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Healthcare IT

Healthcare on wheels

By Jianggan Li | 18 February 2009

Sometimes handheld devices are deemed unsuitable for the needs of clinicians – in this situation the answer may be to add wheels.

The burden of carrying (and guarding) mobile devices such as PDAs and tablets has become a hindrance to the effectiveness of their adoption. Other constraints include battery life and, particular, their limited screen size. To address these limitations, bulkier solutions have been adopted.

Pascal Tse, Chief Information Officer of Saint Teresa’s Hospital in Hong Kong, says to avoid this, tablets can be mounted on top of the pushcarts that doctors and nurses use. The system now still has the barcode scanning capability, and an optional extra battery pack at the pushcart ensures that clinicians can do their round without charging it halfway.

This is not yet enough for Dr Wong Merng Koon of Singapore General Hospital (SGH), who thinks two screens are better for doctors to compare medical images and do other things: “Therefore, COWs came to our mind,” he says.

COW refers to ‘Computer on Wheels’, a pre-integrated system which normally comes with a desktop computer and two big displays.

An Uninterrupted Power Supply (UPS) ensures the machine remains functional while on the go. Wong calls the UPS ‘anti-boot machine’ as it is only used when the COW is being moved from one place to another so that the clinicians don’t need to reboot the system.

The UPS that SGH is currently using lasts for only 30 minutes – enough for such a journey from one bedside power point to another. Better UPS systems come much bulkier and heavier, with a much higher price point – expensive and not really mobile.

Oddly the short battery life solves the problem of clinicians forgetting to charge their mobile devices, as charging now becomes a habit for them which they have to do all the time.

However, the biggest disadvantage of a COW is its monstrous size, which Tse, Dr Wong and Dr Low Cheng Ooi, Chairman Medical Board of Singapore’s Changi Hospital, are all concerned with.

“You really have a real estate issue,” notes Dr Low. “You need space to park these devices in the ward, and for certain units, it’s impossible to move it in to begin with.”

Shrinking the COW

In Taiwan’s healthcare setting, space is also a big constraint. “The room between beds is not that big and is not sufficient for a COW with two screens to be pushed in,” notes Joseph Ho, CIO of Chang Gung Memorial Hospital (CGMH).

Fortunately, one advantage CGMH could cash in is the strong manufacturing capability of Taiwan’s IT industry. Ho’s team procured integrated, custom-made pushcarts from the industry at a very attractive price point.

The system consists of a panel PC with a 17-inch high definition screen which is integrated onto the pushcart which nurses use. A battery pack is installed at the bottom of the cart to provide four hours of uninterrupted power and also balance the whole unit.

The PC itself is ruggedised to the industrial grade. “In a hospital’s environment, it is inevitable for the pushcart to collide from time to time,” explains Ho. “Making the PC ruggedised also protects it from the liquids we often encounter.”

Facing the space constraint, the screen is divided into two halves if the doctor needs to compare medical images, “and it is adjustable easily through the keyboard,” according to Ho.

Both barcode and RFID scanning are included, and used according to the different functions.

There are also a few design factors that Ho has put in place to suits the specific needs of the hospital. Firstly the height of the screen needs to be adjustable, suiting all the nurses, short or tall.

“The wheels need to be of superior quality for easy movement of the machine. Otherwise after a few years our petite Asian nurses will have strong arms to compete in weightlifting,” he jokes.

Another consideration about wheels that Ho is concerned with is the noise: “it has to be as quiet as possible, otherwise patients will not be able to rest.”

The system has been in use for a number of years and according to Ho, responses from clinicians have been very positive. “We also extended that to the emergency department,” he says. “During major disasters when patients can’t get to the ward in a timely fashion, these mobile workstations, with all the data needed, can help provide vital treatment even in the waiting hall.”

Ho says another advantage of this unit is that it improves communications with patients and helps educate them as well as their family members. Nurses and doctors can use readily available information to illustrate to the patients and to get the point across fairly easily.

Safety and security

With wheeled solutions, or mobile solutions in general, the issue of security and privacy is highlighted when Doctors are moving around all the time and they are often interrupted by requests from nurses, patients and other parties – sometimes for just second, sometimes for hours.

It is very known that in healthcare, security and privacy are always one of the top concerns. How to, and when to automatically lock the system becomes tricky here.

