Technology

By Nancy Torner

Many of the mobile devices available to help nurses improve patient safety and streamline workflow have existed in one form or another for several years or more. A surge in the use of these devices is a more recent development tied in part to wider acceptance and installation of wireless capability, the move toward electronic medical records and the prevalence of medicine bar-code labeling, according to consultants, suppliers and users of the technology.

“It’s the chicken and the egg thing. Why would you implement these solutions if you haven’t even implemented electronic medical records?” says Gregg Malkary, managing director of Spyglass-Consulting Group, a market intelligence firm and consultancy based in Menlo Park, Calif. “It’s a matter of priorities.”

Today’s devices offer person-to-person communication or bring data collection technology to the point-of-care—a few can do both. Communication devices lean heavily toward wireless voice over Internet protocol (VoIP). Some of these devices offer hands-free voice recognition, some are similar to traditional phones and some also handle medication administration and other applications.

Data devices include pocket and tablet PCs; laptops with docking stations, wall mounts or on wheels; personal digital assistants (PDA); bar-code scanners; and vital sign monitors. Hardwired devices exist, but most are wireless. Some include infrared and/or radio frequency identification (RFID) readers as well as cameras and communication capabilities, but the majority run on Windows-based software.

Whether information collected by these devices integrates with hospital information systems depends on software interfaces. Hospital software vendors write their applications around a mobility suite that allows them to mobilize their own applications at a nurses’ station. Consequently, not all devices or device features are necessarily compatible or usable with the back-end applications.

Devices are moving away from their thick client role, where all programs are loaded directly onto the device, and becoming thin, where devices log onto a hospital’s wireless system and access programs via a Web browser, says David Brooks, president of BCC Consulting based in Durham, N.C. “Four years ago I would have said anything that wasn’t built on a thick client was really not a good solution, but there’s been improvement both on the hardware side and in the infrastructure.”

Initially, computers on wheels (COWs) were popular, with the intent of bringing real-time documentation to the bedside. In reality, carts generally are abandoned in hallways because they are big and bulky, Malkary says. Other mobile solutions each have pros and cons, ranging from being awkward to handle, to screens that are too small to read, he says.

One device garnering attention lately isn’t mobile at all—it is a wall-mounted PC in patient rooms or in strategic locations in hallways that nurses can rotate, move up and down and fold out of the way. 

A panacea?

No single device is a silver bullet, says Jeff Schou, senior director of Global Healthcare Solutions, Industry Solutions Group of Motorola Inc. “There is always a mix of devices on the floor. It really depends on what you are trying to do. Ask what the business problem is that you’re trying to solve. Then, look at what technology solves that problem best.” Different devices offer different form factors, different sizes and ergonomics and different bar-code technologies. The best way to assess the differences is to hold a demo fair for nurses to pick what fits their particular workflow best, he says.

The top software application rolling out globally is medication administration, prompted by mandatory bar-code labeling on medicine down to the lowest level of packaging. About 700 hospitals use this application, he says. “Even if you are the best hospital on the planet and you have a 1 percent error rate, if you’re doing 2 million administrations per year you’re still making thousands of medication administration errors,” Schou says. The average dispensing error rate is between 6 percent and 7 percent.

Even with technology-enhanced medication administration, corners are being cut, Malkary says. It is possible to remove bar-code labels or print extra labels, enabling nurses to enter these bar codes into records later rather than in real time. “Nurses won’t admit that, but it’s going on across the country, which totally defeats the element of patient safety in the application,” he says. “You could easily mix up the bar codes, which could result in a medication error or somebody dying.”

Simplifying bedside data collection is an important part of the safety process.  Cristina De Martini, global practice leader of health care for Zebra Technologies, Vernon Hills, Ill., says a study by the College of American Pathologists found that specimen labeling errors account for 55.5 percent of all identification errors.

Zebra’s handheld mobile bar-code printers are designed to combat specimen identification errors. By generating bar-code labels for blood and other samples at the time they are collected, the possibility of labeling errors is eliminated.

Elsewhere, Motorola’s MC70 handheld enterprise digital assistant can document who gave what medication to whom and when, and charges are logged only when medication is dispensed, which streamlines inventory control. It also supports tasks such as transfusion verification and documentation of specimen collection and vitals and has a wide range of additional features.

