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Carts in a Time of Transition

June 25, 2010
by Mark Hagland
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As multiple trends shape how clinicians do their work, CIOs ponder the future of mobile carts

Executive summary

CIOs are actively trying to figure out how to plan for the mobile computing needs of their clinicians in the next several years. Though a broad range of viewpoints prevails across the healthcare system, most CIOs believe they will continue to rely heavily on mobile computing carts to meet clinicians’ computing needs within their facilities, even in the face of the emergence of newer, tablet-sized computing devices. Clinician needs and preferences remain paramount considerations as CIOs move to replace sometimes-aging current fleets of computing carts.

Hospital and health system CIOs are finding themselves pulled in multiple directions these days when it comes to the deployment of mobile carts for clinical computing: so much so, in fact, that it sounds like one of those classic “on the one hand, on the other hand” stories. On the one hand, CIOs are committed to meeting the needs of nurses, physicians, and other clinicians, as they pursue their critical work on a day-to-day basis, and that means doing as much as possible to address clinicians’ practical needs - and their preferences - for computing tools. On the other hand, as they look toward the horizon at a new generation of smaller and smaller mobile devices, some CIOs are actively trying to figure out where the concept of computers on carts will fit in what could be a drastically changed computing environment several years down the road. And on yet another hand, most of those interviewed for this report believe that mobile carts will continue to play an important role going forward, though perhaps with some modifications over time.

Mark Bolster, UPMC

In other words, as is the case with practically every important issue facing them these days, hospital and health system CIOs are expressing a broad range of views on the strategic future of mobile computing carts.

Some, like Jim Venturella, CIO, hospital and community services, for the 20-hospital University of Pittsburgh Medical Center (UPMC) system in Pittsburgh, Pa., are firm believers in carts as a fundamental facilitator for clinician computing in today's complex work environment. “For us, carts are an integral part of workflow for our nurses and for many of our medical residents, and I think that will be so into the future,” says Venturella, whose massive organization currently has over 2,200 carts deployed across UPMC's facilities (1,700 computing carts, and 500 medication carts). “We've got many different models of deployment of PCs across our facilities, and in my view, there is no perfect solution to that element of computing, whether it's PCs in patient rooms, right outside patient rooms, or hanging in the hallways.” In that context, he says, “Carts are the best model out there, because of their flexibility, though they tend to be expensive.” Like many CIOs, he plans to keep replenishing his organization's fleet of mobile carts, and cites many factors for the success of carts in his health system's hospitals, particularly the fact that clinicians, especially nurses, use them as portable workstations, especially in crowded, older facilities with limited space. Residents at UPMC's academic hospitals are also big cart fans, and use them for physician documentation, results checking, and to access the organization's picture archiving and communications system (PACS).

Jim venturella
Jim Venturella

Other CIOs, like Gregory Veltri, vice president and CIO of the 500-bed Denver Health, a public hospital in Denver, Colo., can see both advantages and disadvantages going forward into the future, but are following what they see as the mandate of clinician needs and preferences anyway. “Our current carts are at the end of life; we've had them five years,” reports Veltri, who has about 100 carts deployed across the teaching hospital. “We'Re looking to replace the current fleet, to my chagrin, because they are a maintenance headache,” he says, “The batteries wear out; the nurses forget to plug the carts in; and the carts take a lot of abuse-parts get knocked off. But,” he quickly adds, the bottom line for him is that “the nurses like them so much.”

Will smaller mobile devices change the landscape?

Strategically speaking, the biggest wild card factor in the landscape for planning around mobile computing is the unfolding emergence of smaller handheld computing devices, with the most attention of late focusing on Apple's iPad, which debuted this spring to much fanfare and hype. At a time when many hospital organizations are replacing aging fleets of mobile computing carts, will the introduction of the iPad - and almost certainly, of competitor products in the relatively near future - change the calculus around cart planning? CIOs are deeply divided.

