Tablet computers in healthcare settings: novelty or necessity?

This article first appeared in the November 2014 issue of Pulse+IT Magazine.

Australian hospitals are increasingly encouraging the use of mobile devices such as tablet computers for clinical purposes beyond laptops and computers on wheels, and evidence suggests this is a popular move. Recent research shows that while tablet computer use at the bedside is not unusual, access to the full range of clinical information systems and how that information is presented on a small device is still a stumbling block to getting the best value out of tablets.

Clinical information in healthcare settings is becoming increasingly digitised. The majority of Australian GPs use clinical software packages for prescribing medications, checking interactions, and recording patient notes. Although the implementation of clinical information systems in hospitals has been slower than in general practice, there are now hospitals that are completely paperless.

With the introduction of clinical information systems, health professionals have had to adapt their work practices to integrate computing devices. GPs have an advantage in that most patient consultations occur in practice rooms within easy reach of a desktop computer or laptop. For doctors, nurses and other health professionals working in hospitals who are constantly moving between patients or wards, the integration of computers into their work is more challenging.

Desktop computers are typically located away from the patient bedside and carrying a laptop or carting around a computer on wheels (COW) is more cumbersome and time consuming than taking a paper record to the bedside. Tablet computers, such as iPads, are often promoted as having the potential to match the mobility of paper records. In theory, tablet computers could be used for quick and convenient entry or retrieval of patient information anywhere and at any time. They could also be used to share information with patients at the bedside, such as showing patients their x-ray images.

In practice, however, the potential benefits of tablet computers can be limited by a hospital’s clinical information systems. Many clinical information systems that are currently in place have been designed to be displayed on larger screens (i.e., laptops, COWs or desktop computers), and as a consequence, the system interface does not translate well onto the screens of smaller devices.

We found this to be the case in a study we conducted comparing doctors and nurses use of desktop computers, COWs and tablet computers [1]. The smaller size of the tablet computers meant that less patient information could be displayed on the screen, requiring users to scroll more to view and obtain information compared to a desktop computer screen. In addition, the on-screen keyboard of the tablet computers obscured the “ok” button of decision support pop-up windows, making it difficult for users to close the window and return to the main user interface.

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Issues of interoperability can also affect the functions that can be performed on tablet computers. If the hospital’s clinical information systems are Windows-based, they may not adequately communicate with or be transferable to iOS devices. In a recent study, we provided 10 senior doctors with iPads for use on ward rounds [2]. However, the devices were limited to read-only functionality of the hospital’s Windows-based clinical information systems and could not be used to access the picture archiving and communication system (PACS) to view radiology images.

During ward rounds, doctors were frequently observed looking up test results and medications, and to a lesser extent patient information, images and reports. Of the computing devices available (desktop computers, COWs, iPads and smartphones) the primary device of choice for accessing information on ward rounds was the iPad (56 per cent) followed by the COW (36 per cent). The regularity of iPad use on ward rounds was somewhat surprising given they were not fully integrated with the hospital’s clinical information systems (e.g., PACS could not be used) and they provided read-only access.

While doctors valued the mobility that the iPads afforded, in order to improve usefulness and efficiency, they emphasised the need for tablet computers to allow full access to existing clinical information systems so that all relevant tasks could be performed on the devices.

The ability for doctors to use tablet computers to access clinical information systems at the patient bedside lends itself to the possibility of showing patients relevant information during care interactions. We hypothesised that iPads could be used during ward rounds to show patients their test results and other clinical information leading to improved patient engagement in their care process [3].

Disappointingly, during 36 hours of observed interactions with 525 patients, we only observed one patient interaction where a doctor used the iPad to show the patient their test result. Nonetheless, 63 per cent of patients, whose doctor had used an iPad, reported feeling very or somewhat engaged in their care process. The patient who was shown their test result via the iPad reported that they thought the device had increased their engagement in the care process. Although doctors believed it is important to engage patients and share information with them to deliver high quality care that fosters confidence and improves patient satisfaction, they preferred to share information with patients verbally.

As it currently stands, tablet computers are more than a novelty but are not as yet a necessity. Tablets are useful for data retrieval during ward rounds but their use as a tool to engage patients in the care process remains limited. Individual health professionals or organisations contemplating the introduction of mHealth are advised to speak to their IT department prior to purchasing tablet computers to understand their local clinical information systems requirements (e.g., operating system compatibility) and any limitations associated with translating the systems to smaller devices. Such considerations are critical if tablet computers are to deliver on their full potential.

