Clinicians, clinical informaticists, and IT leaders at the 20-hospital University of Pittsburgh Medical Center (UPMC) health system have been moving forward on many fronts to improve care processes for patients and for clinicians. One of the numerous innovations at UPMC, which was developed by a corporate-level IT team, but is being implemented first at UPMC Presbyterian Shadyside (the flagship hospital facility of the health system) is an ensemble of “SmartRoom” technologies that together are facilitating more effective care delivery patterns among UPMC clinicians. Carol Scholle, R.N., clinical director, transplant, and dialysis services at UPMC Presbyterian, has been the clinician leading the clinician/clinical informaticist teams in their collaboration with the IT professionals on this project.

For their innovative work in this area, Scholle's team earned the third-place award in this year's Healthcare Informatics/AMDIS IT Innovation Advocate Award program, co-sponsored by Healthcare Informatics and by the Association of Medical Directors of Information Systems (AMDIS). All three winning teams were recognized in May during the Healthcare Informatics Executive Summit held in San Francisco.

The UPMC team's submission to the program included the following: “This team implemented a new bedside charting technology on a high-acuity abdominal transplant step-down unit. This SmartRoom technology utilizes an ultrasound-based real-time locating system, in which the nursing team wears tags that are identified by sensors located in the hallways and in the patient rooms.

WE ACTUALLY HAD THE NURSES WEAR PEDOMETERS, AND FOUND THAT THEY WERE WALKING AN AVERAGE OF 4.5 MILES PER SHIFT; AND THEY GOT THAT DOWN TO ABOUT 3.8 MILES PER SHIFT.

When the caregiver walks into the room, the touch screen mounted on the wall announces the caregiver by name to the patient and then presents HIPAA-compliant information to the caregiver. The system also allows the caregivers to do routine documentation through a touch screen interface, and they can access key clinical attributes about the patient-meds, labs, vitals, etc. Finally, the system has a patient- and family-centered component that engages the family in the care process, and provides education and entertainment. This is a new technology built at UPMC, and this unit was selected because of their leadership and willingness to try new technology.”

Among the numerous results attained: most routine documentation is now done in between 40 and 70 percent less time than in the traditional system; patient satisfaction scores have soared, because of the perceived patient- and family-friendliness of the new caregiver behaviors (including both doing bedside charting, and the deployment of the “announcing” technology when clinicians enter the patient rooms); and nurses have significantly cut down on the distances they walk daily, because of the increased proximity of computing devices, thus increasing their efficiency and their ability to spend more time at the patient bedside.

Scholle spoke recently with HCI Editor-in-Chief Mark Hagland regarding the work behind this innovation, and its implications for the future of care delivery. Below are excerpts from that interview.

Healthcare Informatics: What was the initial impetus or strategy behind this innovative work?

Carol Scholle, R.N.: It does go back one step earlier to Shadyside. There was a situation that occurred where a patient had a latex allergy, and that information wasn't available at the bedside, so the patient was exposed to latex-a kind of sentinel event. So some very smart people like Dave Sharbaugh [who continues to lead the SmartRoom technology development at UPMC] decided that we needed to automate the process of providing whiteboard-type information. So they came up with the idea of pulling some information from the electronic patient record and displaying it in patient rooms.

And one of the challenges was that, as the system became more mature, there was the desire to interact more with it, and one early iteration was using a light pen on the screen in the room-it was the television screen in the room, either the patient's or a monitor screen. That was an early iteration.

And then there was an engineer who kept working on the idea, and it was determined that our CEO wanted to try this on a larger scale and in a more robust form. So at that point, we looked at Presby to see if this could be more successful. At that point, my VP, the vice president of patient care services and our chief nursing officer, recruited me to get involved. That was in the fall or winter of 2009.

AN IDEA TAKES ROOT

HCI: You worked with IT and others in the development work?

Scholle: We worked with IT and the SmartRoom Team. At that point, through our Small Business Ventures division, they pulled together a small company that is affiliated with the UPMC corporation. And the very first nursing unit to try it was Unit 12 North, which is an abdominal transplant step-down unit. And we looked at the physical environment. We have private rooms and semi-private rooms at Presby, and we initially wanted to focus on a unit with private rooms, which 12 North had; and I felt very strongly that we needed to work with a staff that would be highly engaged in developing this. And 12 North had been very involved with the Transforming Care at the Bedside work advocated by IHI [the Cambridge, Mass.-based Institute for Healthcare Improvement].

It's really a rapid-cycle change method-you would try something new and quickly tweak it, and then spread it. So they were very familiar with this kind of concept, and receptive to it, and were able to give us the kind of feedback we were looking for, to improve care processes and make life easier for front-line caregivers. So we met with them formally weekly, but the SmartRoom team folks and the unit leader, Marcia McCaw, R.N., talked daily. So it was a developmental process and continues to be.

