Trouble at the Bedside

June 24, 2011
Gregg Malkary When the nurses at Genesis Health System in Davenport, Iowa started utilizing laptops, a small problem presented itself. They found
Gregg Malkary
When the nurses at Genesis Health System in Davenport, Iowa started utilizing laptops, a small problem presented itself. They found they had to strain their eyes in order to read the information on the compact screens; some even had to get bifocals. To remedy this, the IT staff brought in bigger models that were easier to read, but — as it turns out — more difficult to maneuver. As a result, the devices sustained a great deal of damage from being picked up improperly and dropped.
Chris Click
As the staff at Genesis learned, the road to IT implementation can be a bumpy one, particularly for nurses who are thrust into the driver's seat and forced to find ways to navigate.

Abandoned carts and other roadblocks

The types of problems that the nurses at Genesis experienced are not at all uncommon. In fact, in many facilities, the issues extend far beyond just wireless devices into many other areas of health IT.

Marion Ball, Ed.D.
In December 2008, Spyglass Consulting released the findings of an end-user market study focusing on the current state of computing adoption by nurses across the United States. The results were eye-opening, to say the least. According to the report, “Healthcare Without Bounds: Point of Care Computing for Nursing,” which was written by Gregg Malkary, founder and managing director of Menlo Park, Calif.-based Spyglass Consulting Group, nurses are growing increasingly frustrated with obtrusive mobile carts, overly secure log-in systems, and unreliable infrastructures.

After speaking with 100 nurses, Malkary unearthed some startling statistics. Seventy-six percent of the nurses reported that mobile clinical carts remain abandoned in the hallway where they are being used as a fixed location terminal, and the estimated number of times nurses were forced to log in and out of systems due to stringent security policies was as high as 80 per day.

He also found that 64 percent of nurses believe that wireless infrastructures are not reliable to support point-of-care computing solutions. “The majority of the time,” says Malkary, “it's a problem of the network, not the device.”

And it's a problem that can't be overlooked by hospital administrators. “If a CIO reads that metric, he's going to say ‘that's not my hospital,’ when in fact, it probably is,” says Chris Click, vice president of marketing at InnerWireless in Richardson, Texas. “There's a lot more to this than just simply having the wireless access points in the ceiling.”

Marion Ball, Ed.D., professor at the Johns Hopkins University School of Nursing (Baltimore) and fellow at the IBM Center for Healthcare Management (Washington, D.C.), was disturbed — but not shocked — by the findings. In her research, she has found that the biggest barriers to IT adoption among nurses stem from unfamiliarity with technology and a lack of understanding as to how they can integrate solutions into their workflow.

“Their job is not to be technologists. They're there, believe it or not, to take care of the patient,” she says, adding that when nurses are averse to using equipment, extra work such as double documentation is often the result. “Nurses are running up and down the hallways to get information. You can put one of those odometers on them. They're literally doing miles and miles of walking because of poor workflow.”

Shirley Gusta
Ball, like many others, has found that while nurses who are skeptical of solutions are more likely to lose faith in the system and to work around the technology, those who have been included in the implementation process are more likely to embrace it. That is precisely why a number of hospitals and health systems are making a concerted effort to include nurses when selecting, testing, and implementing IT solutions.

Making nurses part of the solution

Genesis Health System utilizes a collaborative documentation group composed of nurses when designing and building documentation systems, according to Shirley Gusta, IT manager of application services. “Their role is not just to look at the hardware. They've helped us design the actual tablets in the system to capture the electronic clinical documentation,” she says.

Deborah Gash
One of the most important benefits of using a collaborative group, according to Gusta, is that it promotes duality of ownership. “If IT just says,and ‘Here's what you're going to use,’ without getting nurses' feedback, you're going to fail right out of the shoot. We need to make sure that whatever we provide will support their workflow and allow them to do the documentation at the point of care, which is truly what we're trying to achieve, so that they don't go back to the nurse station and document.”
Billie Whitehurst, R.N.
Genesis used feedback from the collaborative group to help solve the laptop dilemma. Now, the nurses use a laptop that has a screen they can read, but also contains a strap that makes it easier to carry.

At Progress West Healthcare Center in O'Fallon, Mo., president John Antes believes the best way to both alleviate and avoid problems is to shadow nurses and get a sense of how they operate during an average day.

“I sat and watched them do their daily workflow myself so I could understand it,” says Antes. Through this method, Antes and the IT team were able to develop solutions that could address the issues nurses were experiencing. They would then pilot the solution in a specific unit where it was tested by nurses. If the results were positive, the solution would then be deployed in the rest of the units.

According to Antes, shadowing nurses enables administrators to observe both the problems that nurses can detect, and those they cannot.

“You can see where all of a sudden they get a little flash or a bump off the network, and it's just enough so that it's not apparent to them, but all of a sudden, all of their information is gone,” said Antes. When that happens, “We can go back and run the diagnostics on the network and identify what happened that's causing that.”

Deborah Gash, vice president and CIO at St. Luke's Health System in Kansas City, Mo., can attest that running pilot programs in the actual care setting can help prevent costly mistakes. At St. Luke's, a team of clinical bedside nurses and designated super-users are asked to identify the features and functions they deem important in devices. Once the solutions are chosen, the team then tests it for functionality and efficiency. It is a process that has served the staff well, particularly as they were able to tweak and fine-tune their wireless network.

“We've taken the approach where before we deploy a device, we're piloting it to see if it fits the need. If it does, then great, we might deploy it further,” says Gash. “But rather than investing a lot of money and technology, we think it's better to actually give it to the nurses and let them use and see if it fits the requirements that they've defined.”