References

  1. Andersen et al. (2009) Mobile and fixed computer use by doctors and nurses on hospital wards: multi-method study on the relationships between clinician role, clinical task, and device choice. JMIR. 11(3): e32.
  2. Lehnbom et al. (2014) iPad use during ward rounds: an observational study. Stud Health Technol Inform. 204: 67-73.
  3. Baysari et al. (2014) iPad use at the bedside: a tool for engaging patients in care processes during ward-rounds? Intern Med J. doi:10.111/imj.12518.

ABOUT THE AUTHORS

Dr Elin Lehnbom
BScPharm, MPharmSc, MClinPharm, PhD, FACHI

Dr Mirela Prgomet
BAppSc(HIM)(Hons), PhD

Dr Elin Lehnbom and Dr Mirela Prgomet are postdoctoral research fellows with the Centre for Health Systems and Safety Research at the Australian Institute of Health Innovation (AIHI), formerly at the University of NSW and now at Macquarie University. They have published extensively on mobile computing devices and clinical decision support tools in healthcare.

State by state: PCEHR and HWAN roll-out for NSW

NSW has been very active in eHealth developments following the launch of the Blueprint for eHealth in NSW in December and the establishment of a new eHealth NSW division in June.

Rural health has also been high on the agenda, with an eHealth strategy for rural and remote NSW developed in association with the wider blueprint.

At the RMA conference, eHealth NSW’s director of innovation, strategy and architecture, Michael Costello, announced that the role of director of rural health within eHealth NSW had been filled. The agency’s new chief clinical information office, John Lambert, is also a rural doctor, working as an intensivist at Orange Hospital.

Dr Costello also announced that the HealtheNet program, which was developed in western Sydney as part of the Wave 2 sites for the implementation of the PCEHR, had now been used to link 26 hospitals in NSW to the PCEHR and would be rolled out to all of other hospitals in the state by March next year.

Dr Costello also said the department had put its rural eHealth strategy in place. “One aspect is telehealth,” he said. “We asked the stakeholders what do you want, they gave us the outcomes that they think rural health [should be] having and one of those is telehealth.”

As outlined in the rural eHealth strategy, NSW is building a Health Wide Area Network (HWAN) to not only boost broadband speeds to rural hospitals but to also further enable telehealth provision.

“So far we have 700 sites which actually have a telehealth installation, whether that is high-def video or down to the corporate chatroom-type of software such as Lync,” he said.

“We are [building] the HWAN, which is essentially the highway and will allow HD video. That is a massive enabler and we are probably going to have that implemented [at the end of] 2015.

“What we would like to deliver in NSW in terms of telehealth is a ubiquitous program across the state where telehealth is not an extra to the clinical experience; it is integrated into the clinical experience.”

State by state: radiology reports through Queensland’s Viewer

Queensland has had an added focus on telehealth since the announcement in last year’s state budget that $30.9 million would be allocated over four years to set up a rural telehealth service.

In September, a parliamentary committee made a number of recommendations on how to improve telehealth provision, including that the Minister for Health, Lawrence Springborg, should lobby his federal counterpart to allow GPs to bill Medicare for direct video consultations with patients.

At the RMA conference, central Queensland GP Ewen McPhee backed the approach but also said he understood the federal health department’s reluctance to make an MBS item number available. Dr McPhee said rural GPs had to show the evidence for the effectiveness of GP to patient telehealth before the department would consider it.

Paul Carroll, acting chief technology officer with Queensland’s Health Information Services Agency, said Queensland had a number of telehealth end points for a number of years, but that take up had been slow due to a lack of incentives or support mechanisms.

“We still don’t have a scheduling capability that is state-wide but some recent innovations have driven up utilisation, particularly around incentives,” Mr Carroll said. “We are now paying both ends of the call. There was 40 per cent growth last year so we are looking forward to continuing that.”

Mr Carroll concentrated on inter-provider and inter-facility information sharing in his presentation on the state and territory panel.

“One of the ways we have tried to support inter-facility care in Queensland is to create our mini-version of the PCEHR,” Mr Carroll said. “We call it The Viewer, and it is essentially an aggregation service for information from a number of other systems.

“Queensland is very passionate about the PCEHR – we think of it as the future of information exchange from the public system in particular and to various providers in the private sector.”

Mr Carroll said that rural GPs with hospital visiting rights could use The Viewer to access a range of patient information. From this week, radiology reports have also been added and are available in 122 hospitals.

