Throughout our EMR implementations, which started in 2001, we have tested countless end users devices. We have numerous Computers On Wheels (COW’s), thin client laptops on a low profile cart (we called these calves), laptops, PC’s, tablets and a mixture of thin client devices. Now that we are pushing through a CPOE implementation we find ourselves engaging with nursing and physicians to ensure our device strategy is solid.
I have to admit that we have done a few things wrong along the way. We have found that non-CPOE environments can live with device issues (albeit not an ideal situation) but when you march towards CPOE these nagging issues can derail a successful go-live.
Five years ago we took the approach to devices that most did during an EMR rollout – hold a device fair, mock up a room and let the best devices win. While this did produce a great device choice we did not take a long term view and underestimated the number of devices which has led to non-standardized device footprints. As we needed more devices in differing locations a similar device was not available and a footprint change occurred. This specifically was an issue through the last five years in mobile carts. Add to this a non-user friendly screen saver, battery issues, continual frustration with carts in wrong locations our historical device success has been less than stellar.
Not everything can be blamed on the decisions or the hardware. While rounding with a nurse who was concerned about a wireless device disconnecting, we noted that when the period key was used on the numeric keypad the application she was using exited – it kicked her out. To the nurse it was a device issue, the root cause ended up being a software issue that was since fixed. We have also seen device lockups that related to a custom form that we created, however the form was developed inefficiently and therefore caused the device to “hang”. Again to the end user that hang was a device issue but the root cause was software design. As we progress with our CPOE project we are heavily focusing on end user suggestions and complaints much more closely. Our approach to device issues has also morphed due to our past experience.
Our approach to device issues and root cause is 4 fold. We look at login, application use and logout with a process encompassing all three.
As we all know there are numerous issues that can occur at login and logout – temporary files, Citrix server issues and network issues to name a few. Obviously there can be application issues and as I’ve stated earlier some of these application issues can be reported as device problems. Most importantly underlying the device use is the process. Process issues can drive IT department crazy. If individuals use mobile carts to surf the web which make them unavailable for physician use there is a process problem. If carts are not returned to a standardized location and plugged in every time this creates a device issue but the root cause is a process issue. If a nurse has to lug a mobile cart around the halls to find medication device frustration ensues.
From this framework we use the five W’s and the one H (http://en.wikipedia.org/wiki/Five_Ws) to get to root cause and then work to solve the issue. Throughout the CPOE project our intent is to be transparent with the device issues that we collect and work through not only the technology problem, but just as importantly the process issues that many times are blamed on the devices.
jbormel says
Steve, Thanks for sharing some of your device experiences. In the context of CPOE, if there were a mobile, tablet-ish device that ran Citrix flawlessly, lasted for 8 hours on a charge, had a usable keyboard and a large screen (~10in), and was affordable, would that be a game changer?
There’s of course a new set of these from different manufacturers being hyped, announced and-or released every year.
I’m carving out those who need barcode readers, for now.
dgash says
Wouldn’t it be great if there was a definite solution to this problem? I have yet to find a care giver that likes to push around a computer on wheels. We’ve tried them and they sit in the halls, usually unplugged so the battery goes dead. Computer in the rooms is OK but the multiple login and security requirements are a burden. Tablets and hand held devices work for some but where to put it when the care giver needs to lay hands on the patient. Product compatibility in a virtual environment just makes the solution more difficult to solve.
Steve Huffman says
I’m not sure I’ll ever see a perfect device and I’m convinced that the software / hardware match is just as important as an elegant device. A good example is the release of the iPad today. After spending some time with mine today, the software works perfectly with the hardware to make a great experience. Usability is phenomenal. Using an EMR to enter physician orders on a laptop/PC/cart is miles away from elegant at this point.
mpau0516 says
Hello Steve,
As the helpdesk here at a major hospital, we’ve been seeing a funny thing for 2 weeks now. On our rubbermaid medcarts, when the nurse’s are connected to Cerner with a Citrix connection, and the screen saver comes on…..
The medcart can’t get out of the screen saver. It looks like the screen re-draw is very very slow. Only one inch blocks of screen appear every 5 minutes. Only a reboot (uhplugging the Wyse) will make the medcart work again. It happens on numerous medcarts intermittently. There appears to be no ryhme or reason. I was wondering if you have ever had a situation like this appear?
Also, I think instead of having one device per nurse/ doctor, it should be one device per room. It cuts down the hallway clutter.
Thanks for any feedback.
Steve Huffman says
Mpau0516,
We haven’t had any issues like the ones you are describing and have been very pleased with the Wyse TCD’s.
Regarding your 1:1 room to device ratio – this works in some settings for us but we find that workflow of certain areas demand a higher device %.
Steve