“Any form of security measure in healthcare setting, if it is elaborate, logon becomes very troublesome,” reveals CGH’s Dr Low.

“You need to prevent unauthorised access when other people see a device lying around, but you don’t want the doctor to re-logon all the time,” he says that an optimal time out threshold needs to be found, balancing security and minimising interference with the workflow.

Taking a simplistic approach, CGMH requires compulsory re-logon after two minutes of inactivity, and system will automatically resume to the previous work once the password is typed in again.

Username combined with password is still the dominant way of authenticating users in the hospital. While exploring different means for double layer authentication, Dr Low points out that other factors are very problematic in healthcare setting. One of the examples he uses is when doctors take off their gloves, there is powder on their hands, which virtually rules out the possibility of deploying fingerprint as a second authentication measure.

“Costs and practicality make biometrics difficult to use,” Dr Low comments. “I believe password plus card or token gives good double layer security.”

Another issue is that many doctors rotate in multiple hospitals/clinics, which poses a problem to the security management. This is particularly a challenge for Saint Teresa’s, where most of the doctors are Visiting Medical Officers from outside the hospital.

At the moment not many of them bring their own mobile devices for clinical use within the premises of Saint Teresa’s, but Tse stresses the importance of proper authenticate those who do so. “When you have security polices and VPN in place, it’s not 100 per cent bullet proof, but at least you achieve adequate level of security,” he says. “Also firewall needs to be in place to ensure that these devices don’t spread viruses in the hospital – viruses are catastrophic in healthcare.”

Is it doctor-proof? Ultimately, doctors and nurses are at the frontline using the system, and their attitude is crucial for the sustainability of any mobile solution. As highly trained and educated professionals, a failure to buy-in to any new solution is effectively the kiss of death. This makes usability key.

“The mobility solutions we have deployed put lots of stress on manpower,” says SGH’s Wong. “Sisters and nurses all have to learn operating system and other tools.”

“Whatever you want to deploy must suit the comfort level of the frontline users,” asserts Saint Teresa’s Tse, highlighting that human factor is very important to the success of any mobile project.

“At the end of the day, we need to ask our users to change the workflow based on the system,” Tse adds. “And whether they are willing to and able to adapt means success or failure of the project.”

“If the users think that the technology is too different and therefore not use it, the mobility solutions will have no value at all,” comments Wong.

Dr Low says that the proof of the usefulness of a system is that the people actually use it and take care of it. “If they don’t like it, they will not take care of it.”

At CGH, an 80-20 rule is adopted. “If 80 per cent of the people use it and like it, we will push forward the deployment,” he explains.

Dr Low adds that during the learning curve, clinicians might spend most of their time in the ward starring at the screen rather than looking at the patients. “This is the initial phase when you are struggling to get things gong,” he comments. “Once you are familiar with the system it will not be an issue anymore.”

Strategy and pilots When a hospital wants to deploy a mobile solution, a pilot project is usually launched first, so says Dr Low. “Through pilot we evaluate whether the system can solve the problems we want to solve.”

“There are a lot of exciting things around mobility, but we need to be realistic,” notes Tse. “Especially when it concerns change of workflow, big bang approach is not going to work.”

IT department also needs to manage the expectations of the management. “Sometimes management gets very excited about new devices and what they can do,” Tse says. “We need to tell them both sides of the story.”

He calls the optimal involvement of senior management active participation. “When we start a new project, we want the senior management to listen to end users and end users to feel that the management is supporting them.” Periodic update ensures that management is fully aware of what is going on at the ground level.

“Ultimately, for a mobility project to succeed, you need large scale cooperation between the users, the IT department, the management and the patients,” Tse says. “There are too many factors which could influence, so doing it in a phase fashion is important.”

“Therefore pilot projects enable us to do it bit by bit, which builds confidence, gives experience and handles the expectation of the management,” he adds.

With so many options to choose from and so many factors to consider about, Dr Low says that at the end of the day, many options need to be provided to users, who can evaluate to ensure that these solutions improve their work efficiency and effectiveness.

“In the area of interest, the ROI and business case are sometimes difficult to achieve because those require quite some investment in the infrastructure,” comments SAP’s Andy. “With pilots, people start realising the benefits.”

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