Feb. 27, 2007 | Do healthcare professionals in your organization want laptop computers? Tablet PCs? Plain old desktop machines? Personal digital assistants? Sure. All can work just fine in clinical environments.
"We want to be as device-independent as possible to give physicians a range of options," says Mary Kay Payne, president and chief information officer of Hoag Memorial Hospital Presbyterian, a 511-bed, not-for-profit facility in Newport Beach, Calif.
In general, when buying hardware for the hospital, Payne looks for standard, off-the-shelf computers without a lot of bells and whistles unless absolutely necessary. "Reliability is very important to us on the desktop side," Payne says. Desktop PCs are in place in administrative areas of the hospital, as well as in pharmacy, laboratory, and imaging departments.
But nurses on patient floors, currently the heaviest users of IT on the clinical side at Hoag, need a degree of mobility, and that means computers-on-wheels, or COWs — typically laptop computers mounted on heavy-duty carts that also carry full-size keyboards, mice, and extended-life batteries. The laptops connect to hospital servers via a wireless network.
Hoag's new tower has three nursing stations and two substations on each non-critical care floor, and each nursing unit has six to eight COWs that nurses roll down the corridors outside patient rooms. "They like to be able to walk out into the hallway and use the COWs," says Greg Bush, the hospital's executive director of information systems.
Tim Gee, principal of Medical Connectivity Consulting, Portland, Ore., likes the combination of processor speed, usability, and mobility that COWs offer, as long as there is sufficient battery power and enough devices so nurses don't have to fight each other to find an available machine. "COWs can be used for meds administration or for bedside charting," he says.
"Nurses' stations are typically overcrowded," notes Harry Anderson, director of purchased services for Irving, Texas-based hospital alliance VHA. "Room for computers is at a premium." The more computing power that can be transferred to the point of care, the better, he says.
A number of manufacturers have developed wheeled carts specifically for hospital operations, with maneuverability, adaptability to multiple hardware configurations, built-in security features, and onboard battery power. Among the larger names in this arena are FloHealthcare, USAT Corp., Rioux Vision, and InfoLogix.
As hospitals build up their IT infrastructure, some are installing bedside computers as an alternative to mobile workstations. That way, clinicians do not have to go far to look up charts, enter orders, and document encounters, while patients can use the same computers to surf the Internet or e-mail friends and family. "I think we're going to see more of that," Anderson says.
Hoag Hospital right now is in transition between paper and electronic records. All nursing documentation, most orders, and results reporting are electronic, but physicians still write the majority of their clinical notes on paper or dictate.
"We're in a hybrid world," Payne says. And, according to Payne, mobile devices work very well in such an environment, as long as users can send documents to whichever printer happens to be closest — which creates a headache for network administrators and records managers alike. "It's more difficult to control where things print with mobile devices."
Says Payne, "It's really a complex workflow issue." (For an in-depth discussion of mobile devices in healthcare, see "Use of Mobile and Wireless Technology.")
"What works for one area doesn't necessarily work in another," Payne notes. Rather than filling out paper forms, patients enter their registration details on tablet PCs. "We're also looking at tablets for the ER," Payne says. Outside of the emergency department, however, nurses tend to prefer full-size keyboards and displays, while physicians like something they can slip into a coat pocket such as a PDA or smart phone.
No matter what the choice for user workstations, hardware purchasing decisions must account for more than just personal preference.
"You really need to consider total cost of ownership," Anderson advises. For hospitals, this includes not only basic considerations like maintenance and data security, but also infection control and expenses related to disposing of computers that have come to the end of their useful lives.
That lifespan typically is about three years for a desktop computer and two for a laptop that's been moved around a lot, according to Ross Ely, executive vice president for sales and marketing at Nampa, Idaho-based hardware manufacturer MPC Computers. Electronics giant Panasonic cites research saying that ruggedized laptops can last up to four years, even with heavy use.
The release of the Windows Vista operating system may accelerate the replacement cycle this year, however. "A lot of our customers have indicated that they're going to adopt it very soon," Ely reports.
The new, resource-hungry version of Windows is just one example of why Gee insists that his clients have a "roadmap" for technology adoption that goes two to three years out to make sure that the hardware they buy now can run future applications. "If you get something that's underpowered and you get something next year it can't support, then you will face hidden costs to upgrade your network," Gee says.
King's Daughters Medical Center in Ashland, Ky., ran into problems while upgrading its network to handle the 30 percent to 40 percent annual growth in radiology volume the hospital has experienced in recent years. Radiology and its associated picture archiving and communications system (PACS) happen to be the largest user of telecommunications services in the 384-bed hospital.
"When I started there, the hospital was providing good, quality care with a shoestring backbone," says PACS administrator Chad Phipps, who joined King's Daughters in 2003. Clearly, an overhaul of the infrastructure was in order.
The expanded network provided plenty of capacity, but also caused so much additional heat buildup that the IT department has had to upgrade its air conditioning three times in the last four years. Now, the hospital is migrating to modular IBM BladeCenter servers, with hot-swappable "blades" that slide into multi-server chassis to share power, drives, switches, and ports.
On the user end, King's Daughters had a serious issue with nurses walking away from computers without logging out, leaving the hospital vulnerable to HIPAA privacy and security violations. The solution was purchasing high-security "thin clients" — user terminals without hard drives — and issuing smart cards for user authentication. Without a card and the proper password, the machines won't work.
