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Healthcare IT

Doing the rounds

By Jianggan Li | 15 October 2009

With more than 2000 beds and 7000 to 8000 outpatients daily, Severance hospital, run by Korea’s Yonsei University Health System (YUHS), is the world’s largest JCI-accredited hospital. It has a vision to provide ubiquitous care to the society, for which it successfully implemented in 2005 a sophisticated EMR system, incorporating computerised physician order entry (CPOE), picture archiving and communication system (PACS) and clinical decision support system (CDSS).

The hospital strives to offer clinicians the best tools to give them full EMR access outside their offices, be it in the wards or outside the hospital building. A mobility solution based on PDA devices were developed and issued to clinicians. However, the hospital encountered an unexpected problem.

In Korea, mobile technology evolves very quickly and state-of-the-art smart phones today will probably be obsolete by Christmas. Severance Hospital replaced its devices twice, but still couldn’t keep up with the market.

“Doctors always want the latest devices, which we find hard to accommodate,” Prof Byung-Chul Chang, Director of Severance Cardiovascular Hospital and former CIO of YUHS, says, explaining why the system fell into disuse in the last two years.

Currently, Mobile Clinical Assistants (MCAs) – medical-grade tablets – are widely used by clinicians at Severance Hospital. are used for test-bed by house staff in Severance Cardiovascular Hospital.
In fact, MCAs’ development has been remarkable since FutureGov last reviewed healthcare mobility, in 2008. Many hardware vendors, including Panasonic with its famously rugged Toughbook series, have launched clinical grade tablets based on Intel’s MCA reference architecture, joining the ranks of existing ones such as Philips and Motion Computing.

At Severance Hospital, nurses also had used MCAs to educate patients. Data, including medical records and PACS images, are shown to the patient with a nurse on hands to interpret the information. However, there were several problems were identified such as speed and difficulty in data entry.

“We have issues with every mobile device,” Prof Chang says. “Doctors always want the most advanced, most sophisticated functions, which will make devices bigger and heavier.” He adds that it has become an important task for the hospital to optimise the system and negotiate with doctors, especially resident ones.

“The appetite for functionality and bandwidth never ends,” says Mark Self, Vice President of Motorola, which supplies many hospitals with mobility solutions. “Although currently most such needs can be satisfied by a Wi-Fi network, people need to keep this in mind.”

Severance Hospital also has Computer-on-Wheels (COWs) deployed in the intensive care unit and operating theatres, and cart-mounted laptops in general wards.

The latest generation of COWs at Singapore’s public hospitals are called Bedside Mobile Workstations (BMWs). Compared to previous generations, a BMW is height-adjustable and connected to a laser printer to print adhesive labels for immediate tagging of patient specimen such as blood samples.

“We try not to have many different types of devices,” Associate Prof Low Cheng Ooi, Chairman Medical Board of Changi Hospital, says. “This is not only to avoid interfacing problems as much as possible, but also reduces the complexity for the support team.”

He also cautions that while making doing the rounds more efficient, mobile capabilities might be abused. “Some clinicians might simply order without seeing the patients,” he says. “We need to have certain control over this issue.”

Communications

In addition to real-time information access and data input, mobility solutions could also streamline communications. The Microsoft Unified Communications solution has been deployed at Severance Hospital to allow effective communications among clinicians and other hospital employees.

Prof Chang reveals that the full function of UC has not been exploited. “For many mobile devices, voice quality in the busy environment is impeding effective communications,” he says. “Improving it is not straightforward.”

A mobile phone-based alert and communications system is also in use in a few hospitals in Singapore, with a lot of effort going into interfacing the system and setting up the rules.

The weakest link, says Prof Low, lies with a proper roster - or a lack thereof. If this is not appropriately fed into the system, the hospital will easily fall back to the manual ‘check the name and call’ process - which is precisely the fallback solution for this mobile messaging network.

Some hospitals use mobile devices to track the movement of patients and clinicians inside the hospital. Prof Low and his organisation, however, are reluctant to set up such a tracking system. “Tracking your patients and clinicians real-time gives you lots of information,” he says. “But you need to make sure there is value to be gained from that information before gathering it.”

