Welcome to the final installation of our three-part series on patient safety. In part one, we looked at broad, industry-wide progress towards improving patient safety using IT. In part two, we focused on medication-management strategies. Now we take a look at mobile computing and efforts to improve patient safety at the bedside.
When leaders of the 15-hospital Ministry Health System, based in Milwaukee, Wis., decided to build a new hospital facility in the Wausau suburb of Weston, they committed early on to opening that facility as all-digital with minimal use of paper. It wasn't just that the building of a new facility presented the opportunity to begin working in a digital environment; it was also that the potential for creating an enhanced level of patient safety was fundamental to the plan, leaders say.
The new facility, 107-bed Saint Clare's Hospital, was constructed in collaboration with the Marshfield Clinic, a very large multi-specialty group based in Wausau.
"Through our all-digital record, we actually have a collaborative tool across our campus, including at Marshfield Clinic," says Tanya Townsend, IT director at Saint Claire's, which opened a year ago. "We have a common tool, and that record is then portable and available across our community. That fact increases patient safety."
In addition, notes Larry Hegland, M.D., the hospital's chief medical officer, "Well before we opened the facility, we started talking about the culture of this organization, and the fact that we were going to be all-digital. We wanted to take advantage of the electronic system, and we encouraged people to report problems" with medical errors. Now, he says, "We're often able to address problems in real time while the patient's still here."
Positive results have been apparent, says Richard Bailey, M.D., medical director of inpatient and hospitalist services at Saint Clare's.
"Because we have ready access to our medical record, we can facilitate order entry at the point of care," says Bailey, whose specialty is internal medicine. "And we have significantly reduced the percentage of orders that are written from verbal orders. We have an astonishingly low level of verbal orders. We have a robust CPOE (computer-based provider order entry) product that is live, with a very robust order set. We have significantly cut down on the number of medications inappropriate for patients, and on the number of inappropriate narcotics for patients; and have enhanced our decision support at the point of care."
Nationwide, experts say they see a strong interest in using wireless infrastructures and mobile devices to improve patient safety at the point of care, though they quickly add that serious investment in this area has yet to reach the level needed to make such innovations the norm.
For example, executives at the Menlo Park, Calif.-based Spyglass Consulting Group in late 2003 performed a market study that found that 90 percent of clinicians were already doing some kind of mobile computing using knowledge-based applications, primarily making use of drug reference databases, reference manuals and medical calculators.
At the same time, the study pointed out that fewer than 5 percent of organizations interviewed at that time were deploying "next-generation mobile computing solutions such as e-prescribing, charge capture and patient-data-management applications that are tightly integrated with existing legacy-based clinical and financial systems."
In the context of using wireless infrastructure to enable mobile computing by clinicians, "Nursing documentation is a great area" to start in, says Gregg Malkary, Spyglass Consulting's principal.
"We're starting to move away from narratives and toward structured input systems. Nurses are spending 50 percent of their time on documentation," he notes, adding that his research consistently finds nurses feeling overwhelmed by the amount of time required to do clinical documentation. "Mobility and wireless provides phenomenal opportunities to extend the reach of a lot of these systems to the bedside," he says, offering the chance to improve patient safety.
Of course, hospital organizations across the country are discovering the benefits of innovation that can bring patient safety to the bedside through mobile computing.
At CentraState Healthcare System in Freehold, N.J., vice president and CIO Indranil Ganguly reports that he and his colleagues have been replacing their core clinical systems — in an overall push for improved patient safety — with bar code-enabled medication administration management. CentraState has also been replacing the 263-bed community hospital's pharmacy system.
Among the key decisions that had to be made, Ganguly notes, were what kinds of mobile computing tools to use (he and his colleagues decided to go mainly with laptops on carts) and the decision to replace the hospital's legacy pharmacy system with one from the same company as the new core clinical system (Soarian from Malvern, Pa.-based Siemens Medical Solutions). Among the many improvements that have already taken place, Ganguly reports, are faster delivery of medications to nurses at the bedside, and a significant drop in avoidable medication errors.
Providing nurses with laptops on carts — in a coordinated initiative also involving bar coded medications — has provided similar gains at Good Samaritan Hospital in Vincennes, Ind., reports CIO Charles Christian.
Nurses have fully integrated mobile computing into their clinical workflow, says Christian, who notes that mobile computing actually began at 267-bed Good Samaritan back in 1998, though full electronic tracking and monitoring of medication administration at the bedside, using bar coding, began at the end of last year.
Now, 98 percent of medications are being delivered to patients in bar-coded form, Christian reports, and he notes that documentation speed has improved considerably. "The last thing we wanted to do was to turn nurses into data-entry people. We didn't want to turn the act of entering data into a paper chart into an electronic version of that task." Avoiding that outcome has required considerable workflow redesign, he adds.
At 319-bed UnitedHospitalCenter in Clarksburg, W.Va., CIO Edmund Collins reports, "We've reduced medication errors around 75 percent" since implementing a mobile clinical computing system that encompasses bedside documentation, automated medication administration, and bar coding. He and his colleagues use the Horizon Admin-Rx bedside medication administration system from San Francisco-based McKesson Corporation, and are using wireless technology to enable the medication administration system.
United HospitalCenter is using a mix of devices, such as computers on wheels and, "a really nice cart we've bought from (Hatboro, Pa.-based) InfoLogix, Inc," Collins adds.
At 100-bed Beloit (Wis.) MemorialHospital, Doris Mulder, R.N., vice president, reports that she and her colleagues have been optimizing their lab specimen and blood collection workflow — using tools from McLean, Va.-based Care Fusion — as part of a broad-based patient safety initiative that began in early 2002.
They are also actively working to optimize medication administration. "We never sold this to the staff as a way to save money," Mulder explains. "(But) it does in fact save money, as our medication errors have decreased by 83 percent in the past three years. And we've always tracked the number of wrong labs we had," but even that small number has decreased since the hospital's patient safety initiative began.
In the same vein, phlebotomists at HamiltonHospital, Dalton, Ga., have seen their clinical workflow optimized through the use of Care Fusion's tools, notes Kenneth Lowery, clinical coordinator, laboratory services, at the 277-bed community hospital. Not only has the ability to track and monitor blood draws improved patient safety and averted potential errors, automation has increased clinician satisfaction at the hospital, Lowery notes.
Those who have led extensive patient safety-driven automation implementations say many vendors still aren't 100 percent on track with their offerings or strategies. "The issue is supporting workflow," says Stephen Davidson, M.D., chairman of the Department of Emergency Medicine at MaimonidesMedicalCenter in Brooklyn, N.Y. "And that's what everybody in the vendor community keeps missing, and that is that clinicians want tools that support workflow. And you have different kinds of workflow from when you're eliciting history, making disposition decisions about patients in the ED (emergency department), or preparing for discharge. And each of these situations might actually best be supported by a different tool."
Flexibility and building a solid wireless infrastructure will be key to success in improving patient safety through automation, insists Davidson, who is his hospital's functioning chief medical informatics officer.
Mark Hagland is a contributing writer based in Chicago.