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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.


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.