Communications of the ACM

Communications of the ACM

Ubiquitous Access: On the Front Lines of Patient Care and Safety

By Chon Abraham, Richard T. Watson, Marie-Claude Boudreau
Communications of the ACM, June 2008, Vol. 51 No. 6, Pages 95-99
10.1145/1349026.1349045
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The U.S. Institute of Medicine has reported that nearly 98,000 people die each year due to medical errors, such as incorrect medication dosages due to poor legibility in manual records, or delays in consolidating needed information to discern the proper intervention [6]. Many of these grievous mistakes could almost certainly be avoided with faster, more comprehensive, more accessible patient documentation at the point of care [6]. Fortunately, institutions are beginning to recognize the fact that employing point-of-care information technology (IT) can increase patient safety and reduce medical errors [12]. In light of these concerns and a severe nurse shortage (an estimated 400,000 shortage by 2020 exacerbated by overwhelming administrative tasks, like laborious manual documentation requirements), an increasing number of hospitals are implementing ubiquitous access [7]. The aim is to reduce caregiver error, streamline convoluted processes, and ease nurse administrative workloads by providing readily available access to enter and retreive current complete patient information when and where most needed—at the point of care [5, 7].

In our research, we examined the use of ubiquitous access (UA) to medical and patient information via mobile information communication technologies (MICTs) by hospital nurses, because they are at the front lines of care and safety. Overtaxed nurses assume even more responsibilities, and the impending nurse crisis may endanger patients if nurses are belabored with antiquated methods of information acquisition (such as hastily handwriting notes or entering information into a computer away from the point of care—both error-prone and labor-intensive procedures) [7].

Sixty-two percent of respondents from a survey of 100 U.S. health care IT decision makers cited wireless enablement of the clinical documentation process as a top priority between 2004 and 2006 [3]. However, IT budgets in the U.S. health care industry have historically been low but are expected to grow to $39.5 billion through 2008 [10]. Our findings suggest that knowing more about the actual benefits derived from UA by studying use at the work process level may spark increased acceptance. At the same time, UA is not without meaningful adoption and usage issues [8]. This is especially true in health care contexts [12].

We selected medical units employing UA for various tasks at the point of care in three hospitals. Technologies supporting UA were lightweight computers mounted on carts to allow mobility (see the accompanying figure). Table 1 provides hospital characteristics and summarizes our data collection. The data was collected post-implementation, when UA had been operational in each unit for at least three months. We interviewed nurses, managers, and information systems personnel at each hospital. We summarize the findings before discussing our recommendations:

UA provides nurses with essential information at the point of care. UA reduces nurses' charting time and anxiety, enabling them to stay longer with patients and chart multiple patients simultaneously. UA helps nurses create comprehensive, readily accessible records for any authorized personnel to review in real time. This relieves them from having to communicate patient information orally. Even though UA may promote reduced socialization among nurses, which people external to the context may perceive as an impediment to acceptance, it is balanced by the efficiency improvements in the work process (such as decreased time for task completion and less congestion at central computing points). Vital information can be difficult to transmit even among willing parties. UA increases in value when systems facilitate detailed records-keeping, reduce charting time, and enhance readability. Consider the following quote from a triage nurse:

"The main benefit...is that you can look up information about their previous care—how many times they have been here for the same complaint—as you triage. Some don't want to tell you that they are HIV patients, so when you review their history you can see that... [UA] makes the triage process quicker. [Before UA] by the end of the day, your hand's cramping. You forget some things or can't read what you wrote, which can cause you to make mistakes."

UA automates the documentation and knowledge inquiry portion of the work process. It also informs in that it provides nurses and intended medical personnel with extensive mutual awareness of the situation in which they are involved [4]. UA supports more timely and efficient information analysis in negotiations between medical personnel concerning aspects of the care-delivery process. For example, in medication administration, if a nurse believes the prescription to be erroneous or not effective, the nurse can enter an inquiry in the system to more efficiently alert the physician and pharmacists via an integrated messaging system. This process is less convoluted and time-consuming than the use of manual records.