King's Daughters began a pilot test of SunRay terminals from Sun Microsystems at one outpatient clinic last summer and will start general deployment of the devices in the next six to eight months as part of a three-year overhaul of its total IT infrastructure. "We don't want [clients] in our institution anymore using local drives," Phipps says. With the thin-client system, data storage, software upgrades, and patches will be handled at the network level. "Client maintenance is zero," he adds.
The thin clients will be limited to clinical areas. "We're not going to use them to replace an administrative-office PC," Phipps says. Management decided that replacement of all 4,000 computers throughout the enterprise would bust the hospital's budget and be too disruptive for employees. The SunRay project thus will be limited to about 700 terminals at about $350 apiece — compared to $1,000 each for loaded desktop computers.
MPC's Ely says that hospitals tend to go for specialized equipment to save space and uniformity to enable network manageability, so the typical $400 computer at a retail store probably won't do.
MPC is just one of several computer manufacturers that produce machines especially for healthcare. A year ago, Panasonic introduced a line of Toughbook ruggedized mobile PCs for hospital use. Tablet PC-maker Motion Computing produces keyboardless, touch-screen computers that weigh just 3 pounds, making them easy for physicians to carry on their rounds.
Other major computer companies with dedicated healthcare divisions include Dell, Hewlett Packard, and Fujitsu. Smaller players abound, offering everything from waterproof keyboards to extended-life batteries. In the area of thin clients, Sun's chief competitor is Wyse Technology.
At King's Daughters, a side benefit of the conversion to thin clients is that each unit only consumes 5 watts of power, compared to 75 watts for a typical laptop computer or 300 for a high-performance desktop PC. Phipps expects King's Daughters to realize net savings of $500,000 in labor and back-end hardware expenses over the next five years as a result of the new clients and servers.
Blade servers can allow hospitals go one step beyond thin clients by putting only a keyboard, mouse, and display screen at the user end and keeping the brains of the computer in back. "If one of [the terminals] goes down, you don't have to go to the nurses' station," says VHA's Anderson. "You just replace a board in the MIS department."
Another relatively new factor in the hardware equation is cleanliness, as hospital-acquired infections have become a major concern for management and the public. "Whatever you do, you have to have something that can be disinfected," says Gee, the Oregon-based consultant. This means keyboards covered by plastic or rubber membranes or at least a surface that won't be damaged by antiseptic wipes.
Anderson says that many of the more than 2,000 VHA member-hospitals have been considering keyboards and mice coated with Microban or similar antimicrobial substance.
On the advice of customers, MPC has developed full-powered computers built into a flat-panel LCD display that not only saves precious space, but is easy to clean. "It's really considerably easier for [customers] to wipe down a smaller unit," says Ely. "We've found this all-in-one unit to be very popular in hospitals."
Of course, germs are spread by more than just touch. "A fan in a patient's room can deposit microbes on a computer," says Anderson. It's a good idea to turn off, remove, or at least disinfect portable fans before introducing computers that will be used near sick patients, he cautions. For the same reason, it might be safer to bring tablet computers into patient rooms because tablets, unlike laptops, tend not to have built-in cooling fans.
Now, hardware decisions are starting to include "smart" medical devices that integrate with, or feed data to clinical information systems. Of note, Baxter Healthcare is producing infusion pumps that send automatic alerts to clinicians if something is wrong, and Cerner has begun to sell medical devices that integrate with the company's flagship clinical information systems. (See "HIMSS 2006")
Gee says that the capture of device data into EMRs is "frequently overlooked," even though lack of integration can introduce transcription errors and force clinicians to enter the same information twice. "There's frequently not enough coordination between IT and clinical departments," Gee says. "All of a sudden, the benefits of having an EMR have evaporated."
"IT vendors have avoided this, except for [in] blood banks and PACS," Gee adds. "It's something that people should be considering." In any case, it's always helpful when new purchases work with existing systems.
As part of its nearly $2 billion program to automate its entire organization (See "Kaiser's $1.8-Billion EHR Project"), Kaiser Permanente is looking to integrate medical devices with KP HealthConnect, the electronic health record being installed by Epic Systems (Madison, Wis.) — but not until the time and circumstances are right. Kaiser will not jeopardize the ability to use a device just to make it connect to the EHR, but will at some point in the future demand connectivity from its vendors — if the federal government or health-IT industry doesn't require it first.
Though each Kaiser region is at a different level of connectivity and at a different stage of implementation, the flagship Northern California region has an agreement with clinicians that they will have some sort of integration in the future. Kaiser is asking vendors for plug-and-play compatibility with medical devices, but the EHR standards process is incomplete, according to Bridget Moorman, clinical systems engineer for Kaiser Foundation Hospitals, the provider side of the Kaiser Permanente organization.
"Our job shouldn't be integration. Our job should be healthcare," Moorman says.
"The primary criterion for a medical device is that it does what it's designed to do medically," Moorman explains. "Is technology enabling or hindering the care process?"
In the paper world, the nurse just has to read the patient monitor and write down the values. "If it takes the nurse eight steps rather than two steps [to perform a given task with IT], the two steps is going to win out," says Moorman.
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