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.