Carlson, Elizabeth A. PhD, RN; Catrambone, Catherine D. PhD, RN; Nauseda, Susan MBA, RN, PMP; Oder, Karl MS; Slaughter, Whitney MSN, RN; Brown, Frederick M. Jr DNP, RN, ONC
Author Affiliations: Professor (Dr Carlson); Associate Professor (Dr Catrambone), College of Nursing; Director (Ms Nauseda), Corporate and Campus Systems; Instructor (Ms Nauseda); Instructor (Mr Oder), Health Systems Management; Staff Nurse (Ms Slaughter), Northwestern Memorial Hospital; Unit Director (Dr Brown), Rush University Medical Center, Chicago, Illinois.
The authors declare no conflicts of interest.
Correspondence: Dr Carlson, 706 Waukegan Rd, 308, Glenview IL 60025 (Elizabeth_Carlson@rush.edu).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).
By 2014, hospital information technology (IT) costs are expected to be $6.8 billion.1 The American Recovery and Reinvestment Act, signed into law in 2009, contains a number of provisions intended to promote health IT as a way to decrease the escalating costs of healthcare and create an electronic health record (EHR) for all Americans.2 The Health Information Technology for Economic and Clinical Health Act establishes incentives for healthcare providers that implement and use EHRs and became effective in August 2010.2 Providers not complying with the standards by 2014 face reduced reimbursements from Medicare and Medicaid.
As conversion to an EHR escalates, organizations are faced with purchasing computer equipment for clinical units. A universal dilemma for nurse executives is how to meet the needs of highly variable workflow, diverse clinical environments, and wide-ranging staff preferences across clinical units, while dealing with budget constraints. Clinicians in Australia were asked what factors were important in EHR device selection.3 Factors identified were availability, speed, mobility, design, ease of use, and low problem incidence. Another study4 identified financial factors considered in purchasing devices, including purchase cost, both the initial and ongoing, implementation expenses, training time, ease of use, and scalability.
With little evidence-driven information published regarding clinical data entry device preference, the research team explored the characteristics of devices considered most important when selecting point-of-care clinical data entry devices in a select population of organizations. Therefore, these data reported provide characteristics that are commonly used as criteria for device selection.
From the Literature
Of the available literature, 1 article described the processes of how devices were selected at Rush University Medical Center (RUMC) and the mathematical tool used to determine the quantity of devices needed.5 Data collected suggested that individual unit workflow, staff scheduling, and physical layout be included in guiding device selection.
Another study conducted 2 separate evaluations to assist with point-of-care device purchasing decisions.1 The 1st evaluation compared the timeliness of clinical data entry of vital signs between workstations on wheels (WOWs) and centrally located stationary personal computers (PCs) on 6 medical-surgical (M/S) clinical units at a large metropolitan medical center. The 2nd evaluation introduced the use of handheld tablets to the mix of PCs and WOWs on a 12-bed M/S unit and examined both the timeliness of data entry and staff perceptions related to devices. Results indicated that 71.5% of the data entry recorded within 1 hour of collection was entered using WOW. When using a PC for data entry, the percentage of data entered within the 1st hour fell to 57%.1 Conversely, data entry between 1 and 6 hours after collection is more often recorded using PCs (32%) than WOWs (18%).1 Tablet usage for data entry was less than 2%1 when documentation was completed more than 6 hours from the designated data time. Pros and cons from a staff perspective included ease and/or awkwardness of use, reliability, and availability of equipment. Workstations on wheels are larger in size and have a shorter battery life and unstable connectivity; however, they were considered more convenient than a PC workstation.1 Tablets were considered highly portable but had reported similar connectivity problems as the WOWs, have smaller screens, and are therefore harder to read and often lacked the necessary capacity to operate efficiently; that is, they crash. For all devices, availability during peak usage times was a concern. In general, clinicians preferred a data entry device if it was available, reliable, and easy to use.
This article is based on a descriptive study using an investigator-created survey. The intent of the study was to describe what clinical devices are being used by institutions identified as the “most wired.”6 The 26-item assessment was created by a team of content experts and was based on the literature (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A270). The assessment included device characteristics and number of mobile devices used by type of unit. Assessment criteria included physical characteristics of the unit and security and usability of the device.
The 2nd page of the assessment (see Document, Supplemental Digital Content 2, http://links.lww.com/JONA/A271) requested demographic information including the type of unit, number of beds, and the number of mobile and fixed devices. Mobile devices were identified as WOW, laptop, tablet, and handheld. Fixed devices were reported as either inside and/or outside patient rooms. Two additional questions queried whether the institutional representative believed they had enough devices to support clinical bedside data entry and the location of any fixed devices in the patient room. Approval from the institutional review board was obtained.
