The deployment of EMRs and CPOE systems

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1 FEATURE: Techology How to Select Ed User Cliical Data Etry Devices Rush Uiversity Medical Ceter Develops Tool to Idetify the Quatity of Devices Needed for the Implemetatio of a ew EMR ad CPOE System. Karl Oder, MS; Susa Nauseda, BSN, MBA, PMP; Elizabeth Carlso, PhD, RN; Jae Llewelly, PhD, RN, NEA-BC; Fred Brow, DNP, RN; Cathy Catramboe, PhD, RN; Louis Fogg, PhD; ad Bria Garcia, MS Keywords Devices, data etry, computer selectio. Abstract Selectig the right types ad quatities of computers to support data etry to a ipatiet Electroic Medical Record (EMR) ca be challegig. I additio to software ad hardware cosideratios, may other variables affect the decisio icludig staffig levels, hospital workflows, ad floor plas. Rush Uiversity Medical Ceter (RUMC) developed a tool to help idetify the quatity of devices eeded i a Patiet Care Uit (PCU). RUMC successfully used the tool i selectig the quatity of devices eeded for the implemetatio of a ew EMR ad Computerized Provider Order Etry (CPOE) system. This case study describes the use of the tool to determie quatities of PCU devices, the advatages ad disadvatages of differet types of computig devices for bedside documetatio ad areas that require special cosideratios i the selectio of devices. The deploymet of EMRs ad CPOE systems has challeged hospitals to provide ubiquitous computer access to cliicias. Studies have show that CPOE i combiatio with cliical decisio support capabilities ca reduce health care costs by reducig the umber of uecessary tests ad suggestig more effective ad less expesive pharmacuticals. 1 CPOE systems with cliical decisio support require cliicias to have access to computers at the poit of care. The eed to access the electroic medical record efficietly at the poit of care is particularly challegig. Oe of the first challeges is selectig the best ed user device for the cliical eed. There are may types of mobile computer devices available to deploy. A short list icludes traditioal PCs, workstatios o wheels (WOWs), laptops, tablets ad persoal digital assistats (PDAs). Each of these devices have advatages ad disadvatages for the cliicia. volume 24 / umber 3 SUMMER 2010 jhim 65

2 Table 1: Device advatages ad disadvatages. WOWs are frequetly deployed i the ipatiet settig for documetatio at the poit of care. A review of the literature reveals that WOWs have commo problems, such as bulkiess, weight, storage, cosistet wireless access, reliability ad battery life. 2,3 Computer tablets ot oly have these issues, but they also frequetly do ot have a keyboard, makig them difficult to use for certai types of documetatio. 4 Laptops have a keyboard, but cliicias eed to fid a place to set the laptop dow i the patiet room i order to use the keyboard. Laptops ad tablets are likely to be iadvertetly dropped, causig damage to the uit. PDAs have small screes that are difficult to see ad may EMR applicatios are ot optimized for the use of a PDA. 4 The selectio of devices requires a collaborative approach betwee cliical staff ad iformatio techologists. Not all devices may fit all workflows ad ot all devices work well with a istitutio s techology stadards. The iformatio techologist evaluates the devices based o ruggedess, the ability to support the uderlyig techology, ad the techical ability to use the istitutio s cliical software. Techically, a device may ot have the processig power to ru the applicatio properly. The cliical staff evaluates the devices based o the cliical workflows. For example, tablets are very difficult to use for textbased etry, such as cliical documetatio, because of the lack of a keyboard. However, oe study did fid them very useful for pharmacists roudig as a part of a iterdiscipliary team. 4 Collaboratio betwee cliical staff ad iformatio techologists is key durig the device selectio process. Not oly must a istitutio decide o the types of devices that they eed to purchase, but they also must decide o the umber of devices that are eeded. The the challege becomes determiig the correct umber of devices. Competitio for devices amog caregivers ca occur withi a PCU. A EMR or CPOE project ca fail if there are ot eough devices for cliicias to use to documet care. Too may devices adds uecessary costs to the project ad icreases the challege of the storage of devices ot i use, ad icreases ogoig maiteace costs. A extesive review of the literature revealed a paucity of articles that describe how to determie the correct um- 66 jhim SUMMER 2010 volume 24 / Number 3

