Computers get smaller, lighter and more powerful all the time. The tide is turning for handheld devices—as they become more functional, rugged and have longer battery life, they have become ideal for a multitude of tasks found in the healthcare arena. From better recordkeeping to quicker, more accurate treatment, clinicians have put handhelds to the test with excellent results.
Access to faster, better service
A fast-growing organization, Leon Medical Centers’ paper-based system wasn't keeping pace. Its five facilities, based in Miami, offer primary and specialty care to the Hispanic Medicare population. The emphasis is on excellent service, and much of the population has limited mobility. So, the organization offers a door-to-door service program which coordinates transportation services with physician appointments. Because the facilities offer therapy, dental care, eye care, pharmacy and more, patients can schedule several services for one visit and get their prescriptions filled before taking the same transportation back home.
Although the transportation program satisfied a critically unmet need, it created workflow challenges. “As you grow, there can be bottlenecks,” says Marcus Gomez, senior vice president of MIS and telecommunications. A primary bottleneck was the pharmacy – as Leon patients waited for their prescriptions to be filled, the transportation staff was left standing idle. With more than 10,000 prescriptions filled on a typical Monday, Leon needed a comprehensive solution to streamline efficiency, reduce operational costs, improve patient satisfaction and reduce the risk of errors. Leon found its answer in a computer-based physician order entry solution (CPOE).
“Technology plays a unique role in our workflow,” says Gomez. “It ultimately translates to better service.”
Gomez worked with CDW Healthcare, who assisted with testing of recommended devices. Leon found the right technology and better service in handheld computing devices. After initially trying them in late 2001, Gomez says that evolution of the device in 2002 “allowed us to take advantage of quick entry and it gave physicians mobility.” He worked with CDW to get the devices in the physicians' hands. He decided to design an interface that would take prescriptions from anywhere in the facilities directly to the pharmacy. That would eliminate double entry and provide the ability to track every prescription. Pharmacy staff could acknowledge receipt of the prescription and send a reply to the originating system.
Since that time, Gomez has experimented with different handhelds and applications. His research and the advances offered by manufacturers led to an ideal device. Displays have improved, the devices have a longer battery life, power has increased dramatically, and they are much less bulky.
Gomez’s biggest challenge, however, was getting Leon physicians to use the devices. “We knew we had to give them a product that would provide exceptional uptime,” he says. “If there’s any difficulty with the technology, they will stop using it altogether. That’s why we made such an effort in jumping on the latest technology and experimenting with hardware.” Leon physicians are using HP iPAQ Pocket PCs.
Some of the physicians were hesitant so Gomez did not force them to use the devices. “They didn’t know if they could trust the technology. They didn’t want to risk it. But we built their trust over time.” The most important method of easing physician concern was the establishment of a reliable network with survivability protection, Gomez says. That stable platform for operations and connectivity helped with physician buy-in.
Willing physicians became champion doctors. Those giving the devices a try could easily see how they could improve their daily workflow. Many of the patients are on multiple medications. But once that information is entered, any physician can access it and easily renew or discontinue prescriptions. Gomez designed the software with few dropdown lists and built in default values. “After they’ve filled 10 to 20 prescriptions, they realize it’s not that complicated. And, patients are thrilled with the result.”
Streamlining and securing the transfusion process
There is no margin for error for blood transfusion patients. Getting the wrong blood type can be fatal and the primary sources of mistakes are mislabeling and documentation errors. Jeannie Callum, MD, blood bank director at Sunnybrook and Women's College Health Sciences Centre in Toronto, set up a pilot program using handhelds in the hematology unit and outpatient transfusion center.
The transfusion volume is very high at Sunnybrook. To better manage the process, nurses use handhelds in all steps of the process. Patients get a wristband with a barcode containing five identifiers. When blood is drawn, nurses scan their own badge and the patient’s wristband. They tell the computer what they are doing and print a label right at the bedside to put on the tube of blood. This process already helps prevent the 1 in 2,000 errors made when drawing the patient sample and 1 in 200 incorrect labels.
