INSIDE THE CURRENT ISSUE

December 2009

Operating Room

EMRs adding wows to COWs

by Jeannie Akridge

Stanley InnerSpace Harmony personal workstation

As electronic medical records weave their way into the everyday workflow of nurses and physicians, the mobile workstation is becoming an essential platform for bringing data to the bedside. Whether you call them COWs (computers on wheels), WOWs (workstations on wheels) or some other catchy acronym, these versatile dynamos can help improve workflow efficiency as well as provide safer patient care. 

"The mobile workstation provides the critical link between the caregiver at the bedside and the patient’s data in the electronic medical record," commented Chad Ramage, vice president, group product manager, mobile computing products for Metro’s Healthcare Division. "By providing accurate, real-time information to the entire care team, mobile workstations support quality care. In addition, today’s mobile workstations can support a variety of point-of-care technologies, such as barcode medication administration technology that helps ensure the right patient gets the right medication at the right time, and vital signs data capture which offers faster, more accurate recording of critical patient information into the EMR.

"A hospital’s mobile computing strategy can play a key role in streamlining workflows on nursing units, reducing costly medical errors, and improving clinician efficiency through applications such as telehealth," he added.

Todd Ross, marketing and communications director, Artromick Inc., described how the company’s new NX10 Workstation is used to enable point-of-care electronic health records. "It becomes a mobile nurses’ station in theory. It gives nurses the ability to streamline their workflow, so they always have access to the electronic medical record and they don’t have to wait for a computer to open up at the nurses’ station, for example. It helps them provide a more consistent level of patient care, because they don’t have to disconnect from the patient to go somewhere to use an electronic health record."

Artromick TX10 Medserver

A convenient and easy-to-use mobile computing solution can be the linchpin that encourages EMR adoption among clinicians. Motion Computing now offers Motion Clinical Workstations designed around its Motion C5 Healthcare Tablet, the industry’s first mobile clinical assistant (MCA), said Mike Stinson, vice president of marketing. He described the Motion Computing solution as a "hybrid model", where clinicians can use the C5 tablet in patient rooms, then dock it onto a Motion Clinical Workstation in the hallway, for example, and complete their data entry. "It gives them the benefit of being able to get the data they need right at the bedside; they don’t have to write it down on a piece of paper and then enter it later."

The workflow advantages grow exponentially as clinicians increase their use of computing solutions at the bedside, Stinson explained. Real-time data capture means fewer data errors due to transcription mistakes and less data latency. "It means that the rest of the hospital system that’s waiting for that data, whether it’s to approve a discharge, or to approve the start of a procedure...the whole system works much more efficiently because you don’t have anybody waiting for the latest vitals from that patient," he said.

Shannon Kennedy, director of marketing, Stanley InnerSpace Corp., urged facilities to keep supply storage needs top of mind as they implement point-of-care computing workstations. "Nurses want to chart right at the bedside but they also need their supplies at the bedside. Whereas some carts may give you the electrical and data component that you need, they might not have storage readily available on the cart, so we brought the two together."

Bringing mobile computing and storage together into one point-of-care system can help bring facilities in line with LEAN principles of process improvement. "[According to Lean philosophies], 95 percent of total activity is considered non value-added," said Kennedy. "If you think about nurse charting, if 95 percent of a nurse’s time is being wasted in the whole process, you have to really dig in and find the waste. One such waste is having a separate mobile computing cart and storage cart."

In addition to a bedside charting cart that accommodates a laptop computer and includes a flat panel monitor arm and articulating keyboard arm, personal workstations from the InnerSpace Harmony line can include keyless entry and a variety of security options.

Stanley InnerSpace is rolling out its Intelligent Locking System (ILS) at the beginning of the year on all of its Harmony small carts. Through the use of either a Prox card, or a keypad on the cart, users can open a single drawer at a time. The ILS software allows managers to control who has access to which drawers, and even to which carts. "It’s ‘command and control’ of all of your carts in a variety of different ways," said Kennedy.

