Feature | April 17, 2007| Shirley Gusta, RN,BSN

Mobile Computing: A Nursing Informatics Perspective

How point-of-care documentation technology became a reality at Genesis Health System.

ICU and ED were among the top priority departments to receive mobile devices at Genesis. Photo courtesy of Genesis Health System

Genesis Health System has been dedicated to providing compassionate and quality health services from its inception over 12 years ago. Living up to that mission has required a commitment to information technology.
For the past three years, that commitment to information technology and how the technology improves patient care has resulted in three 100 Most Wired awards for the health system. In 2006, the Genesis hospital campus in DeWitt, IA, was recognized as one of the 25 Most Wired small and rural hospitals in the nation.
“Information technology is supporting Genesis Health System's evolution toward a complete electronic medical record and seamless flow of information that connects us internally and externally,'' said Robert Frieden, vice president of Information Services and CIO.
Core to the success of these endeavors have been solutions that allow our clinical providers to have access to the right information at the right time and in the right manner. To achieve this objective, point-of-care technology has been one of our key areas of strategic focus.
The introduction of point-of-care technology at Genesis began with our mobile computing with laptop devices utilized by our visiting nurses in the field. The systems and technology used for these clinicians required the devices to be docked for the download and upload of patient demographic and clinical information. Key requirements for these initial deployments centered on device size, weight, durability, dependability and ease of use.
While the experiences have remained relatively positive, some of the factors that presented challenges centered around device weight and portability. The nursing staff definitely struggled to carry all the needed supplies and equipment into each client's home, so the additional weight of a laptop further complicated their efforts. While device damage did occasionally occur, it was minimized through the use of laptop carrying cases that provided extra protection during the transporting process.
Within the hospital setting, the mobile devices were first deployed in the obstetrics, intensive care and emergency departments in two of our hospital facilities. The devices utilized were Winterms and computers on carts that also provided connectivity to fetal and physiological monitors at the patient's bedside. These initial deployments were not wireless, but nonetheless provided flexibility for the providers to document at the point of care and also efficiently acquire patient specific data from the monitors into the electronic clinical documentation. These devices and specialty clinical information systems remain operational today in the OB and ICU areas.
While plans are underway to transition from these stand-alone solutions and toward our Cerner HNAM integrated clinical information system and data repository, the technology has remained very reliable, equipment very durable and overall, the solutions have effectively supported documentation at the bedside.
Full Bedside Strategy
For our more comprehensive deployment of point-of-care technology at the patient's bedside, the fundamental concepts were very similar. However, we added wireless connectivity, access to multiple applications and device mobility to the mix of requirements. We considered several options, including devices permanently mounted within the patient's rooms.
We engaged nursing in the overall device evaluation and additionally, the engineering department was involved in the discussions regarding specifically where the devices could be mounted. It was determined that bedside device mounting was not feasible. This was primarily due to space limitations and the clinicians' desire to never have their back toward the patients as they interacted with the computers.
Initially we deployed several device options in the acute settings, including wireless computers on wheels (COWs), wall-mounted cabinets with thin- client devices that were positioned outside the patient rooms, wireless laptop devices and stationary PCs located within the nursing station and physician work areas. We planned the mobile device allocations for both the nursing and ancillary departments based on the maximum number of staff that would be working at any given time.
With the availability of the laptop solutions, the nursing managers and staff quickly shared their dissatisfaction with the COWs. The space requirements, due to the cart size, presented problems both within the patient's rooms and the storage areas. We have now reduced the number of COWs on most units and they are now primarily used during the patient admission process. The positive attribute of the COWs has been the minimal damage as compared to our other mobile solutions.
Reality Sets In
We anticipated the wall-mounted thin-client device would be heavily used and a major staff satisfier, but quickly learned this was not the case. The quick log-in to the system was a plus for these devices; however, they were just not convenient enough for the charting process and the nursing staff desired a place to sit while they worked. As with the COWs, we have experienced minimal damage with these devices. These devices do remain in all of the patient care areas and are primarily used by ancillary staff, nursing students and occasionally physicians.
The laptop deployment has been our most positive solution, but that has not been without issues. Following the successful use of models that our VNA staff used, the hospital nursing representatives agreed to move forward with the same style and model of devices. These mini-laptops were approximately 7-by-10 inches and weighed around three pounds. The plus to this model was truly the ease of portability and touchscreen functionality.
