GUEST COLUMN

Will wireless’ work in a real-life setting?

Examples show technology’s pros, cons

By Matt Hisle, PE
Superior Consultant Holdings Corp.
Southfield, MI

(Editor’s note: This is the second of two articles exploring the biggest gains in wireless technology.)

Speaking in the fourth century BC, Chinese general Sun Tzu said, "No battle plan ever survives contact with the enemy." The same can be said for technology. What looks wonderful on paper may not always work in a real-life hospital environment. The health care institutions that are the subject of this article have actually implemented wireless solutions. These case studies provide important lessons regarding what works, as well as what doesn’t work.

Emergency transport: Beginning the cycle

Delivering care to the patient’s location, regardless of where that might be, has long been the domain of emergency response teams, paramedics, and emergency medical transport services. With recent advances in handheld computing and wireless data communications, we are able to put a powerful new tool in the hands of these teams and improve the financial picture for service providers at the same time.

At a regional emergency medical service (EMS) in the South, three companies — Zoll Medical in Burlington, MA, Westech Mobile Solutions in Vancouver, BC, and AccuMed Billing in Riverview, MI — teamed up to provide a system of applications and services targeted directly to the emergency medical patient served in the field. Each emergency medical technician (EMT) and paramedic is provided with a customized handheld pen computer that provides a variety of information.

Specifically, this device guides the EMT/ paramedic in diagnosis and treatment, provides information on potential complications, and speeds record-keeping and billing. By virtue of its ability to guide the user through a series of input menus, the system creates an electronic record of the emergency call that is uploaded to the appropriate information system. This electronic record replaces the messy and sometimes unreadable paper record (run report) commonly developed.

Not only does this system improve the speed and quality of care delivered to the patient before arriving at the hospital, it vastly improves the information flow. The patient record is available quickly and accurately in a paperless format. This process avoids courier costs for paper records and reduces data entry and error correction time, there by significantly reducing processing costs.

At the EMS claim billing end, the real value is in the improved accuracy of the initial run report. Because you cannot go back and change a run report, and because many run reports do not use accurate terminology to describe symptoms, errors abound, which can increase rejected claims.

As a result of improved accuracy (such as correctly identifying an advanced life support vs. a basic life support run, the correct ICD-9-CM codes can be submitted and compliance maintained. Preliminary estimates indicate that increased reimbursement revenue from improved accuracy can result in a 10% to 15% improvement in revenue associated with emergency transport.

These improvements do not come without problems, however. High-rise buildings and tunnels make real-time data communications less reliable than desired, so backup data download systems are necessary. Additionally, extensive training is required for emergency medical staff. Applications that require perfect entry all the time may result in frustrated end-users. The costs for hardware, software, and communications may be prohibitive. However, as companies such as AccuMed begin to share both the costs and the benefits with the systems users, total cost of ownership for the emergency system could become reasonable.

Once a patient arrives at the hospital, registration and paperwork can be a daunting process. In 1997, two hospitals in the Midwest began a pilot test to implement the use of portable laptops to speed the registration process for emergency department patients. The hospitals allowed roving medical staff to access and input information into the patient management database in real time, using a Proxim Wireless LAN and a TCP/IP network doing terminal emulation.

The staff collected such primary information as the reason for the visit, type of insurance coverage, and basic personal health history. Patients were interviewed in private treatment rooms, sometimes as treatment was being provided.

From a patient service perspective, the results were very positive. Patients perceived that care was provided faster, information was obtained in a more private environment, and most importantly, patients no longer sat in a waiting room engrossed in paperwork. The hospitals eliminated all but two registration tables, and staff spent more time attending patients than ever before.

On the downside, battery life was a significant problem. The staff had to continually re-charge the system. Other concerns included:

      • effectiveness of integration with clinical and financial systems;
      • care and handling of antennas;
      • speed of the laptop;
      • dependence on single point of failure access points.