Benefits and limitations influencing acceptance of UA. Primary benefits that promote acceptance are:

• Reduced time required to validate questionable drug prescriptions and medical interventions, which can delay patient care;
• Greater ability for nurses (and subsequently the hospital) to defend against accusations of, and liability for, negligent care;
• Easier and timelier quality assurance for processes and verification associated with patient care; and
• Greater ability for registration personnel and nurses to maintain patient confidentiality by silently reviewing existing information. Also, UA can offer resources of needed information for situated action. For example, nurses can better negotiate with patients to comply with medication regimens by using the system as a medium at the point of care. As a nursing informatics director reports:

"You can use the computer system to be a part of the [patient and caregiver] relationship. You develop interfaces with graphics that the doctor [or nurse] can use to better explain conditions to the patient. For example, you can create a graph of depicting how a patient's blood sugar is not under control based on historical data. You can show them and ask: 'What are they doing? Are they not taking the medication?' Or you can say, 'You are doing very well on this weight reduction plan for the past three years,' and you can show that to them in terms and schematics that they can understand... You can also reassure the patient that he or she is being given the right med, which fosters trust... The patient becomes engaged that way in [his or her] own health care information... The patient becomes a partnet in managing their own health care and taking some responsibility to make sure the data they see in the record is correctly associated with them."

Limitations that hinder acceptance are:

• The inability to generate desired benefits when technologies, such as document and label printing and copying are not bundled with UA on a mobile workstation;
• Cumbersome IS designs that divert nurses' attentions away from patients;
• Nurses' lack of typing skills, lack of professional exposure and training to IS/IT, or general technology aversion; and
• The short battery life of power packs for mobile workstations.

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Recommendations

How can hospitals take full advantage of UA specifically to address the documentation and information acquisition components of nursing workflow? We propose seven action steps for attaining the full benefits of UA:

1. Nursing education programs should integrate electronic patient-care-documentation-skills development into nursing curricula.

While some nursing programs include basic information systems/personal computing classes, many still do not, according to the nurses interviewed. The result is that, while nurses may be exposed to IS in other parts of their education, they may not be deeply familiar or comfortable with either wireless technology or information systems concepts. Nursing informatics is a separate discipline, but nurses trained in these programs typically do not perform daily clinical tasks. At the very least, nursing schools should partner with hospitals employing UA to expose student nurses to the technology and promote developing typing skills to expedite data entry.

Additionally, technology-mediated situations often force the user to pay more attention to the technology than the person seeking service [11], the patient in this case. Thus, the technology forces the user to engage more closely with the screen than the situation or certain aspects of the task, such as patient interaction. These actions are at the expense of the needed attention the patient expects, and which the nurse is accustomed to giving. Therefore, systems hardware and software must be designed to minimize the level of disengagement of the nurse from the patient in order to access or enter data during the work process. Also, nurses must be trained in how to orchestrate the technology in the work environment so as to maintain sufficient patient interaction to establish a bond and relieve anxieties that can impede the work process. Indeed, the technology design and subsequent user training is heavily contextually based. To truly add value, it must be designed to support how, when, and where nurses engage patients and document interventions.

2. Hospital management should use technology as a recruiting and retention tool.

One in five registered nurses plans to leave the profession, and 64% state they have inadequate time with patients [7]. These alarming statistics are likely to worsen as the pool of qualified nurses dwindles and those remaining are pressured still further. However, this study suggests that UA can address some of these factors, including job stress, working conditions, morale, patient-care time constraints, and paperwork burdens. It is possible that no other current technology may be as useful, at relatively low cost, for addressing such a wide range of nursing frustrations. Hospitals that implement UA—and provide ample, supportive training in its use—may find themselves more able to recruit and retain talented nurses, a significant advantage in a fiercely competitive labor market.

3. Hospital management should create a culture, including a nurse vision statement, emphasizing the benefits and value of nurses' involvement in technology.

Nurses and hospitals benefit from understanding the value they will both receive from large-scale IS implementations. Otherwise, nurses tend to focus on their strength: patient care. According to a manager working with a large health-care system in the northeastern U.S.: "Hospital management and IS departments must make initiatives important for nurses, as well as doctors. You have to make this [technology implementation] salient to the nurses by promoting its effectiveness in decreasing administrative workload and explain how what they [the nurses] do or don't do impacts the whole care-delivery process. But you [as part of management] have to show how you are going to support them in supporting the organization... You just can't dump the technology there and expect them to use it, especially if you are replacing this chart they use to carry around with a computer on a stick...They think you are giving them more to do in attempts to make the physicians' jobs easier." Thus, nurses should be involved in physical device selection, development of interface tools, and refinement of usage processes.

4. Hospital IS departments should support development or adaptation of wearable devices and multi-function mobile carts by manufacturers to support wireless use.

