Online documentation: making it work with POC technology – Methodist Hospital uses point-of-care technology to develop computer-based patient records – Company Operations
Methodist hospital is using point-of-care technology to quickly make the computer-based patient record become a reality.
Methodist Hospital, Arcadia, Calif., has an immediate requirement for accurate and meaningful clinical information that is readily accessible to all who have a need to know. Thus, like most progressive health systems, Methodist has determined, as part of its integrated business and technology planning processes, that the computer-based patient record (CPR) has to become a reality as quickly as possible.
The CPR, broadly defined, is a composite of a variety of feeder systems from across the continuum of care, a clinical repository or warehouse to intelligently store the data and a technology infrastructure to integrate and present the information.
Feeder systems include all of the traditional hospital applications. They also include those newer applications designed for direct data entry by clinicians. For these systems to be used satisfactorily, they must be designed to enable the easy recording of findings and care provided, physician order-entry and review of the information from the point at which the patient encounter takes place. In the 1980s, such systems were called “bedside” and were primarily designed for nursing use. Benefits of these systems were described in terms of saving nursing time and improving the accuracy and legibility of documentation. In concept, these benefits were attractive but for most hospitals the benefits of nursing specific systems, often using “stand-alone” technologies, were not justified.
The mid 1990s, however, present a completely different situation. The focus has expanded from the bedside to wherever there is interaction between patients and clinicians. As the healthcare information technology environment explodes, the costs are decreasing and the input devices are improving. Most importantly, the system integration tools are sufficiently sophisticated to provide considerable added value.
Methodist Hospital is a 347-bed acute-care facility that is part of the Southern California Healthcare System. Its location puts it in the forefront of managed care. In 1991, the hospital, recognizing the need for quantifiable clinical information to compete in their intense market environment, began a planning process to implement advanced clinical systems. In 1992, after a year-long selection process, Compucare’s Affinity product was chosen for its functionality, flexibility, open systems, real-time ad-hoc report writer as well as the system’s RISC architecture. Then, in 1993, the organization ventured into a beta site agreement with Compucare for its online, multidisciplinary, charting applications. The project was called CHASS, for online Charting/Assessment. Phase I took place during 1994 with two pilot units and included physical therapy, respiratory care and social services. Each discipline provided valuable insight into what would be required in screen design, standardization of charting practice and hardware requirements.
Unfortunately, for the project team, the results from the pilot were less than satisfactory. Multidisciplinary care givers felt that the benefits of CHASS could not be realized by recording information first manually, and then later entering it into the system through devices located in the hallways. After much frustration caused by duplicate documentation and occasional waits for an available device, it was recognized that online charting would not work at Methodist unless the documentation occurred at the point of care.
To the delight of all involved, executive management stood behind its resolve to automate clinical documentation and agreed to expand the scope and cost of the project to include point-of-care (POC) devices for data capture. The project team was reorganized and new members were included. Their charge was to determine what hardware and software changes were required for success.
The project was led by a multidisciplinary task force chaired by the director of Physical Medicine Services and included representatives from Information Services, Nursing, Education, Medical Records and Therapies. Reporting to this Task Force was the CHASS Workgroup. This workgroup was led by a dedicated project manager who organized 16 staff from all over the organization. Their job was to design screens and workflows. Participation required approximately six hours of time per week. Computer literacy was not required. It was felt that a mix of staff both with and without computer skills would generate the most use-friendly system. Additionally, they wanted a combination of skill levels and professional backgrounds. This same staff became the unit experts working in teams with their peers to address and design unit-specific requirements. Additional personnel were asked to join as needed. Admitting and emergency room, for example, helped with design of admission screens. The medical staff’s Computer Technology Committee was consulted as advisors. HIS members of the workgroup focused on the requirements, design and testing of a POC device.
Identifying a POC device
Staff on the pilot units were clear on what they needed in a device to support charting of assessments and vital signs. They needed PC’s in the nurse stations, a wall-mounted device in the hallways that would meet safety codes and a portable device for patient rooms. As mentioned, they had tried to use PC’s in the nurse stations and a stationary PC in the corridor. That approach had not worked. With spirits buoyed by the visible, strong support from Methodist’s leadership team, and recognition that they were exploring new territory, the workgroup enthusiastically began its search for the right POC technology.
The workgroup began by identifying evaluation criteria (shown below). Then, with guidance from Compucare, the following products were identified and evaluated:
* laptop PC’s,
* handheld devices,
* Telxon and Toshiba pen-based computers,
* Datalux Touch screen monitor or portable PC workstation, and
* Planar’s wall mounted or portable terminal workstation.