Workstations from Rubbermaid Medical Solutions feature an electronic locking system that can be activated via a PIN code or RFID badge, and a recently launched network fleet software that allows facilities to push codes out to the entire fleet of carts at once, said Jeffrey Chochinov, senior product marketing.

Armstrong Medical’s Aluminum Auto-Locking Cart with Optional Proximity Reader allows users to simply wave their prox card in front of the reader to open. The cart can be locked by pressing the lock button or setting the Auto-Lock Timer for anywhere from 1 to 998 minutes.

Med management

Motion Computing MCW-200 with Motion C5 MCA

Hospitals are seeking mobile workstations that incorporate more sophisticated medication management systems, observed Len Hom, product marketing manager, mobile medication solutions, Omnicell. "The biggest thing that we’re seeing is the movement towards carts evolving from a workstation on wheels where clinicians are accessing their applications, to an environment where they additionally need to securely transport meds in the carts. So hospitals [are] asking for carts with drawer systems."

"You need to be able to transport meds securely from the dispensing cabinet to the patient’s bedside," he said, citing guidelines from the Institute for Safe Medication Practices (ISMP) which state that clinicians who transport multiple patient medications from the cabinet to the bedside should use a computer-on-wheels, with label-specific patient drawers and the ability to lock if unattended.

"Our carts fulfill those requirements, and take it a step further in terms of the patient labeling of the drawers," Hom noted. "You can do that automatically through some of our software applications. A clinician can start their shift, very quickly select the patients that they’re going to take care of on that shift, and basically at the push of a button, automatically assign those patients to a drawer on the cart as opposed to having to go through some type of manual process to label the drawers.

"Independently-locking drawers add another layer of safety and security," he continued. "A lot of the workflow today is hand-carrying medications from the cabinet to the bedside, and many, many times, interruptions occur during that process. Nurses are looking for places to secure those meds during those interruptions before they get to the bedside. By securing the meds in a mobile cart patient-specific drawer that’s locked, it gives them the peace of mind that the medication is safe until they do go administer – that they’ve got the right med for the right patient."

Add-on software options further boost patient safety. Omnicell Anywhere RN allows nurses to safely issue medications remotely from a mobile workstation, and Omnicell SafetyMed SW application verifies ISMP’s 5-Rights of medication administration.

"We see an increase in adoption of what we categorize as medserver products," said Ross of Artromick’s TX10 and TX11 Medservers. "They’re not medication carts, but they’re not really workstations. They have high-end security solutions for the storage and organization of medications.

Ergotron StyleView

"Having a solution that has a small footprint, is easy to maneuver in and out of tight spaces, but still has organized medication storage, that has high-end security, keyless access, automatic relocking, the ability to audit that information so that they can take this medication delivery vehicle right to the patient’s bedside, has become more and more popular," Ross observed. "People are understanding the workflow advantages; it creates a bridge between the medication dispensing cabinet and the patient’s room. We see this adoption of medservers as becoming a critical component of what we call the last 50 feet of the medication administration process."

With the mobile workstation serving as an "access point for the electronic medical record, for it to really be valuable you need to [understand] the [hospital’s] underlying initiative," emphasized Chochinov. He described the various stages of EMR adoption as outlined by the Healthcare Information Management Systems Society (HIMSS).¹

"Most hospitals are looking at stage 3, where they start to put the initial clinical documentation systems in place. Stage 5 is looking at closed loop medication management, which typically involves a barcoded medication implementation."

"The key element is the workflow that’s created," said Chochinov. "The idea of having each patient’s medication in a separate secure drawer" can help reduce time nurses spend walking back and forth between patient rooms and the medication dispensing room, or waiting in long lines at the medication dispensing unit, he indicated.

Omnicell mobile cart

MeritCare Health System, based in Fargo, ND, is using custom-designed workstations from Stanley InnerSpace. "MeritCare kicked off its barcode medication administration project in June of 2006," shared Tricia Erstad, RN, MSN, clinical informatics systems analyst. "One of our first priorities was to select a computer and barcode scanner solution. The nursing departments had computers at the centralized nursing station and in cabinets in the hallways, but they did not have devices at the bedside or any devices that were mobile.