“We still have six to go, up around Mt Isa and Mornington Island,” he said. “We’ve got medication profiles and that is unlimited, and every doctor in Queensland Health can see the PCEHR.”

In addition to being able to view the PCEHR, Queensland is sending information to it in the form of discharge summaries.

Mr Carroll said about nine per cent of discharge summaries created in Queensland hospitals are being sent to the PCEHR for patients who are registered, and public hospitals are sending around half of all discharge summaries electronically to GPs, a figure that he wants to improve.

“For a lot of GPs, we haven’t taken the trouble to actually connect with you, so if you are a rural GP and you are not getting discharge summaries, there are opportunities for that to occur,” he said.

“Specialist letters are also going out electronically. From an inbound perspective, it is relatively limited but there are referrals inbound.”

State by state: AMT-coded prescribing events in Tasmania

ACRRM past president Jeff Ayton provided an update on Tasmania’s progress in eHealth and telehealth at the RMA conference on behalf of Tom Simpson, acting CIO for the Tasmanian Department of Health and Human Services and former executive director for the state’s acute care pharmacy services.

Dr Ayton said there had been significant advances in electronic discharge summaries in Tasmania, with 90 per cent of discharge summaries sent to GPs within 48 hours.

“Electronic referrals are beginning to happen as in other states and there is support from the one Medicare Local with general practices,” Dr Ayton said. “As in all states, there is the issue of specialists not being as connected as the GPs are, but in the public system that is starting to happen.”

He said there had also been progress with regard to telecare, with DHHS investigating options to work with the Tasmanian Medicare Local to broaden linkages between acute and primary care.

On the PCEHR, all four referral hospitals have been linked to the PCEHR for some time to upload discharge summaries, and the state is now working on a Connected Care Foundation project involving the implementation of a clinical portal and data repository that will also allow PCEHR viewing by clinicians in early 2015.

“We have been working hard to integrate things with the National Prescribing and Dispense Repository project with the uploading of AMT-coded prescribing and dispense events to the PCEHR,” Dr Ayton said.

He said there is also an ePrescribing project which is rolled out across all outpatient clinics.

Tasmania is also working on a child eHealth record project to implement an electronic version of the Blue Book.

Tasmania’s government announced earlier this year that it was changing the way healthcare is structured in Tasmania, moving the three Tasmanian Health Organisations (THOs) into one agency called the Tasmanian Health Service by July next year.

As part of what it is calling the One State, One Health System, Better Outcomes reforms, the government also plans to look at eHealth in an issues paper.

“Tasmania was the first state with NBN capabilities so there are huge opportunities, but also being a small state with four major referral centres there is the opportunity to make things happen quickly,” Dr Ayton said.

Waiting game for general practice IT

This story first appeared in the August 2014 issue of Pulse+IT Magazine.

Train IT Medical principal and owner Katrina Otto is better placed than most to judge the current state of IT and eHealth uptake in Australian general practice. She has noticed a lot of confusion in the last six months over the direction of national eHealth measures such as the PCEHR, but she remains a keen advocate of using technology to improve practice processes.

Q: Since the review into the PCEHR was announced last year, have you noticed that practices are still keen on using the system, or has interest dropped away?

A: I find that a lot of people think that the PCEHR has stopped, so yes, interest has dropped away. Medicare Locals are no longer funded to support practices with set-up or training for eHealth so now that support has stopped people think eHealth has stopped. What has reinforced this idea is that for many practices their Medicare certificates have expired. Quite a few told me they tried to upload shared health summaries recently only to find it wouldn’t work – this has led to the belief that eHealth has stopped. Previously this would have led them to call their Medicare Local for help but now there is no eHealth help available so confusion reigns.

Q: Are practices generally aware that there was a review of the PCHER or were they not really paying much attention?

A: No, I haven’t found that there’s a broad knowledge that there was a review or what they were recommending. I have been trying to let doctors know the government didn’t kill the PCEHR – they did say they are going to support it. When I say that two of the recommendations that came out of the review are that it was going to be opt-out and they were going to change the name, everybody seems to really like those ideas. Whatever the name becomes, changing it from the PCEHR is very popular and the idea of opt out is also very popular. But when we talk about it, the question always comes back to ‘are we are going to get paid to do this? The general feeling is that this is more work for GPs, it will take more time and there is no payment for it.

