From COW to iPad to Google Glass

 

So far, my posts have been focused more on the software side of ICT in hospitals, such as EHR, CPOE, and CDS. This time, however, I will focus more on the hardware side of it.

When doing a more research about the concept of connected hospital explained in my previous post, I came across this video about Toronto General Hospital.

 

The video was produced in 2010 and shows how the best practices looked like at that time: installing a battery-powered PC into nurse’s medication carts (dubbed “MedCart”) to replace a traditional paper based instruction, and using a Wireless Devices on Wheels (WDoW) so physicians have a constant EHR and CPOE access. Of course, these efforts chiefly aimed to ensure portability and mobility of information access which increase not only the hospital operational efficiency, but also the quality of patient care.

 

But these hardware technologies became a little bit outdated two years later, when people saw Apple’s iPad (and arguably any tablet devices) as a genuine disruptive technology which will replace the MedCart, WDoW and other Computer on Wheel (COW) technologies. Why would a physician pushing a cart with a big computer on it when he / she can access the same information through an iPad? The iPad's battery life is also good for 10 hours, perfect for a hospital environment. As comparison, a typical COW has a battery life of 4 hours (although some of them are lasting for 12 hours). When the nurses or physicians need to change the battery in the middle of the shift, it is of course seen as counterproductive. A research shows that 62% of US physicians use a tablet device, in which iPad is the dominant platform, for professional purposes in 2012. To give you a better illustration on how iPad changes the hospital operation, Healthcare Australia (HCA) has the following video:

 

So these are the past and present of ICT in hospitals. How about the future?

Now, the hospitals and other application developers are visioning the implementation of wearable technologies, such as Google Glass, to support health care service. As of now, at least four startups are focused on Google Glass application for healthcare. So how will exactly Google Glass improve hospitals operations? Please, compare the previous videos with the one below.

As you can see, Google Glass is envisioned to be connected with EHR, enable remote collaborations between physicians and hospital staff, help monitoring the patients’ vital status anytime and anywhere, and facilitate tele-consultation with specialists. All these can be achieved instantly in a real time basis. Furthermore, unlike using iPad and other tablet devices, using a wearable technology like Google Glass means that the physicians and other health care providers do not need to get their hand off the patient while accessing important information. The efficiency in the hospital operation has never been better.

That's it for now!

The Connected Hospital

My posts to date explain how EHR stored the data recorded by the physicians and other health providers, and how this data can be shared easily to other stakeholders. Clearly, EHR is the key example that illustrates how ICT can help a hospital to achieve a state called the connected hospital - a vision of a fully integrated hospital where wireless technology allows care givers and patients to roam throughout the hospital while providing accurate and timely monitoring. A lot of hospitals see this vision as the “promised land” of ICT integration. UCSF shares its vision of connected hospital in an amazing video here.

This video shows that ICT can do more than ensuring accurate patient records and enabling real time data analysis through EHR. In this post, I will elaborate two of many instances that UCSF mentioned.

Patient Survey

So a hospital has implemented the EHR system, in the hope of increasing patient satisfaction. However, how does it know that the patients are indeed satisfied? In my previous post about best practices, I shared how important it is to have an ICT optimization team in order to identify and implement improvement opportunities. Patients are evergreen source of innovative ideas if hospitals listen to what they say and probe for more. Furthermore, patients can also be the best source for identifying unsolved problems. Therefore, a patient survey is an important source of data set that a hospital should collect and analyze.

Evaluating a paper based survey, however, is very time and labor consuming. This fact makes hospitals limit the sample size and questions to a manageable amount. As a result, hospitals tend to miss a lot of information. ICT helps to solve this problem and enables e-Survey, as shown in this video.

Example of e-Survey Utilized in Hospital Setting

Brockton Hospital in Massachusetts has implemented this method. When about to leave the hospital, each patient is given an iPad so he / she can fill out a survey about his / her experience in the hospital. This e-survey allows a real time feedback and alerts the hospital management team whenever a patient rates the service as poor. This means the hospital supervisors can provide quick coaching and guidance to their staff as soon as possible.