"After many months of research, device fairs, and trials, the nurses had not found a standard device that they could recommend for purchase," she recalled. "Patient care room layouts and storage availability varied between the two hospitals’ campuses, as did the patient population needs. Devices that were considered included: computers on wheels, in-room computers on articulating arms, and mobile computing tablets."

The solution, said Erstad: "MeritCare worked with Stanley InnerSpace to design a storage cart that became a ‘nurse zone’. The cart was redesigned with a pull-out, adjustable laptop tray; a medication drawer with an electronic locking key pad; and two additional drawers for storage. The device also has a pull-out tray on one side and a flip-up tray on the other side for procedures and extra work surface area. We purchased 342 custom-built Stanley InnerSpace Carts that were placed in med surg, critical care, surgical day unit, pediatrics and the family birth center.

Pharmacy delivers a daily supply of the patient’s medications to the locked medication drawer every day. Nursing assistants stock the supply drawers with syringes, needles, linens, and other supplies."

"Having the medications, supplies, and computer in one location at the patient’s bedside has improved nursing efficiencies, as they are not having to ‘hunt and gather’ medications, supplies and a computer every time a medication is to be administered or when new linens are needed," she commented. "When we move to online documentation, the expectation will be to utilize this device for real-time charting and for end-of-shift reports. Other computers will be added outside of the patient room for additional viewing and online documentation."

Point-of-care flexibility

Rubbermaid medication cart

Because workflow and technology needs are constantly evolving, workstations must be flexible and versatile. Look for those that are built off a common platform and that can be easily modified as needs change.

For example, carts from Stanley InnerSpace feature the same side rail for mounting accessories, pull-out drawers for easy reconfiguration as well as removable trays and dividers.

Omnicell’s mobile carts can be configured in the field for maximum versatility, noted Hom. "If your workflow starts to change, you can easily add multiple drawers to our carts in the field without having to either purchase a new cart or send it back to the manufacturer. You can add a variety of accessories such as barcode scanners, baskets on the back to transport supplies, and privacy screens in addition to our software applications that are integrated with the mobile carts."

Rubbermaid’s carts are designed on a common platform that can be customized, modified and upgraded to fit a hospital’s workflow. For example, as facilities move through the stages of EMR adoption, storage drawers can be configured on the go, with carts that can accommodate medications for up to 12 patients at a time in individually locked drawers, said Chochinov. The company also offers what he described as a popular "interim" solution with a medication expansion pack that provides up to six individual drawers. The carts are pre-wired to accept add-on devices down the road, he noted. "We’re seeing a lot of people integrating vital signs monitors now because they want the real-time data to be in that EMR on the spot."

Metro, a division of Emerson, recently realigned its healthcare division by integrating its clinical storage products with Flo Healthcare, Lionville Systems and medDISPENSE’s mobile computing and medication management systems. The Metro Flo Series of wireless mobile computing workstations seamlessly connects clinicians with real-time information at the point of care, and the Metro Lionville Series allows for technology integration while offering alternate power systems and additional options.

"Metro workstations are designed to deliver value as a long-term investment by accommodating upgrades to monitors, power systems, storage and other technology components," said Ramage. "By supporting easy upgrade through a modular design, Metro workstations can evolve from basic EMR and clinical documentation to enhanced features such as vital sign capture, medication management, CPOE, telehealth and PACS/imaging."

Artromick offers customized cart solutions designed around a facility’s workflow, said Ross. "Flexibility means, can the clinicians make the cart what they want it to be? Can they hang the barcode scanner on the right side or left side? Is the work surface big enough? Can they put add-ons? Nurses like certain things to be in certain places on a cart, so the idea that the clinician can configure the cart the way they want to is important. Then also there’s flexibility for the IT department to put on what hardware solution they want to use, whether it’s a laptop, thin client device or all-in-one computer."

Armstrong aluminum auto-locking cart with proximity reader

Earlier this year GCX Corporation introduced its VHRC Series mobile solution, a customizable cart solution that offers a fully modular, open architecture design with integration of off-the-shelf GCX components. The use of interchangeable existing products eliminates design time, in return minimizing product lead time while lowering cost, according to the company.