We did very quickly find that damage to the devices was going to be a challenge, since they are carried without the protection of the laptop cases that were used in the VNA setting. Because of their small nature, they were often picked up by the screens (resulting in cracked screens) or dropped (cracking the casing and damaging the vital components). While we still have a mix of preference to the smaller model, the screen size was also a frustration for the nursing staff — especially those with bifocals. We also deployed a larger model laptop, approximately 10-by-14 inches, with, again, mixed reviews. The larger screen was a plus, however equipment damage continued to be problematic.
Battery life has also been a source of issue and device dissatisfaction. Initially the battery charge lasted four to six hours, but, with continued 24-hour utilization, the charge decreased dramatically. Our experience has been that the batteries should be replaced every nine to 12 months. Additionally, each patient care area will need to plan for the space to house the charging components if special battery docking stations are required.
Getting Tough
Today, we are now deploying Panasonic Toughbook devices and have finally achieved a more sustainable solution. The models we are using now have a handle, a tethered stylus and a larger screen. The clinical users are much more satisfied with all aspects of these devices and the damage to the devices has dramatically been reduced. While the feedback has been very positive, we are attempting to resolve a few minor issues, including easing the process for touchscreen calibration and how to better support left-handed users (the stylus is permanently tethered on the right side). To avoid some of the battery-related issues, the clinical users are now connecting the devices to the power cord adapters while working within the nursing stations. Our vendor representatives have been positive to work with and we look forward to our continued efforts to refine the overall process and tools.
What Have we Learned?
Durability is an absolute requirement. When the devices are out of commission, obviously this leads to users’ frustration and dissatisfaction, and the benefits for real-time, current patient information are then reduced. Other considerations include:
• Spares — you will never have too many. We initially provided for a designated number per hospital campus, but we never had enough available. Our new metric for spare allocations is one spare for every 10 devices per unit.
• Device Counts — plan for the maximum, plus. Our metric for mobile devices allocations based on the maximum number of staff that would be in working per shift for the most part supported the general documentation needs. However, do not forget about the higher number of staff during shift changes. If you are planning to move toward paperless shift reporting, be sure you have a process defined that will accommodate the extra staff needs.
• Wireless Connectivity — plan bandwidth and infrastructure to support all of the wireless needs. In addition to mobile computers, we also deployed Vocera hands-free communication devices. This technology has been very well received and widely utilized within our clinical areas and has also had a very positive impact on the care delivery process.
The access point placements, bandwidth requirements and roaming functionality need to be very carefully planned and coordinated. Dropped signals and devices that compete for access point connectivity have added to frustrations of the users during critical functional operations. If Radio Frequency Identification (RFID) is also planned for your organization, careful coordination will be required if you are intending to use the same wireless environment for both technologies. Adequate access point installations and bandwidth allocations will be key to your success.
What is Next on our Horizon?
Finding the perfect mobile device for the physicians will be essential for their use of the electronic medical record. Our emergency room physicians today are using mobile and stationary devices for their documentation and order entry processes. We have tried several models with both positive and negative feedback. Device size and connectivity remain critical to the success of use for devices within these fast paced, critical clinical areas.
As we plan for the future and devices that all physicians will use within our facilities, we need to ensure the devices support their varied processes and practices. We envision that the physicians will round through each facility with one device, logging into the health system network once (upon arrival) and utilizing smooth roaming features if they move between devices or physical locations. With these devices and at the point of care, they will have access to the critical functional mass of clinically relevant information, including PACS images, historical clinical records and all current clinical details.
We are also presently testing device options that will allow bar code scanning at the point of care. Because we do feel that the most efficient solutions will be devices that support multiple functions, we are trialing wireless Bluetooth bar code readers that will work in conjunction with our current laptop solutions. We are early into our testing phases, but hopeful that we can effectively extend the use of this technology without having to introduce different devices that solely support the bar coding functions.
To support our commitment to our patients, physicians and employees, Genesis Health System continues to strive for service excellence through use of advanced technology that enables an efficient and effective clinical care process. Our investment in technology has also been an investment in patient care, which has earned Genesis national recognition for three consecutive years.

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