Point-of-Care Solutions in Health Care for Clinical Transformation
Many forces are aligned today at the health care enterprise that are forcing information
technology (IT) departments to aggressively reengineer care delivery. This reengineering
process has resulted in hospital IT vendors developing many new products that
take advantage of wireless local area network (WLAN) technology with handheld
mobile computers. These mobile devices, coupled with proliferating WLANs in hospitals,
are proving a potent mix. The term "mobile computing" has been a buzz-phrase in
health care for several years now, but the absence of useful applications —
save those that could be run on a laptop mounted to a cart — has traditionally
restricted growth. The ability to retrieve or input data at the point of care,
instead of at the nurses' station, is proving valuable on several fronts in this
clinical transformation.
In this paper, I'll examine the forces mentioned above and the solutions being implemented. I've purposely left computerized physician order entry out of my discussion, based on my belief that most people involved in health care are familiar with the concept. My preference is to discuss several applications for clinical staff other than physicians.
The Point (of Care)
The nursing shortage, along with increased attention to reducing medical mistakes, has dramatically increased the rate at which hospitals are adopting mobile computing technology to enhance productivity and improve patient outcomes. Traditionally, all of the hospital's information systems were only accessible at the nurses' station, which from a workflow perspective is neither where information is needed most nor where the actual data collection occurs. Mobile computing has forced a paradigm shift to retrieving and recording data at the point of activity — namely at the patient's bedside. The development of useful mobile applications that interface with existing network applications and offer returns on investment that would make any CFO smile, means your clinical staff may be using mobile, handheld computers sooner than you think.
As wireless LAN technology in the hospital has evolved, several significant advances have made going wireless easier. Costs have dropped and standards have emerged as the technology has matured. A wireless base station — the bridge between your wired network and your mobile devices (known in the industry as an access point) — can now be purchased for less than $1,000. The client-side devices, which "hang" off the wireless backbone, are coming down as well, and speeds are now up to 11Mbps.
Interoperability, which is the ability for one manufacturer's products to communicate with another's, has also made significant progress. Most providers of equipment (Cisco, Intel, Nortel, Symbol, and others) have standardized around the 802.11b wireless communications protocol. Security, an issue even before HIPAA, is handled by technologies such as Kyberos, VPNs, and LEAP, which provide encryption through the air and secure, multi-level log-ins on the client device.
Transforming Clinical Care
Whether you agreed with the conclusions of the December 1999 Institute of Medicine study, "To Err Is Human"1 or not, the resulting outgrowth has been countless television specials and magazine articles devoted to the number of people seriously injured or killed each year as a result of medical errors. The problem grabbed national headlines recently, as a teenage girl succumbed to complications from a mismatched organ transplant. A recent study published by the Archives of Internal Medicine in September 2002 noted,
"Medication errors were common (nearly one of every five doses in the typical hospital and skilled-nursing facility). The percentage of errors rated potentially harmful was 7 percent, or more than 40 per day in a typical 300 patient facility. The problem of defective medication administration systems, although varied, is widespread."
The federal government has begun acting to address this problem, in many cases by using IT-based solutions. On March 13, 2003, the Food and Drug Administration released a proposed rule requiring bar codes on medications down to the unit dose level.2
Early adopters have already utilized this solution. Using a mobile computer with an integrated bar code scanner at the patient's bedside, the clinical staff scans the patient's wristband, which has a bar code printed on it. The caregiver then scans their personal badge, and finally scans the unit dose medication. The mobile computer then communicates via radio to the hospital's IT system to ensure that the right patient is receiving the right medication at the right time, via the right route, and in the right dose. It also electronically documents who gave the medication and when it was given. These systems have been so successful in reducing errors that the American Society of Health-System Pharmacists (ASHP), among others, was instrumental in recommending to the FDA that it require that all medications contain bar codes. Health care IT companies that have deployed (or are about to deploy) this type of application include McKesson, Cardinal Health, Baxter, Bridge Medical, Cerner, Omnicell, and Mediware, to name a few.