When blood is issued, the barcode on the bag is checked. “We know which nurse checked the blood, which is time stamped,” says Callum. “The nurse scans the patient to check compatibility with the tag on the bag.” Patients receiving blood have their vital signs checked every 15 minutes. The nurse enters that information right into the handheld. Because “the safety and accuracy of a manual system depends on how meticulous the nurse is,” the handhelds make it much easier for the nurses to record the necessary information and validate that the right patient is getting the right blood. With this system, a siren sounds if a nurse starts setting up a patient with the wrong blood type.
The pilot program has been very successful, Callum says. “Before, two nurses had to check blood together. Now they can spend more time on patient care.”
For good results, the handheld technology has to be very simple and very robust, she says. "Flips between screens must happen instantaneously. We can’t tolerate any downtime.” Plus, condensation on the blood bags means the labeling and scanning must be up to the challenge. Even though the units aren’t “ruggedized,” Callum says the staff can swab them with disinfectant once an hour for good infection control.
Despite the success achieved, training was a major issue. Most nurses don’t have a lot of experience with computers, Callum points out. And, many nurses over 40 need reading glasses. A primary reason the facility decided on the MC50 from Symbol Technologies Inc. was that the screen is easier for them to read.
The workflow of the unit where the devices are used is important to consider. The nurses in the outpatient unit use the computers every 15 minutes. That frequency meant they could learn how to use them faster on their own than through training sessions. The inpatient nurses only use the computers once a day or even every other day. “When you use them less frequently, there are more training issues,” says Callum. She recommends introducing the devices in units where there are fewer nurses but use is more frequent. And, if you start in an area that is only open from 9-5, you won’t have to deal with 24/7 support.
But for Callum, “there is no question that we will eventually use [handheld devices] for everything.” Next up, Sunnybrook will introduce the mobile computers to its unit for premature babies. While those patients may only get blood every couple of days, some get breast milk every couple of hours. “So there is lots of opportunity for error,” she says.
Leading the way to better communication
Brian McCardel, MD, an orthopedic surgeon in Lansing, Mich., uses a tablet PC from Motion Computing and couldn’t be happier. The “clipboard” style of the unit allows him to take notes and make eye contact with his patients. McCardel was more interested in a tablet than a unit with a convertible keyboard to prevent distractions from his patients. Plus, he can still surf the web, retrieve images and perform other tasks. The tablet “requires very little text entering. I’m not missing out without a keyboard.”
He also was interested in a lightweight, durable device that had a battery lasting seven or eight hours. In the hospital, “there is literally no spare real estate.” The unit attaches to a shoulder strap and McCardel can simply hang it on the coat hook in patient rooms. The tablet has proven quite durable. He says he’s broken most palm-sized devices and “they’re hard not to drop.”
When McCardel is on call, he can simply leave the computer live on his kitchen counter and call up images at any time. With three of his partners now using the devices as well, they can fill in for each other since they have access to patient clinical information at any time from any location.
McCardel also uses the device right in the operating room. He sees a big opportunity for handhelds in the perioperative area. “For people moving from patient to patient, it’s easier to have a device they carry with them rather than going back to the workstation,” he says. “There’s a time delay associated with that.”
Successful use of handhelds means looking at the hardware and software in combination, he says. “They are intriguing devices but they only make sense if you have both the hardware and software.”
Reactions from other clinicians and patients have come fast and furious, McCardel reports. “I’m stopped in the hospital all the time.” The facility has a physician portal which takes several disparate systems and puts them under one umbrella, which McCardel can easily access on his tablet PC. “People are stunned to see the lab results right there.” Meanwhile, patients have shown interest in his tablet. “I thought people would be turned off, but elderly patients are delighted because they realize they don’t have to repeat information for each provider. They’re on lots of meds and are clued in that that can be a problem. They realize that the more networked we are, the safer they are.”
McCardel says most patients have a natural curiosity to see their x-rays. If those images are only available at the nurses’ station, patients can’t see them. He can pull up an image in the PACS and mock up a screenshot with arrows and circles. “It’s been a huge boon from a patient understanding standpoint.”