"Wearables," such as handheld scanners and tablets that can be clipped onto waist belts, free nurses' hands to hold a scanner, deliver medications, or aid a patient in numerous ways. More streamlined designs for the mobile carts might make the carts more maneuverable, more able to fit between beds, and—with additional shelves or desktop space—more conducive to multiple uses. These innovations already are in place in other industries. For example, aircraft mechanics use similar configurations to fulfill their need for mobility and access to critical information at the point of service.

5. Documentation devices should be integrated to mimic the workflow (scanning, label and document printing, copying, and electronic signatures that maintain patient confidentiality) to support ease of use.

As long as nurses and registration personnel must make trips back and forth to a desk or station to generate and retrieve paperwork or ID tags, they will have a significant disincentive to use technologies supporting UA. Patient registration typically requires validating identification and insurance information, copying documents or cards, printing wristband labels, and securing signatures on documents. This time-consuming process can be expedited, while significantly reducing nurses' frustrations, when supporting devices are combined on a single mobile cart.

6. Hospital management should extend UA to other tasks that involve location, time, and identity or are highly information-intensive and interdependent. Table 2 provides examples of prospective processes amenable to UA.

7. Hospital management should incorporate software and hardware necessary to support automated patient and medication identification on the mobile workstations to ensure nurses are charting on the correct patient.

Manual charts typically are kept at patients' bedsides or in boxes outside of their rooms, rather than carried by nurses as they make rounds. Conversely, UA technology is mobile, and a nurse has constant access to patients' records despite location. Safeguards must be in place to ensure that nurses are charting on the right person, not to mention sterilizing the necessary hardware per intervention to prevent spreading infections as the nurse moves from one patient's location to the next or when the carts are passed to other nurses in subsequent shifts. Some hospitals' medication administration systems require barcode scanning of the ID wristband issued during registration and the medication label to ensure the correct medication is given to the correct patient. The system alerts the nurse if any scanned information is inconsistent with the prescription, such as incorrect patient, inaccurate medication or dosage, and invalid time for medication delivery. Some form of identification (such as barcoded wristband or RFID tags) that patients wear throughout their hospitals stays and that can be validated by embedded wireless security features is imperative for patient safety, and nurse and hospital liability protection.

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Conclusion

Effectively designed UA initiatives can help allay potentially fatal errors, improve patient safety, and boost overall quality of care. Additionally, UA provides a comprehensive view of the patient's medical information, which is imperative for caregivers to effectively and efficiently service patients at every point in the care system. Caring for the patient's data is as important as caring for the patient because poor patient data quality could lead to a fatality.

The U.S. health-care industry has been a laggard when it comes to IS investments. This should change as evidence—sometimes difficult to quantify in dollars but easily identified in care- and work-quality terms—of the return on investments from implementations are publicized. Such evidence includes the 250% error reduction in the drug-ordering process that saved nearly $300,000 from 2002 to 2003 at the completely wireless El Camino Hospital in Mountain View, CA [2]. Access to information is vital to the way hospital staffs do business, and it will soon be known that tethered technologies cannot deliver the performance needed to adequately decrease administrative workloads and promote patient safety, especially for extremely mobile work forces.

It is possible that U.S. hospital administrators are comfortable with the performance of tethered systems, in which they have made substantial investments. As the status quo, tethered computing appears to have become a sustaining technology (in that it maintains the rate of historical performance improvements that stakeholders expect [1].) Therefore, for many hospital administrators, UA may be viewed as a disruptive technology (requiring process reengineering, technical restructuring, and/or systems integration). This label may not be the most effective way to foster acceptance of UA, particularly in more conservative health-care organizations. As it has been claimed: "Health care may be the most entrenched, change-averse industry in the U.S." [1].

It would be more helpful for hospitals to view these technologies not as disruptive, but as dovetailing, a convergence of the technology characteristics, organizational assets, and task performer's capabilities that disrupts the old economics of the task without disrupting the task environment or the relationship between patient and nurse [8].

Under these circumstances, UA can help reduce documentation errors and preparation time while improving information quality and nurses' working environments. Hospitals that embrace UA can increase patient safety across a wide range of caregivers, departments, and responsibilities. By collecting and delivering vital information when and where it is needed most—at the point of care—hospitals can spur their transformation into more efficient and effective and safer institutions.

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The Digital Library is published by the Association for Computing Machinery. Copyright © 2008 ACM, Inc.

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