On one end of the spectrum are executives like Denis Baker, vice president and CIO of the 800-bed Sarasota (Fla.) Memorial Hospital, who says, “From my point of view, carts were a bad solution to the problem to begin with. Maybe, given the state of laptops at the time, they were the only practical solution” a decade ago, Baker says. But, he says, he objects to the cost of carts, and to what he sees as the lack of healthcare-focused customization he'd like to see on the carts currently being deployed in hospital organizations. Baker sees a future, including at his organization, which is building a replacement patient care tower, in which “We'll be getting away from the personal computer concept, and creating community computers, with charging stations for devices outside every patient room, and devices fairly ubiquitous throughout the patient care area.”

Denis baker
Denis Baker

But most CIOs are far less categorical about the issue, and even those, like Russ Branzell, CIO and vice president of IS at the 427-bed, two-hospital Poudre Valley Health System in Fort Collins, Colo., who would like to try to migrate to smaller devices like iPads, see a continuing trajectory for computers on carts. On the one hand, Branzell says, “Organizations that haven't made a considerable investment in carts will probably look for other solutions, such as the iPad-type device, which already has more robustness than it did a few months ago.” On the other hand, he says, “I think we will use our carts for four or five more years, but we may reconfigure them, based on nurses’ preferences. So instead of having heavy laptop devices on carts, we may instead be working on very thin notebooks or on touch-screens driven by VMware (virtualization software developed by the Palo Alto, Calif.-based VMware).”

Other CIOs are strongly inclined in favor of carts to begin with; and among those is David Muntz, senior vice president and CIO of the Baylor Health Care System, a 14-hospital system based in Dallas. “I favor carts to begin with, because they enable mobility, especially for nurses,” Muntz says, adding what other CIOs have noted: “Carts are really for nurses; desktops are fundamentally for doctors. The only things l don't like are the battery power issues and the large physical footprint of carts,” he says. In any case, Muntz says, “Right now, the problem with the tablets and other small form factors is that you need both hands free when you go into the patient room. And the small form factor is better, but not for bedside computing.” At Baylor, Muntz notes, “We let users choose how they'll compute; and some units have chosen wall-mounts. But no matter what configuration of devices you choose, there will be a mismatch for at least a part of your organization,” because, he says, clinicians will inevitably express a range of preferences among quite diverse mobile computing options.

Such results are backed up by studies, such as a few performed in the past couple of years by researchers in the Waltham, Mass.-based Emerging Practices division of the Falls Church, Va.-based CSC. Based on studies of clinician work patterns and device preferences commissioned by large hospital systems recently, Jared Rhoads, senior research analyst in CSC's Emerging Practices, says, “I definitely could see a roaming pharmacist using the iPad, and maybe some docs; but you can't use it for everything. Hospitals are not going to be deploying iPads en masse, completely replacing laptops and carts.” Instead, especially for nurses, Rhoads sees most hospital organizations continuing to rely strongly on mobile carts, with a combination of different types of computers (sometimes fully loaded laptops, but in many cases, so-called “dumb terminals”) on them, for most of the intensive, day-to-day computing needs of non-physicians. “In our organization's recent study of laptops, workstations, and mobile devices, there wasn't a clear winner” in terms of clinician preference, notes Fran Turisco, principal researcher in Emerging Practices. Put another way, Rhoads says, “We found that no one device within any organization has ever turned out to be both the most preferred device on the part of some people and yet also the most acceptable to all people. In fact,” he says, “the device that tends to excite some people the most, turns some people off.”

Given all this, CIOs will inevitably have to determine what their organizations’ clinicians want in terms of a mobile computing environment, and how precisely they work, in order to create the best working conditions for them; and for the vast majority, that will mean ongoing investments in computing carts, say most of those interviewed for this article. What advice would CIOs like UPMC's Venturella give their colleagues? “Start from the standpoint of workflow,” he urges. “Make sure not to overbuy, but also that you have enough devices out there. And that will probably mean devices of different types, and from different vendors. It's all about understanding workflow, and understanding your facility configuration - and satisfying the clinicians who strive to deliver the best patient care every day.”

Healthcare Informatics 2010 July;27(7):26-29

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