Based on GCX’s unique channel-mount design, the VHRC Series allows a wide variety of computer equipment, patient monitors and other medical equipment to be combined in a single workstation that addresses specialized application needs – including the integration of medical devices with new EMR computer hardware. Modular options, including a popular laptop enclosure, slide-out keyboard and locking drawer, and multiple flat-panel and monitor mounts, are available for VHRC Series.

Ergotron’s non-powered and powered StyleView 31 and StyleView 32 Carts are designed to provide functionality at a low price point. The lightweight StyleView 31 non-powered cart is available for both notebook and flat panel monitor configurations. Either computing configuration can be further customized by adding an electronic locking drawer. The feature-rich StyleView 32 powered cart is also available in the notebook and flat panel monitor configurations, with or without one or two electronic locking drawers.

Options from Motion Computing include built-in barcode scanners and cameras on the C5 MCA as well as the ability to add storage or medication administration drawers, baskets, disinfecting wipe containers, glove boxes, etc., to the Motion Clinical Workstations. "Over the life of the cart – it may start out as a rounding cart, but it may end up as a medication administration cart. It should be able to be flexible enough so that you can maximize its useful life," suggested Stinson.

Rubbermaid’s new LCD Access Pack is an accessory system placed around the LCD monitor to organize common supplies used by nurses at the point-of-care, such as med cup dispensers, alcohol-wipe bins, tape spools, etc. Other signature items on the Rubbermaid workstations include a keyboard and task light, document protector and spill retaining work surface.

Ergonomic features are critically important as well. "The nurses are standing for a long period of time so you want them to be comfortable," said Kennedy. Stanley InnerSpace workstations feature flat panel monitor arms with various swivel capabilities and height adjustment features, an articulating keyboard and laptop tray, as well as a mouse pad that swivels out to provide a comfortable work surface.

"Metro workstations offer a wide range of ergonomic features that make them safe and comfortable for clinicians to use every day," noted Ramage. "Key features include an adjustable monitor height for use both while standing and a comfortable seating position for clinical documentation; a keyboard tray that pulls forward and articulates right or left for unobstructed access to drawers and medications; maneuverable-monitor mount that tilts, swivels and rotates to ensure optimal viewing angle; and an advanced design that brings the clinician closer to the point of care and help increase patient satisfaction."

Metro Flo Series mobile computing workstation

The integrated, vertically adjustable channel found on the GCX VHRC Series allows simple height adjustment, while handle placement makes transport easy and a small foot print allows space-saving storage.

The Motion Clinical Workstations are height adjustable from 47" to 27" for a seated or standing work surface.

Floor surfaces should also be taken into consideration when choosing caster and wheel options for workstations. "Depending on the hospital environment, whether you’re on carpet or linoleum or some type of smooth surface, there are different wheels that are available that are optimal for different surfaces," said Hom. For instance, if you have a lot of thresholds that you have to go over, a certain type of wheel may be more conducive to going over those thresholds."

Omnicell also offers pivoting casters that are double-wheeled which allow easy maneuverability of the cart – an attractive option for tight hospital spaces "where you need to be able to pivot on a dime," described Hom.

Improving uptime

Battery life can make or break a mobile computing solution, with various options providing greater degrees of power efficiency and run time. "It depends largely on what hardware you want to use," explained Ross. "For example, no matter what battery solution you’re using – it doesn’t matter whether it’s sealed lead acid, lithium ion, or nickel metal hydride – if you’re using a laptop you’re going to get less run time than if you’re using an all-in-one computer. It’s the way that the computers use power." Eight to 10 hours of run time with a laptop may not be feasible, he noted. "That requires a very large battery, it makes the cart heavy and therefore it’s not as easy to maneuver. So there’s a balance between how they want carts configured and what hardware solutions they want to use."

Noted Chochinov, "the thing we try to do where possible is advise the client on certain devices and away from other ones based on run time. It’s often the case that the hospital is buying technology with the carts, and not all monitors and computers are created equally."

Vendors including Artromick and Rubbermaid suggested DC-based power solutions over traditional AC-based for greater efficiency and longer run times.