Wireless phones enhance neonatal care

At a Midwest regional hospital, wireless phones were instrumental in implementing a "quiet hospital" program targeted in the neonatal ward. The health care professionals were sensitive to the negative impact of excess noise on newborns, and ringing phones and beeping pagers were major culprits. Each nurse was equipped with a portable phone that would vibrate or chirp softly when ringing, and all other phones and beepers in the area were banned.

In conjunction with other noise reduction efforts, average sound levels dropped significantly. According to the nursing director of the neonatal intensive care unit, while this program reached its primary goal, other more subtle benefits were observed:

• Because they were freed from a traditional desk, nurses tended to spend much more hands-on time with each infant, and they reacted more quickly to problems.

• Nurses were able to increase their communications with each other and with other health care professionals.

• Communications with parents increased dramatically, and satisfaction with hospital services went up accordingly.

Saying to a new father, "I am here with little Susan now, and all is well. Do you want to hear her?" turned out to be a quite powerful experience for hospital staff.

Nonetheless, there were problems with the technology:

• The phones were one more thing to carry around, and several experiments were necessary before a comfortable method of wearing the phones evolved. As it turned out, one common method was not enough. Different individuals developed different approaches, some even using headphones for better hands-free access.

• New protocols had to be developed to ensure maintenance of appropriate sterility levels.

In the hospital: Patient charting

In many hospitals, clinical care nurses are experimenting with better ways to interact with their patients and their computers. One of the most common applications has been patient charting. A large Southern health care system is now working on its third generation of systems to improve nurse bedside time with patients, accuracy of information, and information availability.

The hospital implemented an Eclipsys package of hardware, software, and Proxim communications systems designed to provide portable links into the hospital clinical information system.

As currently implemented, a custom-built wireless appliance is created by installing a flat panel display, a computer/X Terminal emulator, a transceiver, a keyboard, and a large battery on a device that looks like an IV pole. These are stored in convenient locations on the floor, in the hallways, or in patient rooms, and, when needed, they are "grab and go." These systems are primarily used for patient charting, directly entering patient vital sign information.

On the plus side, the system has learned from these pilots that:
• Where other computer terminals are scarce, these systems are used constantly, and user satisfaction is high.
• These systems allowed the hospital to avoid constructing and wiring a large number of dedicated workstation locations.
• Some doctors (particularly in urology) have begun using the systems to obtain clinical information access at the patient’s bedside.
• Use of these systems has increased the time spent bedside and on direct patient care, eliminating trips to the central nurses’ station and eliminating paperwork associated with writing information, then re-keying it into the computer.
• Information quality and speed of availability has increased.

On the downside, the system found that:
• These systems demand end-user education or they will end up cluttering the halls.
• Proximity of fixed computer workstations dramatically decreases utility of the systems.
• Reliability is a key to continuous use. Poor reliability from telecommunications problems and software or hardware problems rapidly leads to rejection of the system.
• The wireless communications system does not interact well with a fixed IP address scheme. Installers must be careful of overlapping zones and dual hosting, particularly with multiple segment addressing schemes.
• The IV pole has proven to be bulky and hard to handle. It is one more thing for the nurse to carry into the room. Experiments to mount similar systems on med carts appear to offer better ergonomics.
• Physicians and nurses are much more interested in handheld units, even if less information can be effectively entered and displayed.
• Costs of the current system do not allow for rapid payback of investment. The best uses are in areas where patient charting must be done often and on a regular basis.
• The restrictions and capabilities of the computer information systems department will determine much of the system architecture and usability for the nurses.
• Physicians don’t want to type, so usage has been low.

The health system has two new wireless pilots under development addressing this application. Right now, the downsides have not been worth the time and investment in these systems, but the long-term benefits are so compelling that the hospital is willing to invest time, energy, and money in continuous improvement.

[James M. (Matt) Hisle Jr. is a corporate vice president at Superior Consulting Holdings Corporation, a nationwide health care and information technology consulting firm. He can be reached at 4000 Town Center, Suite 1100, Southfield, MI 48075. Telephone: (248) 386-8300.

If you have a successful or unsuccessful program, pilot, or installation story on wireless technology, please e-mail Hisle at Matt_Hisle@enterprise.supc.com.]