Staff quickly prioritized what they needed after seeing these products. The device must have wheels, wireless capabilities, full-sized keyboard, color monitor and a pen input device. The custom designed prototype now being used on the pilot units consists of an IVAC blood pressure/pulse monitor, a Telxon pen computer, and a Scorpios 101 keyboard. All are mounted on IVAC poles and are on wheels. The care giver wheels the battery powered device to a convenient location into the patient’s room and enters data as soon as it is collected. When not in use, the device is plugged into a socket in the corridor. Since nursing staff were already accustomed to plugging in the IVAC BP monitor after use, this was an easy transition. The Planar wall mount workstation is also well liked by everyone as it provides alternative charting just outside the patient’s room when that is the preferred option.
The hardware options of laptop PCs and handheld devices were eliminated because of the constraints related to the smaller keyboard and difficulty keeping such items secure.
Response to POC systems
In contrast to the initial reaction to online documentation experienced in Phase I, there is now a much more positive response to the system. Interestingly, despite an initial concern from staff who “can’t type,” the keyboard is being used much more frequently than the pens. Ancillary personnel have expressed the most satisfaction with the portable device for use during bedside assessments, progress notes and discharge summaries. Nurses find the POC device especially useful for admission assessments. Aides have found that by quickly inputting vital signs as soon as they are taken, they are saving time by not having to “double document” and are not having to be reminded to “chart the temps” when patients need them for direct-care activities. Due to timely data entry, information is immediately available online and the unit is able to post vital sign paper reports for physicians at 9 a.m. and 1 p.m.
The medical staff has found the consistency and legibility of information on the patient-care summary helpful. Indeed, several have indicated that as a result of the patient-care summary, they are much more cognizant of their patient’s status than when they had to extract and decipher information from various places throughout the “old” patient chart. Patients have also responded favorably to this new use of technology. Many are, at first, curious. But all recognize the long-term value of increased automation once it has been explained.
From a technical perspective, the Telxon Radio Frequency Network has proven quite satisfactory. However, there is dissatisfaction with the clarity of the Telxon monitor. Staff have complained that it is difficult to view information on the screen. Both the Toshiba and Planar monitors were rated higher by staff and HIS.
Both pilot units have supported the implementation of the Affinity software and POC device housewide. This decision was reached after careful review of response to the system and the POC approach, as well as the achievement of what were defined as critical success factors.
Critical success factors
The CHASS workgroup identified five critical success factors that they felt must be met before implementing housewide. They have satisfied all of these requirements and now plan to implement all remaining units.
Online documentation must take the same or less time than manual charting–The staff perceived online charting as follows:
* 33 percent felt that charting time was improved,
* 33 percent felt that charting time was about the same as manual charting, and
* 33 percent felt that charting time took longer than manual charting.
Radio frequency must be reliable: no lost data–Lost data is rare and attributable to user error when investigated.
Charting will not be redundant–Nursing staff and ancillary staff on both pilot units chart one time using the computer. Some nurses deviate when keeping track of selected vital signs on their clipboards.
Hardware will be standardized on all units: portable POC devices–All units will be equipped with wheelmounted RF POC devices with a full keyboard and touch pen. Planar wall mounted workstations and PC’s will be installed in nurse stations and hallways or specified workrooms.
Assistance will be readily available and suggestions for change valued-Pilot units have been satisfied with the unit expert role and the forms available to record ideas for changes.
Online documentation of vital signs and patient assessments on all remaining medical and surgical units is in progress. Each unit will receive duplexing printers, POC devices, wallmounted workstations, PCs, RF antennas, cabling and chairs based on the size of the unit. A 30-bed unit with a rapid turnover of patients will receive four POC devices, four wallmounted, three PCs and two printers.
Planning continues for other clinical disciplines and ambulatory departments to both enter data and access information from the system. Methodist Hospital is steadily advancing toward a totally integrated computerized patient record that will facilitate clinical decision-making, support care givers and quantify the level of care provided. Although the hardware to support POC data capture is still limited, Methodist has shown that with the right attitude and a supportive vendor with flexible software, online documentation can be successfully implemented.
Methodist’s POC device criteria
1. 486 PC
3. Physical dimensions
4. Battery live (more than six hours)
5. Keyboard (pop-up, full sized)
6. RF capability
7. Alternate input: mouse or light pen
8. Screen size
9. Clarity of screen
10. Color screen capability
11. Auto sleep
12. Graphics display
13. Operating system
15. Sustained “droppability”
16. Sterility/infection control
17. Roaming capability
18. Host connectivity
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