To read the full story, click here for the August 2014 issue of Pulse+IT Magazine.

Opinion: When IT upgrades are necessary

The decision to upgrade IT is one that is never taken lightly, as the cost can vary dramatically. Unlike the consumer market, upgrades in the healthcare industry are never performed merely to obtain the latest and greatest version of a product for bragging rights.

Instead, external factors are at work and can include:

With such a wide variety of potential issues, knowing when and what to upgrade is possible for those without technical know-how, but technical support, whether on-premise or remote, is necessary to diagnose problems. Most medical professionals are not concerned with IT and instead prefer to concentrate on patient care.

However, medical professionals, during their daily usage of IT functions, can also notice problem indicators such as slow online access or a delay in entering data, which are often primary indicators of a performance issue. User feedback or alerts from linked clinics can also indicate service issues. All such feedback is taken as valuable information in diagnosing network or workstation problems.

Issues that reduce productivity are then investigated by your technical team. Most are resolved quickly but others may require hardware or software upgrades, whether changing a faulty router, adding additional memory or storage to crucial workstations or removing viruses that have caused unnecessary network traffic.

Regular preventative maintenance can identify potential issues in advance and are performed by experts, with the necessary knowledge to install required updates, remove dust build-up on equipment air vents (when dust blocks vents on a PC chassis, the processor can overheat, with replacement often necessary) and perform connectivity tests.

If IT support is outsourced, regular on-site visits are recommended to maximise productivity and ensure business continuity. Hard drives, for example, rarely fail without warning but many users ignore the drive integrity warnings that occur when a workstation is started.

For that very reason, it is important to ensure that back-up procedures are operational. Tech professionals also validate this process, which is crucial when dealing with medical data.

In many cases, server management is simply too time-consuming and expensive, with cloud solutions sometimes eliminating upgrade worries completely by providing a virtual desktop solution for data management.

In such cases, internet access is essential and perceptive clinic owners will ensure that back-up services are available if the primary broadband connection is compromised.

Medical professionals are best advised to concentrate on their core activities and retain IT staff to ensure that necessary processes function without interruption.

Rob Khamas is an eHealth solutions strategist with REND Tech Associates.

Take a simple selfie to screen for anaemia

Two Monash University medical students who last week won the Microsoft Imagine Cup for their Eyenaemia app have also won the quantitive self category in the Health Informatics Society of Australia’s (HISA) Apps Challenge, with the overall winner to be announced at the Health Informatics Conference (HIC) in Melbourne next week.

Monash students Jarrel Seah and Jennifer Tang picked up $50,000 in prize money for their app, which is able to analyse the pallor of the conjunctiva of the eye and calculate the risk of anaemia.

While the app – which measures conjunctival pallor by asking users to take a selfie of their eye along with a colour standard, and then calculates haemoglobin levels – can be used by anyone, including pregnant women and children, it has been designed to be simple to use and could easily be used as a screening tool in the developing world to target conditions such as malarial anaemia.

Each user has an an account, stored in the cloud, so they can regularly monitor their haemoglobin levels. The user’s target haemoglobin levels are customised according to WHO guidelines for the diagnosis of anaemia.

It has also been validated, the duo says, and can objectively evaluate the colour of the conjunctiva and return the same result every time.

Mr Seah and Ms Tang went up against 125 students and 34 teams in the Imagine Cup world finals, which were held at Microsoft’s TechReady19 in Washington State last week. The Eyenaemia app won the world citizenship category and then went up against two other teams: the winner of the games category, Brainy Studio from Russia, and the innovation category, Estimeet from New Zealand.

Eyenaemia will go up against the winners of the other three HISA App Challenge categories – 14-year-old Dhruv Verma for his PROTEGO app for monitoring older people at home; the DoseMe app for personalised medications dosing; and the Traffic Light app that allows diabetics to monitor their carbohydrate intake – with the overall winner announced at HIC next Wednesday night.

Standard terminology for electronic management of medications

This story first appeared in the July 2014 issue of Pulse+IT Magazine.

Public health strategies are now being implemented in all states to streamline the supply and economic management of medications in their hospitals, strategies that may also significantly reduce the risk of medication errors for patients. Standard terminology to describe medications and standards-based medicines formularies are key components of Australia’s future eHealth systems.

As readers of Pulse+IT would be well aware, the Australian health system is looking to eHealth solutions to improve the quality of outcomes for patients as well as achieve operational efficiencies to ensure that the health system is affordable and sustainable.