The FDA has estimated that the proposed standardized bar code system for medications will reduce medication administration errors by 50 percent, which would amount to a financial savings of $3.9 billion. More importantly, it would reduce the number of incidents in which medicine is improperly dispensed by more than 413,000 over the next 20 years, clearly providing significantly better outcomes. A study in 1997 showed each adverse drug event costs approximately $4,685 for each affected patient.3 For a 300 bed hospital that means a staggering loss of more than $68 million per year. Even if we were to argue that these statistics were overstated by 1,000 percent, we're still left with $6.8 million, which, if reduced by 50 percent, still easily provides a return on investment that can be measured in months.
In conjunction with the FDA, Congress has been striving over the last few years to develop a system to provide for effective medical error reporting and reducing systems. The most current legislation is the Patient Safety and Quality Improvement Act (H.R.663).
Another critical issue facing the industry and helping to drive wireless technology to the point of care is the worldwide shortage of nurses. Facilities everywhere have no choice but to place increasing demands on their already overworked staff, while at the same time trying to figure out how to meet those demands with fewer and fewer people.
A hospital's nursing staff faces multiple challenges relating to communication. Most critical is their ability to respond quickly and efficiently to patient needs. The nursing shortage has only compounded the inefficiency of old nurse call systems, which involve a multi-step process that leads to frustrated staff, unhappy patients, and even medical errors.
Here, the clinical transformation includes enabling the nursing staff with wireless phones. New nurse call systems are now able to route patient calls directly to caregivers with wireless phones. When a patient initiates an alert, the caregiver assigned to that patient will receive a text message on their phone's LCD display showing the room and bed number, as well as the nature (priority) of the call. The caregiver is then able to press a single button on the handset to speak directly with the patient through the bedside nurse call intercom from wherever the caregiver might be, even from another area of the facility. Once connected and in contact with the patient, the caregiver may elect to:
- Illuminate "service reminder" lights for the patient. These correspond with red, amber, and green lights, allowing specific designations by staff.
- Illuminate the corridor lights and, at the same time, page the assigned caregiver's back-up person. The nurse call system provides the ability to assign a primary, alternate, and charge nurse to every patient bed.
- Speak with the patient, indicating how long it might be before it will be possible to visit the room.
- Access menu actions, which could include medication requests. This would save the caregiver time by not having to go to the room and speak to the patient, and then go get the medication and return to the room.
Benefits
There are many benefits including:
- Improved efficiencies by automatically and directly notifying care-giving team of patient requests.
- Improved patient satisfaction due to additional direct contact with care-giving team.
- Immediate notification of "code blue" calls to code team members.
- Improved efficiencies as a result of removing nurse call-answering responsibilities from unit secretary and support staff.
- Improved healing environment by reducing overhead paging noise currently generated to locate staff or make staff aware of necessary information.
- Ability to send text messages from the nurse master station to selected individuals or groups.
- Consolidation of wireless infrastructures. Hospitals can now use one wireless LAN for data applications and voice, simplifying the IS support requirements.
- Improved efficiencies and communication as these same phones are integrated to the PBX. This provides the capability for both internal and external phone calls.
The beauty of deploying such a voice-enabled system is that the exact same wireless network that a hospital uses to exchange data with clinicians can also be used for voice and patient monitoring. Voice-over-IP wireless phones allow mobile voice communications with anyone in the facility, using the same wireless infrastructure that supports handheld devices running data applications. Whether it's a nurse call system or a doctor calling down to the lab, the necessity of making calls from the nurses' station is alleviated. An ROI for this application looks like Figure 1.
Figure 1: Voice-over-IP wireless phones allow mobile voice communciations whith anyone in the facility to alleviate the necessity of making calls from the nurses' station.
Applications Rule the Day
Mobile computers and voice systems provide value to clinical transformation only if they do at least one of three things - increase the level of patient care, increase caregiver productivity, or help eliminate mistakes. As health care enterprises and the IT systems providers come to terms with new challenges, innovative solutions continue to be released that address the medical error and worker shortage issues. Some of the other applications that are receiving interest include:
- Positive patient identification
- Specimen collection
- Viewing lab results
- Vital signs and I/Os
- Procedure instrument inventory
- Supply management
- Charge capture
Interestingly, all these applications have returns on investment that pay for themselves in short order.
