In an era of tight healthcare budgets, it’s become extremely important for healthcare IT leaders to figure out how to stretch their dollars—and their technology—to better achieve the goals of meaningful use and accountable care. That’s just what the five-hospital University of Missouri Health System (UMHS), based in Columbia, Mo., did when it adapted its barcode scanning system for mobile patient- bedside medication-administration documentation.

“Looking at what technology you already have and how you can use it in new ways [is important],” says Debra Dow, senior project manager, Tiger Institute, University of Missouri Health System. “There’s always a vendor out there that offers a specific solution to address a specific need, but that becomes expensive and ends up being a lot more maintenance to support that separate application or vendor.”


Debra Dow

Dow works in the Tiger Institute for Health Innovation, which the University of Missouri Health System, in partnership with the Cerner Corporation (Kansas City, Mo.), formed in 2009 to go beyond current best practices and create new solutions that enhanced the quality and safety of patient care. The University of Missouri Health System’s IT department is run by Cerner, and all five hospitals and 52 ambulatory sites have the Cerner electronic health record (EHR) as their core clinical information system.

Dow, who has a team of 28 associates, manages incoming project requests and the resourcing of them. Within two years, the University of Missouri Health System has seen rapid adoption of clinical best practices and moved from a HIMSS Level 2 to 6, as well as being recognized as a Most Wired hospital, and receiving the Missouri Quality Award.

To solve the problem of transferring patient vital signs to the EHR, the University of Missouri Health System sought to implement an efficient and timely method for mobile patient bedside documentation. Vital signs and pain scores are critical, and if they are not input in a timely matter a nurse might not be aware of critical information like a patient’s pain medication needs or potential infection risks.

Historically, nurse technicians at UMHS would round on the units and collect vital signs of all the patients consecutively, write the information down on paper, and then enter the results into the EHR in a batch process. A timed study found the length of time on average from point of collection to results being entered into the EHR was 32 minutes, which potentially impacted patient safety due to the time delay. For example, the delay in entry reduced the effectiveness of assessing the risk of conditions like Sepsis or monitoring the increase of temperature after surgery.

Since not all patient rooms had PC workstations, the only mobile device nurses and nurse techs had access to at that time was the barcode medication administration device (the Honeywell Dolphin 9900). This device also supported the Cerner CareMobile product, which made the implementation and adoption of bedside documentation much easier.

The workflow design for the mobile documentation included electronic EHR rules that triggered tasks upon patient admission, such as collecting vital signs, intake and output, activities of daily living, and pain scores at the bedside. In addition, this automation allowed for positive patient and staff identification through barcode scanning.

The project planning started in May 2011, and documentation was implemented by that July. Initially, the project was rolled out to one floor for issue resolution; then in a span of three weeks, the team rolled out the technology to all 12 units. For the first two weeks, the device was used 7,429 times, which was a high usage rate.

A key for this IT project was the coordination with the nursing staff, says Dow, which allowed her team to show results in a short amount of time, allowed for quick user adoption, and was budget-neutral. Essentially, the current medication administration devices were enhanced to allow for mobile point-of-care documentation, which has shown to be a successful method of capturing patient data and ultimately improving patient care.

“A factor in why this [project] got done instead of something else is because of the fact that it was budget neutral; we didn’t have to go ask anyone for money,” says Dow. “It was a fairly simple build within the EHR, and nurse educators on the units agreed to do the training, so we really didn’t have to involve a lot of people to get this in place.”

Another reason this approach was taken was the fact that this would be an interim solution. UMHS is planning to build a new patient care tower adjacent to University Hospital (its main campus location in Columbia) that will have vital sign machines (provided by the Skaneateles Falls, N.Y. -based Welch Allen) in all patient rooms that wirelessly feed the data into the EHR. “Instead of taking two to three years to [implement this project], we actually got to that point in two to three months knowing that two to three years down the line this technology would be replaced by something that was actually better,” says Karen Nickell, R.N., nursing architect, Tiger Institute, University of Missouri Health System.


Karen Nickell, R.N.

Nickell, a 14-year IT veteran, designed the build and worked with the device professional to build the workflows and develop special server configurations. The implementation team included IT services, nursing leadership, 12 unit nurse educators, and six staff members from the education and training department. “Just in time” training for an average of 30 to 60 minutes per person was provided to the nurses and nurse technicians on the units.

Compliance was continually measured post-implementation, says Dow. Tiger leadership followed up with nurse coordinators on floors where nurse techs were still using paper, and worked with them to ensure compliance. “I actually ran weekly reports and sent it to the management of the units so they could look on it and see which of their staff was using [mobile documentation] and getting the information in a timely manner,” says Nickell. “And if someone’s name was not on that report, they could go talk to them. Educators and managers were adamant that this would be used for patient safety and workflow.”

To measure success, a pre- and post-implementation time study was conducted, and significant improvements were found. The average length of time from point of collection to results documentation in the EHR decreased from 32 minutes to 2.2 minutes. This project has resulted in improved patient care and safety, efficient nursing workflow, and care team satisfaction, says Dow and Nickell. Documentation errors have been reduced, electronic health advisor rules now trigger in a timely manner and the care team workflow and satisfaction is improved.