One of the most significant financial costs to the Australian public health system is the supply of medications. Australian and global studies have shown that strategies to reduce medication business process inefficiencies can also significantly reduce the risk of medication errors for patients.

Each state health system now acknowledges that effective management of medications through purchasing, prescribing, dispensing, administration and reconciliation processes will reduce the overall cost of the provision of needed medications to patients. The fundamentals are now in place that allow a state health system to effectively manage the business of supplying medications and also reap the benefits to patients and clinicians that follow.

In recent years electronic prescribing and administration initiatives in hospitals have helped reduce the frequency of medication errors. Medical record and medication chart legibility errors are typically the first problems to be addressed by introducing clinical software solutions. Significant progress has also been made in reducing medication administration and pharmacy dispensing errors by the use of software tools.

To read the full story, click here for the July 2014 issue of Pulse+IT Magazine.

Patient portals high on the agenda at General Practice 2014

A panel of experts will provide insight into the use of patient portals for general practice at the Conference for General Practice, being held in Christchurch in late July.

Patient portals are high on the agenda in New Zealand, with the National Health IT Board (NHITB) currently working with district health boards and primary health organisations to try to get all general practices providing patients with access to a portal by the end of the year.

NZ’s leading general practice software vendor, Medtech Global, offers a patient portal called ManageMyHealth that is estimated to be used in about 20 per cent of all practices. The technology is also being promoted in Australia, where Medtech has a smaller footprint.

ManageMyHealth allows practices to offer online appointment bookings, repeat script request functionality, recall reminders and lets patients view their medical records or lab results.

The NHITB says giving people direct access to their health information has benefits including enabling better management of chronic conditions and the ability for patients to have more input into their treatment.

The NHITB is supporting the development of both self-care patient portals and shared care plans for chronic and complex health needs as part of the National Health IT plan.

Royal New Zealand College of General Practitioners CEO Helen Morgan-Banda recently gave qualified support for patient portals, writing in an NHITB newsletter that the college was supportive of all methods of bringing primary healthcare to New Zealanders.

“However, we recognise there are a number of important issues around the portals that need careful consideration, such as permissions, confidentiality of information and access, security and the sharing of information with other health professionals, and the use of electronic communications for contacting patients urgently,” Ms Morgan-Banda said.

“The college has already spoken to the National Health IT Board about being actively involved in helping the college develop the processes and a code of practice around patient portals, so that members and the New Zealand public can feel comfortable and confident with this new way of accessing health services.”

General Practice 2014 will hold a panel session on day two of the conference on July 26, discussing the questions of whether patient portals are a must-have tool for GPs and whether they really can improve patient outcomes.

The Conference for General Practice will be held at the Air Force Museum in Christchurch from July 24 to 27 July.

NZ telehealth gears up as ultrafast fibre rolls out

Waikato Telehealth, the NZ Health IT Cluster and Health Informatics New Zealand are holding an evening seminar in Hamilton later this month to provide an update on regional and national telehealth initiatives.

Maxine Elliot, CEO of Ultrafast Fibre, which is rolling out a fibre network in Hamilton, Tauranga, Wanganui and New Plymouth as part of the government’s national broadband action plan, will discuss the effect of ultrafast broadband on health service delivery in the region.

National Health IT Board CEO Graeme Osborne will discuss NZ’s moves to roll out patient portals throughout the country as part of the integrated care initiatives work program in the National Health IT plan.

Other speakers include dermatologist Amanda Oakley of Waikato Teledermatology; chair of the National Health IT Board’s consumer panel, Stephanie Fletcher; Bruce MacDonald of the faculty of electrical and computer engineering at the University of Auckland, who will discuss the use of robots in helping people manager long-term conditions; and Roy Davidson of Whangarei Hospital on how to make telehealth happen.

The telehealth seminar will be held on Tuesday, June 24 at the Atrium at the Waikato Institute of Technology. Register by email to denise.irvine@e3health.co.nz

The seminar comes as interest in the capabilities of telehealth grow in NZ. Earlier this year, Canterbury PHO Pegasus Health and Auckland’s ProCare joined forces to establish a new joint entity called Homecare Medical to provide a variety of telephone and virtual health services.

Homecare Medical will implement a technology roadmap and new support systems for its telephony platform, including the roll-out of the UK-designed Odyssey Tele Assess clinical decision support system. It is also working on how to access shared care records and partnering with St John NZ to connect patients with their healthcare home.