3 Table 2: Sample calculatios for a critical care uit ad a medical uit. ber of devices eeded for the deploymet of a EMR. A tool eeded to be developed i order to calculate a ideal umber of devices. CASE STUDY RUMC, a full service academic medical ceter located i Chicago, embarked upo the implemetatio of a itegrated cliical system i the fall of The implemetatio of this system ecessitated the purchase of ed user data etry devices for cliicias for use o each PCU. Requiremets of the devices icluded: miimal use of space/storage, PCU electrical capacity, the ability to documet at the bedside, the ability to documet outside of the patiet room, eough devices for all cliical users at peak staffig times (icludig teachig rouds), ease of use ad provisio of the optimal device for each role. While ideally the support of oe or two devices was deemed more ecoomical for the orgaizatio, it quickly became apparet that a mixture of computig equipmet would eed to be selected i order to best meet the multiple eeds of ed users. Various types of devices were defied ad tested for use i the RUMC eviromet. While techically all of the device types could be deployed, a selectio process eeded to be developed to determie the right mixture of each device for each PCU. Table 1 defies each device type ad the advatages ad disadvatages for each. The selectio of the types ad models of devices to deploy was made by a iterdiscipliary committee composed of urses, physicias ad iformatio techologists. The cliicias represeted a cross sectio of the istitutio icludig critical care, medical, surgical, obstetrics ad pediatric areas. Hospital Service Departmets (HSD) were also represeted. RUMC had may statioary workstatios already deployed i the ursig statios for CPOE, testig result review ad viewig of PACS images. However, RUMC did ot have a large deploymet of devices that could be used at the poit of care. Therefore, the focus for the committee was to determie the best device for bedside use. The committee also determied that patiet eye cotact would be a problem with wall mouted workstatios. Wall mouted workstatios were also rejected due to the expese of purchasig oe per patiet room ad the cost of moutig the uit ad providig etwork cablig ad electricity. The exceptio to this was i the boe marrow trasplat uit. Each room was equipped with a workstatio o a credeza located by the door. This was doe i order to maitai the sterility eeded withi the specialized care eviromet. Tablet computers were also reviewed. It was foud that the tablet pe ad small scree size could ot create a optimized data etry eviromet usig RUMC deployed EMR software. Therefore, most of the cliical staff rejected the use of tablets for data etry. However, ipatiet psychiatry preferred the tablets because they are a less itrusive device to use durig a cliicia / patiet ecouter. PDAs were immediately rejected because of the lack of support from the EMR vedor. Upo cosideratio, the committee decided to pursue the WOW optio because of its flexibility. The WOW ca be moved (ulike a wall mouted computer) to aother area that has a eed for more uits. The WOW also has a large scree ad keyboard that allow for eterig otes more easily. The height of the keyboard ad moitor are also adjustable allowig a cliicia to move the cart to a coferece room or the ursig statio ad sit dow i a chair to documet. Laptops were evaluated ad it was determied that laptops would be difficult to use i patiet rooms primarily because patiet rooms lack areas to place the laptop ad type while still facig the patiet. However, Residet roudig teams foud the laptops useful. Oe residet examies ad iterviews the patiet while a secod residet documets the ecouter. A laptop was assiged to each team to use for order etry ad results review while roudig. This resulted i icreased WOW availability for use by ursig staff. HSD s were assessed idividually as each had special eeds depedig upo the services they provided. For example, Physical Therapy eeds were very differet tha those for Dialysis. Geerally, HSD eeds were met with a combiatio of WOW s (providig itra-departmet mobility, especially for procedure areas) ad laptops (providig extra-departmet data etry). Laptops were required for extra-departmet mobility (e.g. care o the patiet care uits) because of the lack of available WOWs i the uits. The uits did ot have eough storage space for additioal WOWs to be