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Mobile computing and interoperability in microcosm

April 8, 2008
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Although I should be spending my time working on big picture, “strategic” things, every now and then some little something catches my interest and I find myself veering off into a skunkworks project. That probably would fall under the category of “poor time management”, but it’s surprising how much you can learn that way.

Recently, we’ve been thinking through options for mobile access to our EMR. I was an early advocate for the Tablet PC platform as a valuable enabler with the EMR.

When we first rolled the EMR out to our doctors and nurses, we did a semi-scientific evaluation of products from several vendors, including Fujitsu, Toshiba, Motion, and HP. We ended up buying 300 or so of the HP TC1100s, because we thought they had the best combination of form factor and versatility- removable keyboard with integrated pointing device, etc.

We’ve pretty much beat the heck out of those devices. They’ve been old and slow for a while now and are dropping like flies. We need to replace them in mass, but there’s not an obvious upgrade path.

The TC1100 was a unique device. What remains in the market are devices that are strictly slates- Motion is big on those and Fujitsu has a good one- or “convertibles” with a permanently attached keyboard that rotates and folds back to allow you to use the pen more easily.

The slates are frustrating to those who actually know how to use a keyboard- which I suspect includes most people under 40 (50?). The convertibles are a little oversized to my way of thinking. You don’t gain much over a plain old notebook computer, except for higher cost.

For what it’s worth, the Motion C5 has fascinated me since I first got wind of it. But, there’s that missing keyboard issue and, more damning for me, the device feels underpowered- Core Solo processor and a max of 2Gb of memory. Some of our docs use Dragon for voice recognition, which is a real memory hog.

Anyway, we’re still trying to answer the question, “What’s the right Tablet device for physicians?” But while we were thinking about that one, I got to wondering about nursing staff that do intake work and put patients in exam rooms for the doctors to see. (Skunkwork alert.)

We had defaulted into giving them the same devices that our doctors used, but I’m not sure that makes sense.

The duties of our “nurses’” (a generic term we throw around that includes RNs, LPNs, CMAs, and nurse’s aides) include calling patients back from the waiting room, taking vital signs, starting a clinic note in the EMR, verifying patient’s allergies, meds, problems, and taking a brief history of the present illness. If the patient is for follow up of ancillary testing results, they confirm that the results are available for the doctor. If the doctor orders in-office testing, treatment, or prophylaxis, the nurses provide whatever they can under their scope of practice and document accordingly.

One of the most recent additions to their work load is the requirement to record National Drug Code numbers for every medication administered for billing purposes. This is now mandated by some of our Medicaid carriers. Those codes convey information on the manufacturer, medication, and dose units administered; they must be copied from the bottle from which the medicine was dispensed where they are displayed in tiny print and a tiny 2D barcode.

I had never given mobile carts much thought until a year or so ago, when I thought that a full featured cart might be a good choice for places like our Oncology infusion center or ASCs. Those are places where the patients are stationary and the nurses circulate around them providing services.

We got a loaner machine from Stinger and found that the nurses just didn’t care for it. Stinger also had what looked like a neat vital sign device that they integrate with their cart- they call it “integriti” (yes the first letter is lower case.) But I couldn’t ever get that device to sync data to our EMR. They include software to drive the thing and will be glad to sell you an interface to your EMR for a price that I can’t remember well enough to quote, but remember as being exorbitant.

Here’s where it all starts to come together…

Tablet PCs- pricey, nurses have to find places to set them down while they’re working with patients, small keyboards if any, small displays, but what about a nice big notebook PC?

Carts- Big ones don’t work, couldn’t integrate vitals with EMR easily or affordably, but what about little ones?

Vital sign machines- Our EMR has done integrations with Welch Allyn. The integrations look easy to turn on. Vital sign monitors aren’t necessary for our nurse’s workflow, but “spot check” devices could be pretty cool.

Bar code readers- We’ve had a dickens of a time finding one that will read those tiny, little 2D barcodes on the medicine bottles, but the ones that (we think) will read them also can work as a digital camera.

SO…

We got a loaner Slimline cart from Stinger. I had one of my guys order us a nice middle of the road, reasonably priced notebook computer. I called up our local Welch Allyn guy and scheduled a time for him to come in and bring some of their spot check devices. I went shopping for yet another bar code reader. We had our own connectathon.

And, you know, we got it to work well enough that I’m going to build a couple of these carts to put in some departments for nurses to use and critique. That doesn’t mean that it was quick or easy.

Welch Allyn had a couple of devices that looked appropriate. One is a little newer technology, is targeted more at the acute care market, and has USB connectivity. It’s certified with version 10.2.6 of our EMR. We’re on version 10.2.4.

The other one does everything that we need it to do and works with the application version we’re on, but its native connectivity is through IR. The WA guy brought it in with a serial connection that, upon closer inspection, consisted of an IR to serial converter that was bolted on next to the outbound IR port.

The notebook computer that showed up had no serial ports. (Have you tried to buy one with conventional serial ports lately?) We had a serial to USB converter laying around that we stuck on it and tried to make work. Hmm, out of the device via IR, converted to serial, converted to USB, into the PC. I wonder why that didn’t plug and play?

Stinger makes a point of their ability to mount anything to one of their carts that you want to mount, but they don’t have a bracket designed for this Welch Allyn device. No doubt that’s because Welch Allyn isn’t a big name in the industry. (Certainly, the fact that Stinger wants to sell integriti has nothing to do with it.) To their credit, they are willing to engineer one for me, but I have to send them one of the $1,500 devices that I haven’t bought yet.

I’m still optimistic that the barcode reader will work out of the box, but it didn’t make it in time for the connectathon, and when it did come in we hadn’t ordered the cable we needed.

What would have made this a more pleasant experience? Standards for port configurations, application to device control protocols, device to application results communications, all adhered to by any vendor- especially the big guys. Coordination between government and payers, medication and device manufacturers, and providers to ensure all are on the same page with reporting requirements and how to comply (the NDC code issue.) Real plug-and-play standards. And recognition by vendors, hardware and applications alike, that, while do-it-all products sound attractive, there’s a LOT to be said for simple products that do what they do very well and can be easily assembled to meet the unique needs of the situation at hand.

If I get these carts to work like I think they should, I’ll start working on seamless interoperability across the US healthcare system.

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