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Mobile Tech: One App at a Time

Beckie Kelly Schuerenberg,
Health Data Management, December 1, 2007

12/1/07 – Executives at Columbia, Md.-based Howard County General Hospital used a variety of criteria to select a wireless bedside specimen collection system last year.

They spent several months evaluating the cost, functionality and other customer implementations for five systems before choosing the MobiLab application from Iatrac Systems, Boxford, Mass. They also ensured the software could integrate with the 200-bed facility's hospital information system, from Medical Information Technology, Westwood, Mass.

Howard County executives, however, didn't do the same due diligence to select mobile hardware for the system. While the software is hardware "agnostic," executives decided to purchase the same PDAs, from Motorola Inc., Schaumburg, Ill., and mobile printers from Zebra Technologies Corp., Vernon Hills, Ill., that a few of the vendor's other customers use.

The specimen collection system, however, is the only application Howard County is using with the new mobile hardware. The facility's hospital information system doesn't support PDAs, so it doesn't have any other applications that can be used on the devices, Edwards says.

Howard County already uses other mobile devices that both systems can run on, such as mobile carts from Stinger Medical, Murfreesboro, Tenn. It also has other Symbol handheld devices tethered to the carts that nurses use to scan bar codes on patient wristbands and drugs during medication administration.

But the hospital didn't balk at purchasing new hardware just for the specimen collection system because it wanted to ensure a successful implementation, says Rick Edwards, senior director and CIO.

"We got favorable references on the devices from the vendor's other sites," Edwards says. "There also aren't a lot of PDAs and mobile printers on the market that are ruggedized and have the bar code scanners we needed for this application."

After implementing the specimen collection system, Howard County began an initiative to enhance its wireless network to better support its various mobile hardware and software. While he's looked into converging mobile technologies and strategies across the hospital, Edwards says it likely wouldn't work.

"It would be nice to standardize the PDAs and scanning devices we use," he says. "But because of the reality of the applications and how they work we haven't been able to do it."

Managing Multiple Devices

While many hospitals are deploying mobile hardware and software for various applications, most, like Howard County, haven't developed an enterprisewide strategy to bring them all together, many industry experts say. Even if they did, however, an enterprise game plan would be difficult to achieve -vendors offer mobile hardware, wireless infrastructure and clinical software that doesn't always play well together, says Cary Brown, senior consultant at Tower Strategies, a Houston-based consulting firm.

"Mobile applications should be driven by the vision of what you want to do and that usually starts with the software," he says. "So most mobile hardware decisions are driven by individual applications."

Disconnected mobile strategies can begin when organizations implement best-of-breed applications with various hardware requirements or clinicians balk at using standardized hardware and software that disrupts their workflow, Brown says.

"The usability of the application and the hardware itself is how most organizations choose their mobile technologies," Brown says. "But there's not one single device that does it all well."

For Howard County General Hospital, automating specimen collection was more important than keeping its number of mobile devices down. Its previous collection process, which involved printing labels at nursing stations before specimens were taken, sometimes resulted in mismatched or unlabeled specimens, says Edwards, the CIO.

Now clinicians use PDAs to access the MobiLab system and scan bar codes on patient wristbands to verify specimen collection. They also use the mobile printers to create matching bar code labels for the specimen containers - all at the point of care. And they use the PDAs to document that a specimen has been collected. The automated process has enabled Howard County to reduce specimen identification errors from 11 per month to one per month, Edwards says.

It also has found some ways to better manage the new PDAs and mobile printers. For example, since MobiLab also can be used on mobile carts, the hospital gave clinicians who already use the carts the option to access the application on it rather than a PDA. The decision enabled some clinicians to only use one device as well as helped the hospital keep hardware costs down.

"While they still have to set the mobile printers on their carts, we saved some money by not having to buy them PDAs as well," Edwards says. "That flexibility was in the software's favor."

Howard County also manages the mobile hardware by requiring clinicians to share devices and has multi-bay charging stations for them at various nursing stations, he adds.

For years, executives at William Beaumont Hospitals required nurses to use the same type of mobile hardware to simplify management and support. But they recently changed their strategy after concluding that one type of hardware didn't fit all clinical applications.

The Royal Oak, Mich.-based delivery system had required all nurses to carry the same type of pager to communicate with patients and other clinicians. A few years ago, it switched to a standard Wi-Fi phone from SpectraLink Corp., now part of Polycom Inc., Pleasanton, Calif., and integrated the mobile hardware with its various nurse call systems.

While nurses eagerly adopted the new phones, there was one application that wouldn't work with either mobile device.

William Beaumont Hospitals' centralized telemetry technicians used to page nurses when a patient's levels reached an alert status. Because there was no way to distinguish these alerts from other pages nurses received, they sometimes were ignored, says Kim Bonzheim, director of noninvasive cardiology and cardiac rehabilitation. The new Wi-Fi phones, however, didn't help because nurses still had to interrupt their workflow to answer them to determine what kind of call it was, she adds.