used by HSD persoel. Oce the questio of what type of device to use was aswered, the questio of the quatity of devices to be deployed remaied. A tool was developed that calculated the quatity of devices eeded for documetatio i the EMR. The primary iput for the calculatio was the peak umber of cliical staff o the uit (physicias, urses ad urse assistats). A 1:1 ratio of devices to urses ad ursig assistats was eeded sice they eed cotiuous access to a mobile device i order to provide care. RUMC is a teachig hospital with Residets, Fellows ad Attedig physicias. The physicias use both statioary computers located at the ursig statio ad mobile computers for roudig. The Residets roud i teams ad each team required oe or two mobile devices whe roudig. Attedig physicias also peri- volume 24 / umber 3 SUMMER 2010 jhim 67

4 odically use mobile devices throughout the day. Therefore, it was determied, i cosultatio with the physicias, that 0.83 devices, icludig statioary ad mobile, for each physicia based o the PCU would be a reasoable ratio. Table 2 cotais sample calculatios for a critical care uit ad a medical uit. Table 2 also shows the actual umber of devices deployed to the uits. Subsequetly, it was determied that the actual umber of devices deployed ad the calculated umber eeded would be iflueced by additioal factors. These factors were the slight variatio i each uit s workflow based o the acuity of their patiets, the floor pla of the uit, ad the frequecy ad umber of ursig studets assiged to the uit. The lack of available storage for uused carts resulted i may uits receivig less carts tha they requested. Ultimately, the actual umber of devices deployed to each uit was determied by ursig leadership i cosultatio with their staff as they cosidered the various factors. Therefore, the calculatio was really the first step i the process of determiig the fial umber of devices per uit ad provided a logical place to begi discussios. Oe last but ot isigificat value of the tool was its usefuless i defiig the quatity of devices required to seior maagemet. Seior maagemet was able to see the logical approach ad stages of refiig the umbers that occurred. After the selectio of the quatity ad type of devices was made, there were still a umber of cosideratios ad decisios that eeded to be made prior to deploymet. RUMC held a WOW Fair to determie the selectio of the maufacturer ad model of the WOW. The WOW fair allowed for cliicias to come ad see the proposed WOWs i a commo area of the hospital. Survey feedback was obtaied from the cliicias ad some vedors were elimiated. The remaiig two WOW models were the tested o the uits. Cliicias completed olie surveys after usig the WOWs o the uits. Iformatio Techologist team members were essetial to selectig the best laptop to be used by HSD persoel ad Residet roudig teams. The laptops selected have miimal fuctios ad oly allow access to the cliical applicatios. For security reasos, the laptops do ot have ay local data storage. This elimiates the potetial issue of Protected Health Iformatio (PHI) beig iadvertetly stored o the device ad maitaiig compliace with HIPAA regulatios. The laptop model selected is a thi cliet termial type that is less expesive to purchase ad maitai. Laptops also require a place to be securely stored ad charged. Special cabiets were purchased ad located i some of the PCU coferece rooms for laptop storage ad chargig whe ot i use. Facility issues were also ecoutered. Older buildigs could ot support the electrical requiremets of the ew devices without ifrastructure upgrades. Electrical circuits ad closets supportig each PCU were assessed ad upgraded for the aticipated electrical load ad to maitai city ad couty codes. While RUMC has made a sigificat ivestmet to implemet wireless techology withi PCUs, frequet complaits of areas where the The selectio of computer devices to documet i a EMR eeds to be a collaborative approach ivolvig cliical staff ad iformatio techologist. wireless coectios were ot available or dropped coectios were ecoutered. A cosultig firm fie tued ad upgraded the wireless access to sigificatly reduce problem areas. Processes were developed to meet bedside eeds for patiets i isolatio. Geerally, a device is assiged to ad remais withi isolatio rooms. I additio, stadard ifectio cotrol procedures apply to all devices. Locatios to house the WOWs, whether withi patiet rooms, closets, alcoves or other areas eeded to be foud as fire codes will ot allow WOWs to be left uatteded