The IS Department's Perspective
Early adopters of mobile computing technologies used their independently acquired PDAs to access the information they needed to do their jobs. They would up load their schedules or a database of drug interactions before rounds. As the suite of health care-specific applications grows, and the "me too" factor among the clinical staff kicks into high gear, IS departments are faced with a daunting challenge, How to support different devices running multiple versions of multiple operating systems while controlling sensitive patient data? The answer is clearly that they cannot. It is this situation that inspired the current usage of application-specific mobile devices, owned and maintained by the hospital's IT department. The staff picks up the devices at the beginning of the shift and leaves them at quitting time.
Additionally, IS staff have realized that mobile devices utilized for health care have unique requirements that consumer-type devices are ill-suited to address. The first is battery life. Mass consumer devices are designed for the typical consumer's habits. The average consumer uses battery-operated devices for short periods of time, typically for only minutes per day. Mobile computing devices deployed in health care are often turned on for a good portion of the entire shift and have radios communicating constantly with the hospital's information systems, which also drains the battery. The minimum requirement for a device in a clinical setting is that it gets at least a shift's worth of battery life per charge. If it doesn't, acceptance by the staff will be a serious problem.
The second challenge facing the IS department, as well as clinical staff, is that a device must be resistant to pathogen contamination when it comes in contact with bodily fluids and must be fully cleanable after exposure.
Finally, the device has to be more rugged then consumer-grade devices. The dynamic and fast-paced environment in which clinicians work invariably leads to handheld devices being dropped and bumped. The mobile device needs to survive this treatment and perform flawlessly moments later. A patient's well being may depend on it.
All of these device requirements point to "industrialized" PDAs, the type (not coincidentally) on which most health care information system providers have deployed their mobile applications. These devices address the concerns noted above. They're designed with increased battery life and integrated radios; they're sealed to prevent contamination and allow for cleaning; and they're "ruggedized" to survive the treatment they are likely to see in a health care setting.
Wireless Adoption
The rate of WLAN deployment has skyrocketed in the last year. A question that continues to be asked is, Do WLAN products interfere with sensitive medical equipment? There is now a fairly large body of evidence that suggests 802.11b does not interfere with such devices. At a March 2003 meeting of the Mobile Healthcare Alliance, an FDA representative stated, "We have not received one report of a medical device malfunctioning as a result of interference caused by an 802.11b transmitter."
The same cannot be said of cellular telephone transmissions, which have had reports of nearby equipment malfunction. Additionally, the Medical Devices Agency (an executive agency of the Department of Health, U.K.) issued a report, which stated, "Our tests failed to detect significant levels of interference from cordless phones and radio computer local area networks, which are installed in some hospitals."
In addition, numerous hospital biomedical departments and manufacturers have conducted tests in that indicate that 802.11b transmissions did not cause equipment to malfunction, which would endanger patient safety. Indeed, in order to make their devices more mobile, many medical-device manufacturers are embedding 802.11b wireless capabilities in their devices. The ability to do data, voice, and patient monitoring all on the same wireless network are yet another reason for the excitement around WLANs in hospitals. As mentioned earlier, another factor in the widespread use of WLAN technology in health care is costs are dropping. Several vendors are now offering "switch"-based solutions that have further lowered costs, make implementation easier, and make managing the WLAN and the connected wireless devices easier.
Summary
Clinical transformation must improve patient outcomes and make the delivery of health care more efficient, while at the same time not disrupt workflow to the point of building resentment in the very staff it's supposed to assist. Any successful transforming technology must have intense participation from the staff, which will ultimately determine its success. Pilots are essential, with feedback from users the most important component of the decision-making process (even more important than cost). A well-structured, phased rollout that, again, heavily involves the user community will also go a long way towards ensuring staff acceptance and the ultimate goal — clinical transformation.
Endnotes
1 L.T Kohn, J.M. Corrigan, and M.S. Donaldson, Eds. To Err Is Human: Building a Safer Health System. Washington: National Academy Press. 1999.
2 www.hhs.gov/news/press/2003pres/20030313.html.
3 Bates, D.W., Spell, N., Cullen, D.J., et al. "The costs of adverse drug events in hospitalized patients" JAMA. 277 (1997):307-311.
