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Connecting End Users to the EMR - the Last 100 Feet
by William E. Ryman, PE
There’s no doubt about it. Every hospital and healthcare provider in the country is busy planning for an electronic medical record (EMR) or is already somewhere along the path toward implementing one. You can also be sure there is some real energy behind these EMR initiatives because this is one thing both George W. Bush and Hillary Clinton agree on. However healthcare providers everywhere are discovering that the dream of a full EMR and a true “digital” hospital requires a lot of investment, hard work, and a big dose of change in how they do business.
One part of the EMR journey that many of our clients struggle with is the “last 100 feet.” What are the “last 100 feet” in an electronic medical record (EMR) or other clinical application implementation and rollout?
The “last 100 feet” is where the end user actually connects to, and interacts with, the EMR. This is analogous to the “last mile” in the telecommunication industry where the end user is actually connected to the public telephone system. In many ways this is where the “rubber meets the road” for an EMR system.
The “last 100 feet” represents what is needed in the nursing units and other clinical areas to give medical staff efficient, effective, and reliable access to the EMR wherever and whenever they may need it. This is also the stage in an EMR rollout where the hospital must address many important considerations that go into any healthcare delivery process such as safety, ease of use, reliability, serviceability, infection control, privacy, and so on. Many hospitals struggle with these issues and the decisions that guide them.
In order for a hospital to negotiate these “last 100 feet” they must determine and reach a decision about the following important issues:
What is the correct number of end user devices required to meet
our needs?
Where should we locate end user devices?
What types of end user devices are most appropriate?
What is the space and network infrastructure implications and what
upgrades are required to accommodate these new devices?
How much will it cost?
How do we promote end user inclusion and buy-in to insure a
smooth rollout?
We recently helped a large southeastern hospital develop their plan to negotiate the “last 100 feet” in their deployment of a new on-line clinical documentation application. This was an important step in this hospital’s goal to have a complete EMR system at their hospital campus. We will share some of the key issues involved, how one hospital chose to deal with these key issues and some important lessons learned along the way.
Before the hospital began to turn their attention to the “last 100 feet” many important decisions had already been made. For example, the Owner had decided on the EMR provider; they had teams in place to lead the rollout, capture feedback and provide input and support; they had gone through extensive training; they had a well developed schedule for rollout and go-live; and from a software and backend perspective everything was understood and moving forward.
But they still needed to determine the types and locations of the end user devices for the hospital’s clinical areas and departments. They also needed to understand what, if any, upgrades to the existing space were necessary. Also, they needed to understand the power and communications connections required to support the rollout.
A word of caution is in order here. The goal of an EMR implementation is to improve patient care, not merely to automate an existing routine that may be flawed. Technology implementations should facilitate and enable positive change in how we provide healthcare today.
A good example is the idea of “real time” or “bedside” charting. In a traditional care delivery model using paper based records most charting occurs after the fact, away from the patient bedside. It is widely accepted that real-time or bedside charting at the point of patient/caregiver interaction is more accurate and timely. This is a policy decision to be made by the hospital’s leadership and reinforced from the highest levels. Our client’s executive leadership had decided as a matter of policy that bedside or real-time charting was going to become part of their patient care model.
Another important decision by our client was a “zero wait” policy for access to the EMR. They were willing to make the necessary investment to insure that any care giver could access the system without having to wait on a device. They also stated clearly that if there was doubt about how many devices were needed, we were to err on the high side and add more.
These policies were intended to influence safer practices and higher quality health care. They were supported at the board level -- the hospital leadership made it clear to everyone why certain changes to process would be necessary with this rollout. These policies shaped how the hospital chose to complete the last 100 feet.
The remainder of the article will discuss key steps in negotiating the “Last 100 Feet:” workflow review, benchmarking, device selection, site review, and end user review.
Unit Review
One of the first key steps is to understand and evaluate the hospital’s workflow. How many users need to interface with the system? Where do these interaction need to occur?
Department champions provided their knowledge of how many doctors and ancillary staff were on the units and when. Unit secretaries collected supporting data for three days, on multiple occasions, recording specifically who was in the station during peak activity hours. Observers spent time documenting activity on the unit to help validate workflow and staff counts. Physicians provided their input through interviews.
We used this information to develop formulas for determining a baseline for device locations and quantities within a unit. As previously mentioned, when there was doubt we added devices based on the hospital’s policy to “err on the high side”.
Benchmarking
The hospital was eager to learn how other similar hospitals had addressed the issues of the “last 100 feet”. How many devices did they deploy? What kinds of devices? Where? What were their issues? Interviews with a number of similar institutions uncovered several key trends.
Hospitals are early in the journey to a full EMR and most are still in the process of rolling out their systems. There was no clear consensus on the best approach. Some used carts; some used hallway stations; several used both. Some had computer workstations in the rooms; some did not.
In the most mature systems, there were about 1.5 devices per bed.
Battery life was a problem for COWs (computers on wheels). No one had a place to put the COWs when not in use.
Device Selection
Physical space, power, and network infrastructure constraints were key factors in the hospital’s decision to use wireless computer carts as the primary device to be used in the patient rooms. The hospital also deployed wall mounted workstations and desktop workstations in significant numbers at nursing stations, charting areas, medication rooms, and other key locations.
The computer cart selection was very important. Key performance criteria for the hospital included work surface, adjustability, cable management, power capacity, infection control, appearance and other ergonomic factors.
One activity that proved valuable was a visit with hospital staff to the HIMSS tradeshow. Hospital staff could touch, observe, and discuss the features and benefits of all the devices under consideration. This “show and tell” changed opinions on many of the devices; some moved off the list and others moved to the top.
Physical Site Review
The next important step was a physical site review to make sure devices could be placed where desired and that the necessary infrastructure (power, network connectivity, space, etc.) was available. The unit review gave us a good idea of what equipment would go where. Combining this knowledge with a detailed facility review allowed us to make minor adjustments in device locations to take advantage of, or compensate for, existing space, power, and connectivity issues.
EDI created drawings that documented the detailed site review information indicating where new power and network connectivity were necessary. These drawings also indicated minor space renovations required to accommodate the new devices.
End User Review
It was important that we review the “draft” recommendations and plan with unit leadership and staff. This was an essential step in seeking end user buy-in to the final outcome. In order to more clearly communicate with end users, the key findings, recommendations, and drawings were structured around individual units of the hospital.
Unit staff provided valuable feedback that helped “fine tune” device locations and counts. By conducting the review on the unit, additional staff were able to participate and “get a look” at the plan’s progress. Our goal was to leave each unit meeting with a finished product and no loose ends.
Summary
Through this negotiation process of the “last 100 feet,” the hospital was able to clearly define for all stakeholders:
Where devices would go and why
What devices would be used at each location
Infrastructure and facility upgrades necessary to support the devices
Associated Costs
As the electronic medical record continues to gain momentum in the healthcare industry, this information and the decisions it drives will require increasing amounts of professional planning. Architects, engineers, contractors, and other service providers to the healthcare market will likely be faced with these questions soon, if they have not been already. More personally, the impact of the EMR’s last 100 feet will affect all of us who require hospital services for ourselves or for family members. We think that makes it pretty important.
For more information on the electronic medical record, please visit www.himss.org, website of the Healthcare Information and Management Systems Society.
For additional information or discussion, please contact us at info@ediltd.com.
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About the Author:
Bill is a Senior Vice President and Principal for EDI, Ltd. His experience includes technology, security, and audio-visual planning and design for regional hospitals, children’s hospitals, and community hospitals, as well as a broad mix of corporate and institutional facilities.
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