i the hallways. Passageway ad egress miimums eeded to be maitaied. There was a belief by the cliical staff that certai vedor WOWs had a sigificatly smaller footprit tha others ad therefore would occupy less space whe stored. Upo actual measuremet of the vedor footprits, isigificat differeces i size were foud due to the uiversal requiremet for stability of the cart. The locatio of the medicatio dispesig statio o some uits also preseted challeges. The cliicia must access the electroic medicatio admiistratio record at each automated medicatio dispesig statio. Geerally, WOW s are wheeled to these locatios whe medicatio dispesig is required; however, due to space limitatios i some areas, secured statioary laptops were deployed o top of the medicatio dispesig statios. Ogoig maiteace ad support of devices must also be a plaed activity. More computer support staff is required after device deploymet. Nurses ad physicias complaied that devices were ot i service ad that repairs were ot timely. A aalysis of support tickets foud a combiatio of problems with compoet durability as well as cliical staff traiig issues. Roudig teams were deployed to proactively fid ad repair devices out of service. Simple problems (broke mouse, loose cables, etc.) were fixed o the spot while more sigificat techical problems were escalated to the appropriate repair areas. PCU leadership cotributed by reiforcig the traiig o the proper use of the devices with their staff. This improved customer satisfactio with the devices ad esured a fuller complemet of devices that matched PCU eeds as assessed by the tool. Budget dollars also eed to be allocated i subsequet years for the plaed replacemet of obsolete equipmet, icludig computers, carts ad batteries. This ca be a sigificat amout of moey depedig o how may devices are deployed. RUMC had to replace all of the batteries i the WOWs after 18 moths due to the batteries age. CONCLUSION The selectio of computer devices to documet i a EMR eeds to be a collaborative approach ivolvig cliical staff ad iformatio techologist. The decisio o the types ad quatities of devices to deploy is based o may factors. The factors iclude 68 jhim SUMMER 2010 volume 24 / Number 3

5 cost, size, durability, ergoomics ad the ability to itegrate ito the orgaizatio s techical ifrastructure. The tool preseted i this paper assisted i commuicatio to executive maagemet of the quatity of devices eeded for the patiet care uits. Devices are expesive to purchase ad maitai. Therefore, providig a mathematical calculatio to maagemet is extremely helpful i articulatig the eed for devices. The tool, however, is just a startig poit. The data from the tool eeds to be validated by PCU leadership based o the idividual uits workflow, staff schedulig, ad physical layout. Every hospital will have areas with special eeds, such as Hospital Service Departmets. These areas eed to be iterviewed to determie the best types ad quatities of devices eeded for there use with the EMR. JHIM Karl Oder, MS, Chief IS Architect, Rush Uiversity Medical Ceter, Istructor, Rush Uiversity College of Health Scieces; 1700 West Va Bure, Suite 374, Chicago, Illiois 60612, Susa Nauseda, BSN, MBA, PMP, Director Project Maagemet Office, Rush Uiversity Medical Ceter, Istructor, Rush Uiversity College of Health Scieces. Elizabeth Carlso, PhD, RN, Associate Professor Rush Uiversity College of Nursig. Jae Llewelly, PhD, RN, NEA-BC, Vice Presidet, Chief Nursig Officer, Associate Dea for Practice, Rush Uiversity Medical Ceter. Fred Brow, DNP, RN, Assistat Professor, Rush Uiversity College of Nursig. Cathy Catramboe, PhD, RN, Assistat Professor Rush Uiversity College of Nursig. Louis Fogg, PhD, Assistat Professor, Rush Uiversity College of Nursig. Bria Garcia, MS, Graduate Studet Rush Uiversity College of Nursig. Refereces 1. Chi H, Wallace P. Embeddig guidelies ito direct physicia order etry: simple methods, powerful results. AMIA Symp Cummigs A, Parker C, Kwapiowski L, Reyolds G. Movig Alog: Usig Mobility Techology to Improve Pharmacist Workflow i the PICU Roudig Process. Joural of Health Iformatio Maagemet. 22(4): Tag C, Carpedale S. Evaluatig the Deploymet of a Mobile Techology i a Hospital Ward. Proceedigs of the ACM 2008 coferece o Computer supported cooperative work, Murphy J. (2008) Promises ad Problems: Mobility ad Electroic Health Records. Joural of Health Iformatio Maagemet. 22(4): volume 24 / umber 3 SUMMER 2010 jhim 69

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