It is larger than commercial-grade devices but considerably more rugged and sealed for easy disinfecting, Schou says. “As we go out into the future, from a size perspective, I’m not sure how much smaller we’re going to be able to get because you need a certain amount of screen real estate,” he says.

It’s a dichotomy, says Cheryl Parker, R.N., senior clinical informatics specialist for Motion Computing. Nurses want large screens, but they want devices to fit in their pockets. They want lots of battery life, but they want lightweight devices. “It’s like it is too big, but it’s too small. That’s where we stand right now and in the foreseeable future,” she says.

Motion Computing, headquartered in Austin, Texas, markets the C5 Mobile Clinical Assistant, a three-pound tablet PC with a handle for easy transport, an integrated bar-code scanner and an RFID reader, although nurses currently make limited use of RFID technology. “I see that as a future asset, including patient tracking,” she says. The C5 enables users to directly document and to look up information. It also has an integrated camera, although only a few main systems can integrate pictures into patient records.

“We have device capability that cannot be exploited yet,” she says. This is likely to remain the norm for mobile devices in general, at least for the foreseeable future, “because coming up with a new hardware device, while not easy and not cheap, is an easier, cheaper project than changing all the vendor software,” Parker says.

Alegent Health’s Lakeside Hospital in Omaha, Neb., trialed and now uses the tablets extensively. While some are dissatisfied with the ergonomics, nurses overwhelmingly prefer the tablets to pushing COWs down hallways and into patient rooms to scan bar codes each time they dispense medication, says Katy Baldwin, R.N., clinical informatics specialist for the mobility project.

Placing docking stations with a keyboard and mouse in every room has enhanced the tablet’s functionality and helped eliminate COWs from most departments, aside from a few kept as emergency backups, which has saved money. The base price for a cart is about $5,000 plus $150 for a battery. The cost per tablet is approximately $2,500, plus $300 for a docking station and about $140 for a replacement battery. Tablets, unlike carts, also work well in isolation rooms because they are sealed and easy to disinfect.

“The biggest obstacle I find with this is nurses like to be able to get off their feet for a few minutes,” she said. Inputting data at nurses’ stations gave nurses a chance to sit and work privately away from patients. Seating has been made available for nurses in other, more public areas, but nurses prefer the stations. “We’ve done a good job of implementing the technology. Where I think we could do better is teaching our staff to use the technology when they’re interacting with a patient instead of viewing them as separate activities.”

Various other solutions have been tested at other Alegent hospitals. Results show that the varied workflows and responsibilities of nurses require multiple solutions. “You’re never going to please everybody; I don’t care what you do,” Baldwin says. “It’s critical that you get the bedside nurse—not the manager, not the chief nurse executive—somebody who’s actually rendering care in that unit to make the decisions.”

One to one

Person-to-person communication is another area of growth. El Camino Hospital in Mountain View, Calif., was one of the first hospitals to replace its overhead paging system with an instant communications badge from Vocera Communications. The badge was endorsed in April by Solutions Inc., a subsidiary of the American Hospital Association.

“It really has improved efficiency between caregivers,” eliminating the need to physically search for a nurse, says Cheryl Reinking, R.N., executive director of patient care services at the hospital. It also has decreased the amount of overhead paging, “so it’s a quieter environment.”

The badge is about 1-inch wide and 3-inches tall and is worn around the neck. To call anyone on the internal communications network, nurses simply need to say the person’s name. If that person is not logged in, the call bumps to voicemail. A badge costs about $375. “Some people see it like the Big Brother.” Reinking says. “Every single call that’s made is kept on a server. So, you can really track calls,” she says. Confidentiality is another concern of some. “It is a speaker. Everybody around you can hear what’s being said.” But nurses can place badges on “do not disturb” and retrieve messages at a more appropriate time in a more appropriate place. It also is possible to page certain groups of people at the same time. Consequently, nurses are able to respond to patients more efficiently and quietly.

The hospital also evaluated different types of handheld computer equipment and found that staff preferred COWs. “It gets down to visualization and the font,” she said. Like hospital’s everywhere, El Camino has an aging workforce that prefers larger screens. “We want to keep those nurses working.”  

Nancy Torner is a feelance writer based in Rosevill, Minn.

This article first appeared in the July 2008 issue of Materials Management in Health Care.

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