Preventive Health Care

When we use our Nike+ FuelBand, we can extract data about our movements, activity levels, and calories burned. When we use Sleep Cycle application, we can monitor our sleep phase easily. When we use Diabetes Buddy application, we can track our blood sugar level actively.

What do these imply?

Just like what Dr. Bokser said in the UCSF video: “We are capturing data from the places we never imagined”. Having this data would help the hospitals and physicians to be more proactive on patient health and promote preventive medications. Cloud computing helps hospitals to bring this idea into a reality.

Example of Preventive Health Care Interface

Letting the physicians in the hospitals to track these data and diagnose the symptoms actively mean the hospitals would know something is going on even before the patients know about it. This will help the hospitals to control patient condition before it is getting worse. Controlling in the early stage means not only patients can be cured easier, but also hospitals can prevent a costly treatment. Therefore, don’t be surprised when someday the hospital suddenly calls you and tells you to see a physician / specialist as soon as possible.

That’s it for now! Stay tuned for the next post!

Patient Privacy and EHR

As we learned from my previous post, EHR system potentially brings multiple benefits to hospitals. EHR allows health providers to instantly store, retrieve, access, and exchange patient information from virtually anywhere. However, patient privacy remains one of the main concerns regarding EHR system. Therefore, I decided to talk more about it in this post.

EHRs are more than just a bank of data. They are eventually about people and can tell stories of a person. As it is nicely put by HealthIT.gov in this video: My EHR is Me. In that sense, only people who need to know should have an access on the records. There are several cases of data breach happened in the hospital. One of them is the case when employees of UCLA health system were found to access celebrities’ records although they did not have a proper authorization to do so. At the end, UCLA health system agreed to pay a settlement of $865,000 with the U.S. Department of Health and Human Services Office for Civil Rights. Lucky these employees were “just” accessing the records. Imagine if the confidential records end up in the wrong hands, the consequences could lead to identity theft, which can destroy a patient's finances, credit and reputation.

It is important to understand that EHR breach’s victims have a right to seek litigation against the hospital in which the breach occurred. Because the nature of EHRs as a bank of information, it is highly possible that a breach would affect multiple patients simultaneously, something that is less probable in the case of hospitals using paper records system. The more patients affected, the more serious legal problem facing the hospital is. The bottom line: hospitals are responsible to keep the EHRs safe and secure.

So what are some key challenges that make a perfect patient privacy difficult to attain? I came across this article by Shahid Shah, which I find it really interesting. He concluded there are seven causes of digital privacy loss in EHRs. However, I would summarize them per stakeholder so they can be understood easier. I have also made the following diagram to support my explanations.

Stakeholder Analysis

1.      EHR system vendors / designers

Hospitals sometimes develop their own EHR system in-house. More often though, they outsource it from a vendor. In both scenarios, EHR system (and other IT solutions) with less than sophisticated privacy-aware system are faster and easier to develop, not to mention that they are considerably cheaper than those with privacy aware system. My previous post talked about how expensive EHR’s implementation could be. Therefore, leaving out or choosing just mediocre privacy functionality in the system is one of the solutions that the vendors take so they can offer their product with more competitive price to the hospitals. If the hospitals develop the system in-house, this can be seen as a cost cutting opportunity.

 

2.      Patients

Shah argued that most patients themselves do not really understand the concept of digital privacy. They made a wrong assumption that by storing their medical records electronically, nobody can touch them but people who are authorized. As a result, patients usually do not really demand privacy as strong as they demand other things. As illustration, when choosing physicians, hospitals, and other health providers, have you ever considered and sorted out your choices based on their privacy views? I don’t. Applying a basic economic concept here, less demand means less supply.