Infotainment

Bedside patient infotainment terminals, popular in Europe and discussed by FutureGov last year, are still gaining popularity in this region. This month (September), Hong Kong Sanatorium and Hospital (HKSH), a private tertiary care hospital, launched such a system for all inpatient area. One terminal is available to every patient free of charge, and doctors use their new staff cards to gain access to clinical information system through the terminal.

Dr Chan Wai Sin, Deputy Director of Macau’s Health Bureau is sceptical about the use of such system for patient infotainment in all the wards. “In many specialties, acute care patients suffer severe pain which impedes them from accessing active infotainment,” he says, pointing out that if such devices are meant for the patients, the instalment needs to be selective. “The exceptions are orthopaedics and paediatrics patients.”

Prof Low, however, thinks differently. “If you are well enough for a phone call, you are probably able to use the terminals for some surfing. If you have the money to buy the option, you’d make sure that you used it,” he says, cautioning that it is important to consider carefully which functions patients really need.

Changi General Hospital has a few such terminals. Here, the issue lies more with a doctor’s access, and not so much patient infotainment. EMR application’s authentication capabilities – including resilient hardware servers and the seamless functioning of software – are vital in determining whether card-based authentication is feasible.

“Authentication has to be fast and seamless,” Prof Low says. “Everything has to be well-coordinated so that users will not be frustrated.”

Input

Prof Chang reveals that, at YUHS, more than 95 per cent of doctors now enter data into mobile devices themselves. “This took a lot of time and hard work,” he says. “But now everyone realises that without a computer their job is much more difficult.”

A feature of tablets that attracts clinicians, Prof Low says, is data input without typing. “Ideally we want a recording device that allows doctors to dictate and translates audio into text automatically,” he notes on the easiest way for doctors to input information electronically.

Although currently technology can be quite accurate (many radiologists use it), the learning curve is steep and background noise in the wards makes very different environment from the quiet room that a radiologist typically sits in.

Even if the technology is advanced enough for accurate voice recognition in busy wards, computing power and storage can be troublesome. “Where do you store the voice information? How resilient is your device and network with such intensive translation?” Answers to these questions are needed, says Prof Low.

So what about cutting edge touch screens allowing you to manipulate data with the touch of a fingertip, something that Apple’s popular iPhone has done? Very useful in certain areas such as operating theatres, current technologies might not cope very well with an environment of gloves and powders.

“They are beautiful to play with and potentially very useful,” Prof Low says. “But you can’t buy a very expensive system that doesn’t add much value to what your existing system is capable of doing.”

Beyond the four walls

Community care has been highlighted as an important direction for Singapore’s healthcare sector moving forward. Fibre-based high-speed internet will be available to almost every household by 2012, and Prof Low believes this will enable the healthcare sector to do more exciting things.

Community hospitals will be built close to acute-care hospitals, so that services such as labs and radiology can be shared. The national EHR programme currently under development will allow nursing homes and community care givers to access all medical information in the future.

Although monitoring & care can be beamed into patient’s homes with as much self-service as possible, visits by community nurses remain essential. The question boils down to how to make such visits more efficient so that the government does not have to hire 50 nurses to cover 50 households.

With wireless everywhere, community nurses can go to homes with sophisticated portable devices to record critical information and administer drugs. Battery life and weight still need improvement, as community nurses might not be able to recharge the devices as frequently as their counterparts in the wards.

Prof Low is optimistic about this, as many vendors are dedicating research to improve the performance of their devices.

Though the use of mobile solutions, as other sophisticated IT capabilities, remains concentrated in the region’s more advanced hospitals, technologies have been advancing and potential value is waiting to be unlocked.

“We don’t know what an ideal mobile device should look like,” Prof Chang. “But it has to support all the capabilities of your hospital’s EMR system, including CPOE, PACS & CDSS, at the bedside and beyond.”

When it comes to mobility, “the demon is always in the detail,” Prof Low cautions. “If the weakest link is not properly addressed, it is very easy for a sophisticated system to fall into disuse and people go back to manual processes.”

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