"Nurses really looked at the phones as big pagers," Bonzheim says. This wasn't helpful and nurses wanted a way to prioritize voice calls.

In March 2005, William Beaumont Hospitals began a pilot of a separate mobile device dedicated solely to telemetry alerts. Now it enables telemetry staff and nurses in three departments to communicate via wireless devices from Vocera Communications Inc., Cupertino, Calif. The mobile technology uses Wi-Fi badges attached to lanyards worn around the neck. The badges are embedded with voice recognition technology that enables clinicians to make and receive phone calls to other badges without using their hands.

Now instead of calling a nurse's mobile phone, telemetry technicians use a badge to call another badge that's been assigned to the patient's room. Badges are grouped by areas, and nurses log in by speaking the rooms they are covering.

Because the badges are used only for telemetry alerts, nurses always know the nature of the call and can answer without interrupting their workflow, Bonzheim says. The technology also automatically calls another badge or broadcasts an alert to all badges if a nurse hasn't responded to the original call in a predetermined amount of time.

And while some nurses now must carry wireless phones and wear a Vocera badge, the additional mobile device is helping them better prioritize their workflow, Bonzheim adds. Since implementing the second mobile device, the hospital decreased its telemetry alarm response time from 9.5 minutes to 37 seconds, she says.

"Our mobile hardware decision was application driven," she says. "The wireless badges were the only mobile technology that was hands free and had a built-in escalation path. That's been a huge time saver for us."

William Beaumont Hospitals has deployed about 100 Vocera badges so far and plans to enhance its wireless network to support additional ones in other departments that use telemetry. It's also working with Vocera and Waukesha, Wis.-based GE Healthcare, the vendor of its centralized telemetry system, to integrate their technologies so the telemetry application automatically can initiate a call to a Vocera badge during an alert.

I.T. Disconnect

While some hospitals are open to purchasing almost any type of mobile hardware or software that can improve clinical workflow, others have limited options. Cost, integration capabilities and I.T. resources are just a few of the factors that also can play into mobile purchasing decisions, says Gregg Malkary, managing director at Spyglass Consulting, Menlo Park, Calif.

"There are so many hardware options that could work for an application, but technology is just one component of it," he says. "Executive buy-in, training time and integration needs also factor into mobile purchases."

Additionally, while the advent of Web-enabled applications has enabled many clinical systems to run on a variety of mobile devices, most software hasn't been fully optimized for the capabilities of each device, Malkary says. So if executives choose hardware that can support a new application but doesn't inherently fit into clinical workflow, they could end up with a lot of unhappy users, he adds.

"There's a huge dividing line between clinical staff and I.T. staff," he says. "There are best practices for I.T. and different best practices for clinicians."

Lehigh Valley Hospital and Health Network included both clinical and I.T. staff in the three-year process to determine which emergency department information system it should purchase. But the Allentown, Pa.-based delivery system was limited in the type of hardware it could use with the application, from T-System Inc., Dallas.

Lehigh Valley serves as a licensed service center for mobile devices from Fujitsu Computer Systems Corp., Sunnyvale, Calif. So its executives wanted to use the vendor's notebook and Tablet PCs with the new ED system.

"The choice of hardware was easy," says Richard MacKenzie, M.D., chair of the emergency medicine department. "We have trained Fujitsu specialists on our I.T. staff and can trade out the hardware 24/7."

When Lehigh Valley implemented the emergency department software in mid-2005, it let clinicians decide whether they wanted to use a Fujitsu convertible Tablet or notebook PC with the application. Clinicians in one of its three emergency departments, however, also were given the option of using the system on Fujitsu notebook PCs mounted on mobile carts from Rubbermaid Medical Solutions, Winchester, Va., because there's more room to maneuver such large devices in that facility, MacKenzie says.

Most clinicians initially didn't like Tablet PCs and gravitated toward using notebook PCs. But after a few physician champions, including Susan Krieg, M.D., began praising the tablets, others began to jump on the bandwagon-so many that Lehigh Valley had to purchase more of the devices to keep up with physician demand.

"In terms of patient flow, the Tablet PC helps me because I can quickly jump from room to room and place orders on the fly," she says. "But if I wanted to covert it and use it with a keyboard, it would be ergonomically tough to type when you are with the patient. If you want to do bedside charting, you have to turn it into a tablet."

The TabletPCs also maintain a battery charge throughout an eight-hour shift, Krieg says. Further, while clinicians must share the devices, most non-emergency physicians don't want to use them, so Lehigh Valley doesn't have to worry about them leaving its emergency departments, she adds.

The ED software, however, functions well no matter if physicians enter data via a keyboard or the pen capabilities on a Tablet PC, says MacKenzie, the chair of Lehigh Valley's emergency department. He and other clinical staff chose the software for this mobile functionality so they could document at the bedside, he adds. They also chose the software because of its ability to integrate with the admission/ discharge/transfer application within the delivery system's HIS, from GE Healthcare, and its Sunquest lab system, now owned by San Francisco-based Vista Equity Partners.