A number of institutions have taken the concept of testing one step further by utilizing simulation or “smart” rooms such as the University of Florida's “Gator Tech Smart House,” the Peter M. Winter Institute for Simulation, Education, and Research (WISER) at the University of Pittsburgh Medical Center, and Kaiser Permanente's Sidney R. Garfield Center for Healthcare Innovation, to name a few.

Facilities such as these, according to Ball, enable nurses to see firsthand the capabilities that certain solutions can offer, such as the Horizon Enterprise Visibility, a patient care visibility system developed by McKesson to deliver real-time, at-a-glance information on large plasma screens at various locations throughout the hospital.

With Horizon Enterprise Visibility, “all nurses have to do is literally walk by and they can see a clinical lab result,” says Billie Whitehurst, M.S., R.N., chief nursing officer at McKesson Provider Technologies in Alpharetta, Ga. The technology, she says, saves nurses from “having to stop their workflow and go pick up the phone or pick up lab results or log into a system repeatedly,” and just shows them the information they need.

Helping nurses to see the value of a solution or technology as it relates specifically to them and their workflow, says Whitehurst, is critical in getting nurses to buy into it. In other words, telling them that McKesson's Connect-RN integrates bar code medication administration, medication cabinets, and pharmacy information systems on a single mobile device won't resonate nearly as much as noting that the solution can reduce nursing lines at medication dispensing cabinets.

It helps “bring the real world experience to every aspect of a solution,” says Whitehurst.

Touting the benefits a product offers in terms of usability is fine, she says, but what makes all the difference is when an administrator can relate the “real world” aspect of a solution. One way to do that, according to Ball, is to have nurses who have been through the implementation process identify ways new systems have improved their workflow.

If they're hearing it from other nurses, she says, “They won't fight it — they'll embrace it. Nurses learn best from other nurses who have used the technology, and have found it beneficial.”

Most importantly, nurses need to know they are an integral part of the implementation process, from start to finish, says Cindy Spurr, M.B.A., R.N., B.C., corporate director of clinical systems at Partners HealthCare System in Boston.

“Nursing touches every part of documentation and workflow on the inpatient side,” says Spurr. “It's critical to make sure that you have nurses involved in what you're selecting, what you're deploying, and how you're deploying it.”

Looking ahead

Click predicts that wireless solutions will continue to evolve at a rapid pace, with innovative technologies like wireless voice over IP, smart phones and smart pumps leading the way. As wireless technologies continue to surface and health systems continue to focus on nursing workflow, it will be more important than ever to head to the advice of those who have just been there, like Antes.

“It's not just an IT install, it's a cultural change,” he says. “You're changing the workflow by having them use these wireless devices and you're changing the way they operate culturally. Make sure that the technology is beneficial in day-to-day work life so that they recognize ‘What's in it for me.’”

Finally, realize that IT adoption by nurses requires patience from everyone involved. A successful install, says Antes, “requires a longer transition period, it requires a little bit more tweaking, and it requires a little bit more time dedicated to getting the install operating and functioning as smoothly as everyone would like.”


Implementing Reduced Sign-on: One Facility's Experience

John Antes
John Antes, president, Progress West Healthcare Center, O'Fallon, Mo.

Explanation of the technology:

“We use a reduced sign-on. On a given day, a nurse could have a half-dozen applications that they need to log in to in order to take care of their patients. What they have is a combination of fingerprint and RFID badge that they wear as part of their ID badge that recognizes them when they approach their computer. They use their fingerprint as their second form of identification, and it then logs them in to all of the different computer programs that they need to log in to. It keeps them from having to carry around a sheet of different passwords and user names. It logs them in, and then automatically logs them off when they leave the computer. So there is a certain time-out, and if they leave the computer, it notices that because of the RFID and it will log them out of the computer.”

Growing Pains:

“That was not an easy process. We just opened our hospital on Feb. 20 (2007), so it will be in place for one year this February. It's only been within the last four months or so that it's been working smoothly. We went through a lot of start-up issues with it, but the nurses hung in there because they knew it was the right solution and it was a better solution than going back to carrying around a cart with all of your different log-ins and having to log in and out every time.

“It was difficult at first getting it to work and making sure it worked properly with each one of our programs that we had, and making sure that the wireless infrastructure worked properly with it. Getting the radio frequency part was probably the most difficult; getting the sensitivity to that, because you wanted it to log a person in quick enough — but not too quick — so that you're still protecting personal health information so someone can't piggyback on you. You want it, but at the same time RFID has certain limitations.”

Ironing out the Wrinkles:

“One of the things we had to work through was that RFID will go through a wall but it won't go through a human body mass. When we first started, we had times where a nurse would walk out of a room and down the hall, and it wouldn't log them out. But they could be standing there doing the meds administration and bar coding in the room, and they'd turn from the computer to the patient to give them their med, and it logs them out because their back goes toward the computer, and their badge is on the front side. It loses the signal.

“As we went through all of that, we found one or two spots within the hospital where we took it off the systems because we were having interference issues. The main one is the emergency room; that's also the only place where our computers are tethered, so that's the only place where we had issues with our computers getting bumped off the network on a regular basis. We're still working through that part of it.

“On the floor, in radiology, in every other area of the house, we're using RFID, but it took a lot of work to get it to function the way we wanted it to function. It was not an install that you walked away from overnight and had it work. We had to keep problem-solving on it, keep adjusting the system, keep trying different things on a pilot basis. About six months into it, we got to a point where the folks would tell us, ‘It's still not perfect, but don't take it away from me, because it's better than the alternative.’

“Right now, what I can tell you is that I think I've only gotten one complaint about the system in the last quarter where it didn't function appropriately. So it's really gotten ironed out.”

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