You think your choice of computers is tough? Try picking one that will survive doctors' rounds, patient infections, long hours on nurses' stations and a lot more risks than the sodas and coffee spills office users pose.
And then there's the problem of how to use a tablet while caring for patients. "As soon as you put one down, you've contaminated it with the fecal patina that exists in any patient room, and it's at very high risk of falling to the floor and shattering," Cucina said.
Still, Cucina hasn't completely discounted the tablets; he's waiting for better models to show up. "If someone shows me a PC that fits in my white coat pocket that is very durable, I'll be very excited. That hasn't happened."
Part of the reason for wanting a pocket-sized device (Cucina likes the Fujitsu Lifebook) is to avoid spreading germs when bringing technology into patients' rooms. But for these purposes, tablets may actually be a bit safer, he said.
"A tablet PC is monogamous with its user and is less likely to become cross-contaminated; a shared terminal has many users and so has cross contamination from and to patients of all users."
Still, he said there's no reason to think the three-ring binders and manila folders the hospital uses to hold paper records are any cleaner than keyboards; the best approach to avoiding contamination is common sense and conscientious hand-washing.
Sunny Bang, manager of technology for the clinical information systems group at UCSF, said security was another reason for going with COWs. Because the tablets are so small, Bang said, they could easily be taken off-site, compromising patients' data.
Bang anticipates that UCSF might eventually adopt thin clients for the convenience and security they offer. However, instead of having many clients communicate with an individual server, he'd use a blade system in which dummy screens communicate with individual PCs instead of a common server.
El Camino Hospital
For Philip Strong, the IT physician liaison and a hospitalist at El Camino Hospitalin Mountain View, Calif., the answer to most of these "this-or-that" questions is "both."
IT purchases need to be bundled into an overall patient safety plan. Once that plan is in place, he said, "Expect to support a group of heterogeneous devices. That's the way it's going to be." Don't get too attached to any particular device, either, he advised. "Experiment. Find a core group of people who are willing to try things out."
Strong is in a somewhat privileged situation because his clinicians expect to use relatively advanced hospital information systems. El Camino was the first hospital to adopt computerized order entry (CPOE) in 1971, and computer terminals are scattered generously throughout the facility. The 400-bed hospital has about 550,000 outpatient visits a year.
Staffers at El Camino started using tablet PCs about two years ago, after some were donated to the hospital by Hewlett-Packard. Since then, the hospital has bought more.
Strong says the tablets are used mainly like terminals; they sit on staffers' desks most of the time. Strong carries his tablet around, leaving it at the nursing station when entering patients' rooms. That's mainly because he doesn't use the tablet in patient rooms to document patient care, but "a happy side effect" is that this practice avoids contamination.
He said he's tried using some of the native tablet applications but they're not up to snuff yet. He is optimistic about MEDimensions, a tablet application built especially for health care, and said the hospital will gradually move toward using tablets at the bedside.
Strong often uses three devices at once: a PDA to look up drug information, a tablet to look at patient data (lab results, for example), and a stationary terminal to order drugs and tests.
This illustrates the challenge of figuring out what equipment is necessary. Tablets are $3,000 each, and clinicians who don't need them should just use terminals. But tablets can also help ensure everyone has access to a computer. "With computer physician entry, you need a critical mass of terminals. The last thing you want is to have docs waiting in line to use the terminal."
Strong says doctors prefer thick over thin clients: "Performance and user interface usually suffers on the thin clients. The user interface [for thick clients] is usually nicer and has better performance, and performance is really important to docs."