 

3.      Government

If you read my previous posts about how the government incentivize hospitals to implement an EHR system, you would be aware that they are focusing on the “meaningful use” aspects. These aspects focus more on functionality and do not put much emphasis on data-centric privacy capabilities. Shah stated that “privacy is difficult to define and even more difficult to implement so the testing process doesn’t focus on it at this time.” Relating back to the cost issues, it is natural then for hospitals that heavily rely on government’s incentives not to focus heavily on patients’ privacy.

 

4.      Hospitals

As stated in my previous post, EHR will improve hospitals’ operation by allowing sharing and aggregating patient information easier than ever. Enhanced privacy system can add a friction in the sense that it discourages data sharing and potentially leads to productivity lost in the hospital. Therefore, hospitals may opt to develop EHR system with less than desirable privacy features.

In conclusion, EHR is a powerful system which can help hospital operations tremendously. But, “with great power, comes great responsibility”.  Implementing the system means hospitals have to be ready to not only take the benefits but also fulfill the responsibilities to preserve patients’ privacy by storing all the information safely.

That's it for now. Stay tuned!!

ICT Implementation Best Practices

My previous posts touch on how ICT, in the form of EHR, CPOE and CDS, can benefit hospitals. Of course, the implementation cost for these technologies varies depending on many factors such as hospital size and technology scope. But in general, they are not cheap. As illustrations, Dartmouth-Hitchcock Medical Center spent about $80 million to implement EHR, University of California - San Francisco Medical Center spent about $150 million, and Duke University Health System spent about $700 million (Yes, you read it correctly, it’s $700 million). As far as federal government incentives go, the Medicare and Medicaid only provide them to the hospitals who are meaningfully using the EHR system. The definition of “meaningful use” is explained in more detail here. But basically, a hospital needs to achieve several objectives before it can claim the reimbursement. This includes making sure that all stakeholders are devoted to use the technologies.

Duke University Health System
It's gonna be $700 million, please. Debit or Credit?

Therefore, it is very important for hospitals to get the full benefit from EHR and other systems by performing the “meaningful use” of the technology. In this post, I will share some best practices how to achieve that.

1.      Full engagement of all stakeholders is the key

EHR and other technologies implementation are not IT department projects. IT department can install the technology quickly and easily. The projects, however, are more complicated than just installing software. These technologies would change the entire hospitals approach and operations. It is wrong to assume that each stakeholder will adjust his/her habits accordingly once a technology is put in. Rather, hospitals would need to secure the opinions and recommendations of the staff. This will eventually lead to their cooperation and commitment in the future. Therefore, the implementation team should include representatives from different hospital areas identifying requirements and implementation elements.

Key: All Stakeholders Involvement

 

2.      Physicians should take the ownership

Implementing EHR and other technologies for the first time will temporarily put burden on the physicians, who might be overworked and overloaded already. As instance, in the beginning it might take a longer time for a physician to input an instruction using CPOE compared to write it on the paper. This will bring frustration. Therefore, it is very important to let the physicians take the ownership of the implementation. That way, hospitals will get the implementation process moving forward.

3.      Educate and Train All Stakeholders including Employees, Physicians, and Staff

Education and training will help smoothening the transition to a new system. Hospitals would need to do this via workshops and seminars, internal marketing efforts, and education campaigns. It is also important to share the implementation milestone, so the stakeholders are aware of the progress. Hospitals also need to recognize some preferences and needs of the stakeholders. For instance, during EHR implementation process, hospitals should not try to force all physicians to do exactly the same thing. Hospitals need to provide several ways to accomplish the same task and offer physicians some flexibility to choose what will fit their practice style the best. This will add the training complexity, but it will guarantee a more successful implementation.

4.      Beside Implementation Team, Optimization Team is also Needed

Optimization team’s main task is to identify and implement improvement opportunities. This especially important during the mid-process of implementation. The other tasks include, but not limited to, identifying the best practices learned by the hospital staffs and retraining the stakeholders the updates based on trials and earlier outcomes.