Stinson noted that the Motion Computing solution consisting of the MCW-200 coupled with a C5 MCA and a monitor can provide an impressive 15 plus hours of run time.

Omnicell power management software lets users know when battery power is getting low through visual cues on the screen or audible alerts on the cart. It can also be set up to e-mail alerts to selected contacts.

Added Salus, "because power supply plays a critical role in supporting energy-intensive point-of-care technology, we offer several options that enable us to tailor the right mobile power strategy to meet a hospital’s individual needs."

Wireless connectivity is also vital to ensuring workstation uptime, and may not be fully understood by all of those involved in the project, said Stinson. "What they [often] don’t understand is the difference between ‘we have a wireless network, and we have the kind of wireless coverage that is going to allow mobile point of care.’"

Service options from Motion Computing range from installation and go-live support (staging, assembling the carts, network design and validation), training and follow-up, as well as maintenance services.

Artromick is developing software "that becomes like a service module to monitor a cart’s health," shared Ross. In addition to onscreen ‘power gauges’, the software allows clinicians to immediately report any problems with the cart. For example, if the cart is not reading the wireless network in a particular area of the hospital, "they can report that directly to their service team, and they can go check it out immediately so that there’s this continuity of the electronic health record environment." He noted, "there are things outside of the cart that become as important or even more important than the cart itself – trial and planning, servicing, making sure that they get the right cart for the right area of the hospital, software that helps them manage service, post-deployment service and preventative maintenance."

Take them for a spin

GCX's VHRC Series Flat Panel with Slide-Out Keyboard and Locking Drawer Enclosure

Bringing in a fleet of mobile workstations is not a decision to be made lightly and trialing of the carts can make a world of difference in selecting a cart designed for end-user satisfaction.

"Ask vendors to send in a demo," recommended Kennedy, Stanley InnerSpace. "Put the carts side-by-side, and let the staff try them out," she said, noting, "We’ll walk them through the process, send in an evaluation cart, and allow end-users to set up all of their equipment to ensure it’s what they need."

"The orders for carts are getting larger and larger," she added. "It used to be that a large order consisted of 10 carts. Now, 50 to 100 carts go out the door on a single order, so you want to make the right decision up front."

"We like to go into a facility and get an understanding of what they’re trying to do with the carts," said Ross, Artromick. "Then when it comes time to try the carts – nurses like to take them for a ‘test drive’ – we’ll work with the clinician and the IT department to understand what’s working and what’s not. ‘Let’s understand why it’s working or why it’s not, and see if a different solution may be better, like an arm solution or a cabinet solution.’ Most hospitals that we’ve seen have a mix of carts and wall-mounted solutions."

"We work collaboratively with any of our prospects and help them evaluate the carts," added Ross. "We literally give them evaluation forms. We’ll work with them to understand why they like one solution better than another, or why they’re getting better run times in one area of the hospital versus another," he said, adding, "It’s important to use what we call multi disciplinary committees, get somebody from Nursing, Pharmacy, IT, BioMed, even Administration to make sure they’re getting the value, that the long term cost of ownership is what they need it to be."

Erstad, MeritHealth, advised facilities to "involve the end users and let them test the device. Be prepared to have a place to store and stage the carts before they are deployed."

Chochinov described the importance of a hospital having an "EMR roadmap". "What initiatives are they doing? When are they rolling out? Where do they need access points? What features do they need? It may vary by unit or function," he said.

"The EMR roadmap is very important for hospitals to think about that, and bring in vendors early on," he added. "You could potentially lose flexibility if you don’t get vendors involved early on."

Ultimately, a good mobile computing solution can help hospitals with one of their most valuable and scarce resources. "There are fewer clinicians out there to support the patient population," said Hom. "So hospitals are looking for ways to be more efficient and a mobile cart system is a way for clinicians to be more efficient with their time, and more importantly to make sure that they’re doing their job safely to ensure patient safety."

Reference:

1. HIMSS Analytics, Essentials of the U.S. Hospital IT Market 4th Edition, "The EMR Adoption Model: An EMR Market Transformation Assessment Tool" 2009.