The emergency department information system's reporting functions, however, aren't as sophisticated as some of the other applications Lehigh Valley evaluated, MacKenzie says. But its mobile capabilities outweighed such shortcomings, he adds.

Customized Mobility

Executives at The Dialysis Center of Lincoln Inc. ensured the mobile hardware and software it planned to use for a new telemedicine initiative had the features it wanted by participating in the technology design process.

Last year, after testing a mobile cart from Flo Healthcare, Norcross, Ga., the eight physician, Lincoln, Neb.-based provider organization approached the vendor about customizing other devices to be used for telemedicine.

"We liked the carts but we wanted to make them multifunctional," says Larry Emerson, CEO. "We had the ability to experiment and a willingness to spend a little money to try something new."

The vendor equipped three mobile carts with video conferencing hardware and software from PolyCom Inc., Pleasanton, Calif. The integrated system comprises a video recording device, videoconferencing software, a digital converter, a remote control and a power unit.

The Dialysis Center executives, however, had a few other requirements for the integrated technology. Because they wanted physicians to be able to conduct full patient exams via the new carts, they had the vendor switch to a 19-inch monitor rather than the 17-inch one that came with the original carts. In addition, executives declined to equip the carts with Tablet or notebook PCs because they wanted a larger screen than either device could offer.

They also had the vendor change the power supply on the carts to AC from DC because the video conferencing technology ran on the former standard and executives didn't want to manage two different types of batteries. Additionally, executives had the vendor ensure the new carts also could be used to access The Dialysis Center's electronic health records system, from London-based Clinical Computing Inc.

After the facility received the customized mobile carts, it still had to fix some other issues before they could be used for the telemedicine initiative, Emerson says. For example, each cart's AC battery only powered the computer on the unit; the video conferencing station on the cart had to be plugged into an electrical outlet. In addition, a local technology services vendor, Kidwell Companies, also in Lincoln, was brought in to enhance The Dialysis Center's wireless network to better support the carts and video conferencing software.

"We went back and forth with some of the technological issues," Emerson says. "But we now have a mobile cart with a video conferencing station."

Last June, The Dialysis Center deployed one new mobile cart at its main facility and the other two at its rural locations. Physicians at the main location use the video recording device-which has pan and zoom capabilities-to view patients on dialysis at the other locations. Nurses at the rural locations move the units to help physicians see patients better. Physicians also can access and enter data into the organization's EHR while seeing a patient, which offers them some added decision support and efficiency, Emerson says.

"We're trying to understand when it's appropriate to use this for a patient visit," he says. "It really helps our physicians do things better and replaces personal rounding. But we don't think this should always replace a direct onsite visit. It's just an option."

Sidebar

Converged network offers more options

Memorial Health System has cobbled together various wireless hardware and software across its 100-year-old main facility. But when the Colorado Springs, Colo.-based delivery system broke ground on a second hospital, I.T. leaders wanted to ensure wireless applications at the new facility were more manageable.

So before the 98-bed hospital opened last April, they implemented the Carescape Enterprise Access converged network system from GE Healthcare, Waukesha, Wis. The application also is marketed as the Universal Wireless Network from MobileAccess Networks, Vienna, Va.

It's designed to redistribute an organization's various wireless signals, including paging, cellular, telemetry, Wi-Fi and radio frequency identification, over a single infrastructure to offer improved signal strength and easier management.

"At our central location it's been build, unbuild and rebuild over the past 100 years," says Bob Barrett, director of information services. "So we thought it would be much easier to implement a distributed system that would enable us to run various applications over a single infrastructure rather than a variety of ones."

Now Memorial Health System's new hospital runs the same mobile technology as its flagship location, but I.T. staff can manage it better and is in a better position to add additional applications when clinicians need them. For example, clinicians at the new hospital now have improved Wi-Fi access to an electronic health records system, from Cerner Corp., Kansas City, Mo., than those at the flagship hospital, and they have more reliable connectivity via mobile carts, multiple types of mobile phones from different carriers and the enterprise paging system. Memorial Health System plans to install the converged mobile network technology at its flagship hospital.

The new hospital also began a pilot wireless medication administration initiative with mobile computers from Hand Held Products Inc., Skaneateles Falls, N.Y. Additionally, it's testing RFID technology from InnerWireless, Richardson, Texas, to track wheelchairs and other supplies.

The converged network's capabilities also have Memorial Health System executives looking at other wireless technologies, including mobile phones that run on both Wi-Fi and cellular networks and Worldwide Interoperability for Microwave Access, or WIMAX, applications.

"The reason for using the Enterprise Access is that over time, we won't have to have a separate infrastructure built for new applications," Barrett says. "We just have to put the right module in rather than running more wiring. The money that we have spent has given us better coverage for existing applications and set us into the future for any other wireless applications we might need."