Testing the Assessment Tool
A pilot test was conducted to test the assessment tool. A cover letter and the assessment were sent to 5 local organizations, including RUMC. Pilot sites were selected from the “most wired” list6 based on collaboration with research team members. Three responses were received (60%). Based on the pilot findings, corrections in grammar, content, and format were made to support reliability and validity of the assessment.
Subsequently, the assessment was sent to the local chief information officers (CIO) at 3 institutions for a 2nd pilot testing.
A broad national sample was obtained by using Hospitals & Health Networks magazine’s 2010 Most Wired Survey,6 which identified the nation’s leading technology-focused healthcare organizations. The cover letter and survey were mailed to the organization’s CIO for completion and return within 2 weeks. Preaddressed and stamped return envelopes were provided. If no response was received within 2 weeks after the initial mailing, a 2nd mailing was sent to the organization. Follow-up telephone calls were conducted by the study team to encourage survey completion and to address any missing or unclear information.
Responses were analyzed using descriptive statistics. Percentage and average rank were used to determine which characteristics were selected most often and the rank assigned. Percentages were used to determine the use of device by clinical area and room location.
Of the 97 surveys distributed, 21 hospitals (22%; n = 21) completed the survey (see Table, Supplemental Digital Content 3, http://links.lww.com/JONA/A272). The respondents included clinicians (14.3%; n = 3), CIOs/senior technical managers (76.2%; n = 16), and unknown (9.5%; n = 2).
Table 1 provides a summary of the device requirements assessment results. The 3 most highly ranked device physical characteristics included wireless, battery life, and mobile, with an average ranking of 3.62 to 3.90 (scale 1 = most important to 10 = least important). The 3 lowest ranked physical characteristics selected by 5% or less of respondents included hard wired, electric demand, and nonmobile. In general, the security characteristics were selected by fewer of the respondents and had a lower rank, with a range of 5.50 to 10.0. Regarding usability, 5 of the 7 characteristics were selected by more than half of respondents (50%-70%), and ease of use for medication administration and ease of use during patient rounding were the 2 highest ranked, with a rank of 3.50 and 3.71, respectively.
Table 2 summarizes the type of mobile devices per unit type and location within the hospital. Beds ranged from 16 to 1266 in reporting facilities. Mobile carts were the most frequently used device (80%-100%). Tablets and handheld devices were used 30% or less. Most devices were located outside the patient room (50%-80%). Eight-eight percent of respondents reported that they felt they had enough devices in the patient care areas to support bedside clinical data entry. When asked where fixed devices were located in the patient rooms, 73% (n = 15) reported that the devices were mounted to the wall. Organizations that indicated that they did not have enough devices stated that “CPOE drives the need for more devices” and that labor and delivery were “saturated and simply did not have enough mobile devices” to support bedside documentation.
Our data demonstrate that many institutions are selecting mobile devices (Table 1). Mobile device characteristics were ranked most often in the 1st tier priority (ranked 1, 2, or 3). The characteristic “nonmobile” was never chosen.
Survey respondents placed a low priority on device security (Table 1). Security characteristics of devices included device encryption, ability to locate the device, and log-in authentication. These characteristics were chosen least often as important. The respondents placed a higher priority on the physical characteristics and usability of the devices than on security.
The characteristics of durability, cost, and low maintenance were chosen often, but they were lower in importance than other device characteristics (Table 1). Interestingly, cost was rated as less important compared with other selection criteria. Cost may refer to both the expense of acquiring the device and the ongoing maintenance. Given that most respondents were CIO/senior technical managers, it was interesting that the technology characteristics (device security and cost) were not more highly valued. This opinion may shift based on continuing and future budget concerns at all levels.
Although the device selection matrix pointed to a low desire for fixed devices (0%), many institutions (86%) deployed fixed devices in at least some of their patient care units (Table 2). The institutions indicated that most of the fixed devices were mounted to the wall, which indicates that it is the most convenient location and saves the most space, although some of the institutions responded that they put the device on a countertop inside the room. Only 1 institution put the device on a cart that was dedicated to the room; that is, the cart was not used to transport the device between rooms. It was reported that there is a mix of fixed and mobile devices used in both critical care and acute care units.
Implications for Nurse Executives
These responses were from CIOs. For consideration of multiple perspectives, the same criteria should be measured on staff and nursing leadership levels. Although the decision to purchase will be at a high level, the buy-in and support for any automated documentation project will be more successful and efficient with staff support and input at all phases. The critical evaluation criteria outlined in this article should be considered during the selection of data entry devices for clinical documentation. Determining the usability and physical and security characteristics that are key for your organization is an essential step before selecting equipment. Further research is indicated to identify suggested workflow patterns to enhance productivity with various devices as staff and physicians work to include automation in the care processes at all settings.