March / April 2008
Nurses Point the Way
By Gregg Malkary, BA, MS
As the principal of Spyglass Consulting Group, I've surveyed clinicians each year since 2002 to evaluate the use of mobile communications and computing devices in healthcare. Each year, Spyglass has published the results of those surveys and identified key vendor offerings and early-adopter organizations in reports such as Trends in Remote Patient Monitoring, Trends in Mobil Communications, Trends in RFID, and separate reports on nurses' and doctors' experiences with point-of-care computing.
We've looked at the point-of-care computing environment in 2004, 2005, and 2007. The most recent of those reports, Point-of-Care Computing in Nursing (2007, November), focuses on the current state of computing adoption by nurses across the United States. The report is based on more than 100 in-depth telephone interviews conducted in April 2007 with nurses working in acute care and ambulatory environments nationwide. In our conversations with nurses, we uncovered strong opinions regarding market opportunities and challenges for adopting computing solutions at the point of care.
The purpose of the interviews was to identify the needs and requirements for point of care computing through discussions about:
- existing workflow inefficiencies in accessing clinical information,
- current usage models for computing devices and solutions, and
- barriers for widespread adoption.
The nurses we interviewed were technically competent and representative of a broad range of nursing specialties and institution sizes.
Point-of-Care Computing Ready to Revolutionize Practice
Point of care computing is poised to revolutionize the way nurses practice and deliver patient care by enabling rapid and secure access to clinical information from any location, at any time to enhance patient safety, reduce the risk of medical errors, and improve nursing productivity.
There are 2.9 million registered nurses in the United States approximately four nurses for every physician representing the single largest healthcare professional group. Despite these numbers, nurses are a scarce resource working in high-stress, data-intensive environments dominated by inefficient paper-based processes. They are continuously on the go and have a constant need to access relevant clinical information and to collaborate with colleagues and patients.
At the same time, the average patient today is sicker, with more physical and cognitive impairments than a decade ago, requiring more complex nursing care involving multiple medical specialties. Nurses are taking care of more patients who are staying for shorter periods. They are under pressure to coordinate, communicate, and document patient care more effectively across a wider array of care team members.
Healthcare organizations have made significant investments, upgrading their clinical information systems and technical infrastructure to extend the reach of existing systems. With the intention of improving access to patient health information for nurses, physicians, and other allied health professionals, organizations have deployed fixed location terminals and a wide variety of mobile computing devices including smartphones, laptops, Tablet PCs, and mobile clinical carts. Progress, however has been slow, in part because no one has developed an ideal mobile device for healthcare and because there is a clear, familiar business model for investment in fixed location terminals. If an organization provides a terminal every 10 feet, that's what clinicians will gravitate toward. It's a self-fulfilling prophecy.
Barriers to Adoption
To support the development and use of effective point-of-care computing devices, vendors and organizations must understand the barriers that are impeding progress. Most healthcare professionals agree that real-time access to clinical data is the goal, but most mobile devices are inadequate or ill-suited for the demands of the clinical environment. Nurses we interviewed are concerned about the usability and portability of computing devices deployed at the point of care. Business class computers are not well suited to meet the heavy demands of nurses working in acute care settings.
When devices are awkward to use and applications ill-suited for clinical workflow, nurses create potentially dangerous workaround solutions of their own. Many of us have heard stories documented during our recent interviews with nurses about nurses removing barcoded patient wristbands and transporting them in batches to a central location for scanning, rather than wrestle a heavy "mobile" cart across patient room thresholds.
Point-of-care clinical solutions are not well integrated with nursing workflow. Nurses interviewed are concerned about the usability and complexity of clinical information solutions. Clinical information systems are being used, but not always in real-time, nor at the point of care. Nurses often double-document, first on paper at the bedside and then re-enter this information into the electronic medical record later on during their shift. Compounding their problems with the hardware and software computing solutions, the complexity of documentation to maximize reimbursement, assure regulatory compliance, and avoid litigation for which nurses are responsible is daunting.
The technical infrastructure required to support point of care computing is often immature. Nurses we interviewed believe their organizations lack reliable networks, systems interoperability across the continuum of care, and efficient security protocols. In a post to his Medical Connectivity blog on December 21, 2007, Tim Gee reported on our survey of nurses:
The study found that 64% of nurses in more than half of the hospitals believe their wireless network is not reliable enough to support point of care computing solutions. That's a frightening majority of the hospitals, with poorly designed, installed and/or managed wireless LANs.... The study describes a hospital in the Chicago are where nurses have taped Xs on the floor where they can get a good network connection. With the exception of leading-edge hospitals the "most wired" hospitals wireless network deployments in patient care areas have a long way to go.
Despite these challenges, we're beginning to see some improvement in the development and effective deployment of devices that bring real-time computing to the point-of-care. Many experts now recognize what common sense dictates: as the chief users of these computing solutions, nurses must be involved in their development, acquisition, and implementation. Workflow should be evaluated and improved up front, using solid, evidence-based management practices, which will allow institutions to get maximum benefit from their investment in technology. Finally, organizations need to take a holistic view of hardware, software, infrastructure, and clinical processes as they consider how best to bring computing to the point-of-care. The trend to mobile and bedside computing is irresistible; if given appropriate tools, the urgency most professionals bring to improving patient care should help accelerate our progress.
Gregg Malkary is the founder and managing director of the Spyglass Consulting Group. He has over 20 years experience working with Fortune 2000 companies to help them use information technology for competitive advantage. Malkary has domain expertise in mobile computing and wireless and broadband technologies, with direct experience in the healthcare, government, manufacturing, communications, and entertainment markets. Prior to founding Spyglass Consulting Group, Malkary was an associate partner at Outlook Ventures, a venture capital firm focused on early stage investments in enterprise software and communications companies. Previously, Malkary was the director of strategic planning for Exodus Communications where he was responsible for identifying, evaluating and executing growth initiatives in the managed web-hosting marketplace. Malkary is an honors graduate of Brown University, with a MS and BA in computer science. He was awarded the prestigious North American Philips Corporation Fellowship for his graduate research work in computer graphics. Malkary may be contacted at firstname.lastname@example.org.