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Located in Richmond, Va., Virginia Commonwealth University Health System (VCUHS) is a $1.4 billion organization that includes the VCU Medical Center, a top-ranked hospital by U.S. News & World Report. MCV Hospitals is the teaching hospital component of the VCU Medical Center, which also includes outpatient clinics and a 600-physician faculty group practice. The 779-bed VCU Medical Center is a regional referral center for the state, and is the area’s only Level I Trauma Center. Recently, HCI Associate Editor Kate Huvane Gamble spoke with VCUHS CIO Rich Pollack about a number of issues, including the health system’s major wireless transformation, the challenges involved in balancing different clinician preferences, and the decision to offer EMR access via smartphones.
KG: I can imagine how much easier it is to have this new building where you can start fresh with wireless and put in state-of-the-art technologies without having to worry about retrofitting.
RP: Oh yeah, and it created something we were worried might happen, and that is a “have and have-not” environment. The people who are in that building have the optimal wireless experience. It’s solid, it’s reliable, and there are no dead spots. It’s comprehensive for your cell coverage, the 802.11, the new Ascom phones, all of that. But the moment you go across the bridge into the older hospital, your wireless experience is suboptimal. So then what happens is, before, people didn’t know any better. Now, they say, we want it like the critical care hospital. And I’m thinking, uh-oh, I knew this was coming. So that’s a little bit of an issue. It’s more the physicians — the nurses pretty much stay put. They’re assigned to a unit in the critical care hospital; they’re not going back and forth that much. But the physicians definitely do, and they’re the ones who’ve started to complain and say, why can’t we have that kind of capability and coverage in our other buildings? And we say, well, you can, but we can’t afford it, especially with the economy now.
KG: It seems like it was pretty fortuitous timing on your part to get construction of the new building started when you did.
RP: Absolutely. We were lucky that I started down this path back in the days when the heath system was doing really well with its margin, and got most of the work done before the economy tanked. It was a perfect storm, actually. When I look back I think, wow, we were lucky in that case, because that would’ve never happened today. It would just be too difficult.
KG: So along with the new wireless systems, you put in laptops, tablets, computers on wheels, things like that?
RP: From a device standpoint, we use a variety of mobile devices. We have about 500 or 600 computers on wheels of different types, and probably almost an equal number of tablets and laptop configuration devices.
We’ve never found a perfect mobile device that meets everybody’s needs; everyone’s a little bit different. Nurses generally prefer the computers on wheels, but even that’s not necessarily true. It depends on their unit and how accommodating it is. And some nurses in some units still prefer the wired PCs. Physicians are all over the place. Sometimes they like the computers on wheels, because, being a teaching institution, they might have an attending with them and interns and residents trailing them, and they’ll use the computer on wheels. They roll out down the corridors as they go patient to patient, and it forms sort of a virtual classroom situation, because they can bring stuff up on the display and discuss the case.
But then other times there are physicians who really prefer a laptop or a tablet, and there are some that really don’t want to do that — they still want a wired PC. I knew from my past history that there is no one-size-fits-all, and you really have to kind of provide a smorgasbord of options, and work with the clinicians to see which ones work best for them.
What we didn’t want was for access to devices or for coverage to become an impediment to the use of the EMR. We wanted to remove the infrastructure as any kind of possible impediment. We didn’t want people coming back and saying, ‘I can’t do this. I can’t do CPOE or documentation because I can’t get to a device. Or, ‘It’s not mobile, or the device isn’t suitable for me.’ So we tried to provide enough capability that that wouldn’t be an issue.
KG: That’s a really critical piece right there. It’s hard enough to get adoption rates where you want them without adding usability issues.
RP: Exactly. You can’t give them any kind of easy out. I mean, who likes change? You don’t find too many people that say, ‘Sure, give me the change. I’ve been doing this for 20 years, but I absolutely want to change.’
It’s kind of funny how that plays out. And still today I see a great deal of variation, even in my own experiences. I had a dermatology appointment at one of our clinics a few months ago, and there were a bunch of laptops that they weren’t really using because of connectivity problems. I talked to the head nurse, and she said, ‘I really wanted wired PCs,’ and actually all of the treatment rooms are set up for wired PCs. They have counter tops and they have network connections to power, but no wired PCs. I asked her what happened, and she said, ‘My colleagues outvoted me. They didn’t want computers in the rooms, they wanted wireless devices, because they didn’t want to log in and out every time they went to a different room.
So now with the wireless not quite working right — which we did eventually fix for them — they were all fighting over the two or three PCs that were at the front registration desk. So I said, let’s put in those wired PCs in the rooms and let them keep the wireless laptops as well. It’s kind of a belt and suspenders approach. That way, they have something to fall back on, because with wireless, as good as you try to make it, it’s still not nearly as reliable as the wired infrastructure. Sometimes it is going to fail, and now they have something to fall back on.
Then I had an appointment at an orthopedic clinic, and I saw that they had little computers on wheels up and down the hallways, and people are working on them nonstop and their wireless is working great.
KG: It’s amazing the differences you can see from one clinic to another in terms of how well wireless is working, adoption levels, etc.
RP: Every clinic and every venue is going to be different. It’s not a cookie cutter; you can’t make a generalization. If you’ve seen one clinic, you’ve seen just that — one clinic. Each one is different in terms of their workflow and staffing and the way they react and use data and the system, and you just have to be very flexible and accommodating in terms of the underlying technology. But you want to do whatever you can to remove any impediment to the use of the electronic medical record. My constant refrain was, what are we worried about, $20-30,000 in devices, when I’ve got a $70 million dollar EMR project hanging in the balance? Let’s get real here. So you have to set the right expectations among your staff. It still requires a lot of work, but we really have accomplished a tremendous amount in a relatively short period of time.