Picking Carts Over TabletsBy M.L. Baker | Posted 06-10-2005
Hospitals Face Tricky Hardware Decisions
The grand vision of health information technology is that electronic tools will help banish medical mistakes, boost the effectiveness and efficiency of clinicians, and make health care more accessible and convenient for patients.
Achieving that vision will require the solution of any number of strategic business, technological and legal issues.
But for hospitals struggling to move forward one baby step at a time, the potential of technology comes down to tactical nuts and bolts issues such as what kind of device clinicians will use to supervise and document care.
Office environments have engendered only a few physical layouts for workstations, largely because of the consistent presence of environmental variables like desks and chairs. Offices also lack the kind of extraordinary requirements often found in medical settings, such as the need to function in rooms that are sterile, or in which all the furniture is on wheels so it can be moved around daily to allow for various procedures.
Those requirements have bred a surfeit of options, even for the basic form factor of medical-IT devices.
Some 20 vendors make tablet PCs - portable computers with touch screen technology - for example.
But besides tablets, which are designed to run on batteries while connecting via wireless networks, hospital IT groups also have the option of placing computers on futuristic carts that take up about as much space as a standing person. The tops hold a computer monitor and keyboard and can be adjusted to fit a clinician of almost any height, whether seated or standing. The bottoms hold long-lasting batteries and a wheel base so the machines will run through a whole shift, and to various beds or rooms in a hospital unit.
More convenient still are handheld units clinicians can carry in a pocket and update with a stylus.
Less dynamic, but often more stable layouts call for computer terminals to be scattered throughout nursing stations, hallways and patient rooms.
Decisions about form factor often rely on efficiency and efficacy, but just as often on their ability to work smoothly with a hospital's existing applications and networks.
Tablets and PC-like computers, for example, can support "thick client" software that relies on the tablet or PC to handle most of the computing load, and use networks only to trade data. "Thin clients," which are practically required on handheld devices but are often run on more powerful machines to simplify the maintenance of the software, present what is essentially a dumb terminal that serves only to pass information back and forth to the clinician's screen, while doing all the processing on a centralized server.
After the hardware is chosen, the IT and clinician team has to decide who gets their own devices, how many clinicians can share a device, and what types of mice and keyboards they should use to prevent theft and to keep infections from spreading throughout hospitals.
To figure out how IT executives make hardware choices within these complex environments, Ziff Davis Internet spoke with five decision-makers at four institutions, ranging from the CIO at one of the country's largest health networks with 27 hospitals to the director of IT at a hospital with 25 beds.
Sutter Health Network
The Sutter Health Networkis made up of 25 hospitals along with dozens of other centers. Procedures and drugs administered at hospitals are checked at patients' bedsides using bar codes, and this requires computers in patients' rooms; the computers are generally on carts.
Wireless Makes Medicine Easier
CIO John Hummel says the rise of wireless has provided the biggest boost to the project because rooms don't need to be specially wired. Not only is that inherently more convenient, he said, it frees up resources so IT can be more responsive to clinicians.
"We went from 'How are we going to get all these people on to the network?' to 'What's the most convenient for them?'" he said.
Sutter clinicians either carry devices from room to room or use more traditional machines on carts.
Which device they use depends on whether a clinician stays in a particular department or makes rounds throughout the hospital. "If a physician or nurse needs to walk around, we'll give them a tablet. If they're more stationary, we'll put them on the cart."
Computers on carts (both tablets and notebooks) are generally cheaper, said Hummel, largely because the tablets Sutter uses are ruggedized versions with a higher price tag than normal versions, a feature that lets them survive being carried on rounds. Though battery life is the biggest problem, the devices are usually good for one shift.
When Sutter began rolling out the bar coding initiative it used thick clients because they had better performance, said Hummel. Now, he's finding that thin clients can do the job. They are more convenient for IT and cost much less for repairs, he said.
"What we've done is started rolling out more and more of our Citrix thin clients, and we're also looking at Microsoft terminals." However, he added, not all best-of-breed vendors offer a thin-client option.