5.      Duplication and Plan B are necessary

Redundant data entry must be minimized. However, the hospital administrators need to have a backup system or at least, a plan of action if the system is suddenly down or not functioning as it’s supposed to be.

                The cost to build a redundancy and backup system is worth the benefit.

 

 That’s it for now! Stay tuned for my next post!

 

CPOE and CDS

Have you ever seen a physician’s handwriting? Most of the physicians that I know have a handwriting like this:

I am sure about the "to" and "75%". But that's about it

So I came across this article and found it really interesting. In 2006, National Academies of Science’s Institute of Medicine released its research findings claiming that 7,000 Americans are killed annually because of physicians’ sloppy handwriting. Furthermore, the research also claims that preventable medication mistakes injured about 1.5 million Americans annually. While the article is focusing on prescription related errors (wrong doses, wrong drugs, wrong frequency, etc.), this issue can actually affect hospitals’ operation in general.

Physicians communicate with other stakeholders not only through prescriptions, but also about other important things affecting patient treatment in the hospital such as order of diagnostic tests, specific instruction on patient care, and referrals. Even if the nurses and pharmacists can read the handwriting with no problem at all, I personally believe it will take some time to train them before they get used to it. At some point, they might be confused with the handwriting and need to contact the physicians back. This “confirmation activity” means a lost work of productivity for the hospitals. But still, could be worse. The nurses or pharmacists might misread it. So clearly, relying on paper-based communication system is not the best practice for hospitals.

So what does ICT offer hospitals to solve this issue?

The technology that you are looking for is Computerized Physicians Order Entry, abbreviated as CPOE. One of the CPOE definitions is a system that allows direct entry of medical orders and instructions for the treatment of patients by a medical practitioner. The orders and instructions are communicated via a computer network to medical staff or other various departments responsible for fulfilling an order or instruction, including pharmacy, radiology or laboratory.

Example of CPOE's Interface

By applying CPOE, hospitals will eventually decrease delay in order completion and reduce errors related to handwriting. In addition, this method of communication allows the medical practitioners to enter the orders and instructions both at point of care or offsite.

Sounds better than a paper-based communication system, doesn’t it?

But wait, there is more!

To make the use of CPOE even more effective, hospitals should also apply CDS at the same time. CDS stands for Clinical Decision Support.

Example of CDS' Interface

Healthcare Information and Management System Society (HIMSS) explains types and examples of CDS interventions in detailed way here. In short, CDS provides physician and other stakeholders with knowledge and person-specific information, intelligently filtered or presented at appropriate times, during data entry tasks, data review tasks, and assessment and understanding tasks. In addition, CDS can be interpreted as a mistake-proofing mechanism which will send alerts and reminders to care providers and also to patients.

Thus, CPOE helps the stakeholders to read the orders and instructions correctly. CDS, on the other hand, makes sure that the orders, instructions, and actions are indeed correct. One research claims that the use of CPOE and CDS eventually decreases the likelihood of error drug order by 48% and estimate a 12.5% reduction in medication errors. Moreover, an actual implementation in Denver Health Medical Center shows that CPOE and CDS decrease turnaround time by 54.5%, 61.5%, and 83.4% in its laboratory, radiology and pharmacy department, respectively.

In conclusion, applying these two systems benefits hospitals by:

-        Improving patient safety and quality by reducing medication prescribing and administration errors

-        Increasing operations efficiency by reducing duplication of services

-        Saving time (and money) for both patients and the healthcare organization

And one last note! If you read my previous post about EHR/EMR, maybe you realize that there are some overlaps between the function of EHR/EMR and CPOE & CDS. You are spot on. The majority of CPOE and CDS applications operate as components of comprehensive EHR/EMR systems. They are not the same tools. Rather, CPOE and CDS are actually embedded in EHR/EMR.

That’s it for now! Please stay tuned.