We went live with this in June 2010, so we've been live there for a year. And then a couple of months after the implementation there, we went live in the GI surgery unit. And that was particularly interesting, because one of the physicians who admits patients there and does surgery is Dr. Andrew Watson, who is the medical director at UPMC's Center for Connected Medicine, and who has some very cool ideas for things he'd like to do to expand communication capabilities with patients.

So right now, we are live on five units, and are working on a sixth. Our campus includes the Presbyterian building and the Montefiore building, and we plan to have the Montefiore building entirely live. Our hospital is called UPMC Presbyterian-Shadyside, which consists of the Presbyterian campus and the Shadyside campus. I'm on the Presbyterian campus, in the Montefiore building, and the units that have gone live are in the Montefiore building. But our goal is to have the whole Montefiore building live by the end of the year.

REAL-WORLD IMPROVEMENTS

HCI: How has this made a difference in care delivery?

Scholle: Among other things, it has saved steps for the nurses. We actually had the nurses wear pedometers, and found that they were walking an average of 4.5 miles per shift; and they got that down to about 3.8 miles per shift; so they were able to save steps. And every minute that they're walking around instead of with a patient decreases their face time with patients. We have also had the kinds of things that nursing assistants are able to do, when they do their vital signs-so there's some ability to do documentation right at the point of care, via the touch screen monitors in the rooms.

HCI: When the caregiver enters the room, the smart screen announces the caregiver by name to the patient. That seems like a very strong patient and family satisfier.

THE CAREGIVERS AT THE POINT OF CARE ARE VERY BUSY TAKING CARE OF PATIENTS WHO ARE MORE COMPLEX THAN THEY'VE EVER BEEN CLINICALLY. SO IT'S REALLY HARD TO GET CHANGE ACCEPTED.

Scholle: Yes, and we had talked about the whiteboards, and prior to that, the nurse was supposed to come in and write their name on the whiteboard, but of course there's the human factor, and sometimes the nurse would forget, and the previous nurse's name would still be on there. And the patients do appreciate knowing which doctor is coming in. The doctors are electronically badged, so their names appear; and we're in the process of universalizing that identification system across all caregivers, including physical therapy.

Another really nice feature for the patients that we just went live with in January and that we're still trying to optimize is our patient education feature. Based on the things the nurse knows about the patient, and what the patient needs to know to take care of themselves and understand their situation, the nurse can go into the smart screen and select some videos and education. And some of those can be very specific. For example, in the transplant unit, they and their patient would have to present this information to patients and family members right after their transplant. And we took that content and adapted it so that it could be made into a module for SmartRoom education; so in addition to attending a class, the patient has that information available at any time.

THE DOCTORS ARE ELECTRONICALLY BADGED, SO THEIR NAMES APPEAR; AND WE'RE IN THE PROCESS OF UNIVERSALIZING THAT IDENTIFICATION SYSTEM ACROSS ALL CAREGIVERS, INCLUDING PHYSICAL THERAPY.

Anyone who knows about transplant patients knows that compliance is a huge issue. Their care is very complex, and the medication regimes are very complex; the kinds of things you can and can't do if you're had an organ transplant-there's a lot of information to know and remember. Some of these patients are taking 28 or 30 pills in the morning and have more to take later in the day. And that piece of education is so critical to their surviving and thriving, and yet is so difficult to deliver successfully, that you can't reinforce it enough. So that's one piece of education available through the SmartRoom technology. And that's one of 200-some videos available.

So the nurse selects the appropriate video for the patient, and then the patient can activate the video through their pillow speaker device, and then the nurse later can inquire whether the patient has viewed the video, and then once the patient confirms they've seen it, the nurse can document that at the point of care.

LESSONS LEARNED

HCI: What have been the biggest strategic lessons learned so far?

Scholle: I think that we did right by selecting that first unit. The first place that you implement a new strategy needs to be well-prepared for accepting the technology. We have had challenges as we've rolled forward, because we haven't provided quite as much support on subsequent units; so that's a lesson because those units weren't quite as prepared for change as that first unit was. So we had to step back and say, we need to provide more ongoing support to those additional units.

HCI: I think healthcare delivery will all be about change going forward; but to have that, you need a culture that is receptive, right?

Scholle: Yes, that's one of the great challenges. The caregivers at the point of care are very busy taking care of patients who are more complex than they've ever been clinically. So it's really hard to get change accepted. And we've made some mistakes along the way. Organizations have made the mistake of saying, OK, let's do barcoded meds administration, that's great, and let's do this and that, and while adding all these technologies may seem like they're making things more efficient, and making care better and safer, but when you combine them, what you've done is to create a really complex working environment for caregivers, particularly when the systems can't talk with one another. So you'll have to have the interoperability to make these systems work together.

I think that's our biggest challenge. But what SmartRoom has done for us has been to make the systems in place work for us in a more usable manner-things like not having to log in all the time. But there are some interoperability issues between our electronic health record and our SmartRoom technology, so the SmartRoom folks continue to work on that.

Healthcare Informatics 2011 September;28(9):36-42