimately, we determined we should provide one device per user, per shift, to avoid competition for access to the system,” says Cannon.

UCSF conducted a time-motion study as part of its initial deployment of the Motion Computing C5 tablet computing platform in 2007, gauging performance improvements over the previous environment of COWs and fixed PC workstations. The research showed less time was spent logging onto the computers and reentering data—giving nurses back approximately half an hour per shift; while latency of data entry into the EMR went from two hours to zero.

“Automating the data entry, instead of having it written down and later entered into the record, enhances the timeliness and accuracy of charting,” Blum notes. “We saw a 15 percent improvement in data documentation accuracy, as well as a 20 percent increase in point-of care-charting on top of vital signs data collection [e.g., patient pain assessment and fall risk scores]. The clinicians can now access more accurate data more quickly, leading to faster diagnoses and care.”

“Our new tablet application connects directly to the EMR for vital signs and other point-of-care documentation,” Blum adds. “It’s a hybrid solution in that you can dock it in a station, or take it out and carry it with you. But we still had to plan some logistics [such as] where the nurses could put it down and where power stations would be located for recharging.”

Making the devices readily available and conveniently located was, of course, only a first step. Users had to be trained to integrate mobile computing applications into their daily routine. Training methodology ranged from classes led by expert “superusers” to hands-on, one-on-one sessions with clinicians. CHCC even created a knowledge base on its intranet with FAQs and a help manual for users.

CCHC’s Cannon sees greater patient safety and better clinical documentation as mobile computing’s big wins. “People talk about time savings with the technology, but I see that as a secondary benefit; you have to take into account the upfront learning curve. It’s most important to focus on safety and more complete documentation. Now we can have a patient’s most current medical information available to everyone in real time. There’s no more asking, ‘Where is the chart?’”

For PinnacleHealth, mobile computing has provided a uniform way of instantly collecting and retrieving a patient’s vital information from anywhere in the facility. “In the wireless environment, everyone has immediate access to EMR information, and can input clinical information and vital signs, and document treatment. The clinicians have the ability to roam around and access the same patient session with a single sign-on and fast log-in,” Brown notes.

Conclusion

Mobile computing streamlines the flow of information from the point of care, reducing the burden of paperwork on clinicians, and promoting greater accuracy through the elimination of transcribed notes entered well after the actual patient encounter. Once a vital sign is measured, a medication is administered, or a test completed, a physician or clinician can view it immediately.

“The use of mobile devices enables us to deliver higher quality care by getting data into the record more quickly and then making it more available to the providers,” Blum says. “It’s one of the technologies that allows us to provide the safest, most effective care we can.”