Hummel said that emergency rooms and operating rooms, where keyboards are likely to come into contact with body fluids, use specialized medical keyboards that can be rigorously protected.
Otherwise, computers are covered with plastic membranes and keyboards, and screens can be wiped down.
"You make sure that the device—no matter what it is—can be decontaminated." If there's a question, for a standard keyboard, you can throw it out. (People interviewed for this article estimated that in the volume they buy, they could buy five to eight standard keyboards for the price of one medical keyboard.)
Hummel said Sutter has used tablets from Dell, Hewlett-Packard and Toshiba, with the latter being the current "flavor of the week." Tablets with a swing top (a screen that spins around to reveal a touch keyboard) are more accepted by finicky staff than those that have the keyboard on the glass, he added.
Tablets have gone through a couple iterations at Sutter, and the technology continues to shift. In particular, Hummel thinks the use of BlackBerrys, with color screens and tiny keyboards, will become popular, though he admits the screen size needs to be larger.
And he's cast his eye further into the future as well. "My grandson was watching 'SpiderMan 2' on a Sony PlayStation2. The movie was stored on the device, and it was great color. The battery lasts for a long time, and it's cheap," he said. "If it's rugged enough for my grandkid, a nurse can't break it."
But he's not yet ready to write the purchase of hundreds of PlayStations into a corporate budget.
Russ Cucina is a clinical informatician and professor of medicine at the University of California San Francisco Medical Center. He is guiding technology adoption at two of the university's hospitals (with a total of about 700 beds).
The ideal situation, he said, would be to have a stationary computer at every doorway, with a real keyboard, a full-size mouse and a 17-inch screen. But limited space precludes that solution, especially at older hospitals with narrow hallways. Cucina said proposals to build computer cubbies in hallways were scuttled by fire codes and other regulations.
Cucina recommends COWs (computers on wheels). "Tablets have a lot of hidden problems," he said. Even a device that weighs only 2 pounds gets heavy when it must be carried around all the time, and he hasn't found any handwriting- or voice-recognition applications he thinks are ready for a hospital environment.
Picking Carts Over Tablets
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."
Hardware Selection in a
Michael Hoar, director of information technology at Schoolcraft Memorial Hospitalin upper Michigan has decided to adopt thin clients because of cost, convenience and security of patient data.
The hospital has about 40 Wyse Winterms terminals on carts, mounted on walls in exam rooms, on desks and at nursing stations. As PCs break or require maintenance, they are replaced with a thin client. So far, Hoar said, the Winterms have been well-accepted by clinicians.
"I don't think any of them realize they're not using a PC," Hoar said. However, a few physicians are using tablets because they prefer that form better. (Several thin-client companies, including Wyse, have introduced a thin-client version of tablets.)
Hoar said the thin clients solve several problems at once: He can buy nine or 10 Winterms for the cost of one tablet, and theft is less of an issue. And when the hospital was using more PCs, memory cards would sometimes disappear from the computers.
The biggest benefit, though, has been convenience: "These Winterms last forever; they never break. On our terminal server, we do all of our maintenance from one place."
Still, Hoar will not completely banish PCs. Some departments, particularly radiology, have quirky applications that could destabilize the server that serves the thin clients. Other professionals interviewed for this article also noted that radiology was an exception to broader IT strategies. Because the images require so much data, for example, the radiologist might be served with a cable to transmit images even if the rest of the hospital is wireless.
More Options Coming
"There are a whole set of new issues popping up as hospitals become more digital," said Gregg Malkary, director of Spyglass Consulting Group and author of several recent surveys about the mobile-device needs of physicians and nurses.
Concerns about technology vary by clinician. For example, 10 percent of physicians worry that spreading infections would limit the use of tablet PCs for daily clinical work, while 61 percent of nurses named infection control as a problem, according to the surveys.
Meanwhile, the computing options available to clinicians as well as the computing demands made on their devices are expanding. Clinicians want smaller, lighter, more powerful devices with larger screens, longer battery lives and secure transmission.
As vendors scramble to meet these demands, hardware options available to hospitals, and the questions about how best to use them, will only increase.