Real-time clinical notes at the bedside

CSC's Healthcare Group recently won the vendors' award in the Clinicians' Challenge competition at the Health Informatics New Zealand (HINZ) conference in Rotorua with a ready-made answer to one clinician's needs: design a system that would allow several users to access and edit a ward round or admission note in real time, preferably using open HTML5 technology on a mobile device.

The challenge, set by Hutt Valley District Health Board registrar Angus Turnbull, was aimed at allowing clinicians to create and edit patient notes at the bedside. Dr Turnbull, now on rotation at Wellington Hospital, wanted to use the ability of mobile devices and operational transformation technologies like Google Wave and Etherpad to make note-taking during ward rounds much more agile.

It was predominantly for efficiency that Dr Turnbull made the challenge, he said. “Creating notes at the bedside is a time-limited process when you may only see each patient for one or two minutes. As you often have multiple team members present, allowing collaborative document editing via mobile devices can significantly improve the utility and acceptance of EMR technology.”

At the moment, ward notes are still being done with pen and paper in a folder, he said. “For some emergency department patients, a laptop on a mobile trolley is used by one team member who often struggles to keep up.”

In his challenge submission, Dr Turnbull wrote that while many hospitals now use EMRs for admissions and will in future likely integrate these with ward round notes through mobile devices, this still posed problems.

“This process can result in delays as one team member must type the whole note via a portable keyboard or touch screen and impair team efficiency, and a better approach is needed given that numerous medical staff may be present,” he wrote.

What he wanted to see was a system that allowed several users to simultaneously edit a ward round or admission note in real time, such as one recording the history while another records examination findings and a third corrects errors.

“This technology should be incorporated as part of an EMR system allowing staff to use their own mobile devices (or devices provided by a hospital) to easily select patients from a team list and simultaneously edit a ward round note at the bedside,” he said. “Options should also exist to copy forward problem lists from preceding assessments, allow for freeform drawings to be attached, and incorporate recent laboratory and radiology results.”

While CSC's Mobility Suite isn't specifically what he envisioned, it does have much of the functionality Dr Turnbull was looking for. Brian Ackland, CSC's software engineer behind the development of the solution, said it was an HTML-based application that currently runs on iPhones and iPads – with Android and other platforms on the drawing board – and allows clinicians to create notes, look up results and record observations on the move.

Dr Turnbull was looking at open platforms like Google Wave or Etherpad as they allow collaborative editing, and while Mobility Suite doesn't use these technologies, part of the challenge for the vendors was to look at the wider context for healthcare, Mr Ackland said.

“The angle that I put in our submission was that in the wider context, it is not just editing a collaborative document, but being able to place orders and record observations and look at results and to do all of those things,” he said.

“At the same time we did get hold of the open source Etherpad software and loaded it up and made our system talk to it. We gave it a little bit of a try but if you are not on a hard-wired network you've got lag in the network, so it wasn't all that successful.”

Dr Turnbull said he liked the idea of Etherpad as it is a free, open source web-based implementation of a collaborative document editor. “I started experimenting with it as a proof-of-concept as it was easy to set up and put together a working example on my own Linux server,” he said.

“CSC felt for technical reasons, chiefly server requirements and some minor iPad interface issues, it might not currently be the best fit for their product, but it’s an easy install for prototyping a collaborative EMR system, and either it or a similar package could be useful to vendors for future versions of their software.”

Part of the collaborative editing element, in which errors can be rectified, was not available in Mobility Suite for several reasons, Mr Ackland said.

“We have taken a more social media approach to recording the notes, just like a person logs onto Facebook,” he said. “You hit the comments area and you save it, and it automatically records the date and time and who you are and shows how long ago a note was recorded.

“Multiple people can be adding notes at the same time, or you could have one doctor recording observations while another is reporting some progress notes. We do have an editing function but that just means crossing it out. For audit purposes we like to keep what somebody has written in its original state. Just like a pen and paper, if someone wants to cross it out that's fine but it's still on the system.”

The Mobility Suite has been designed with CSC's webPAS patient administration system in mind, but as it has been built on HTML the company is looking at how it can be redesigned to sit on other vendors' EMRs, Mr Ackland said. CSC will also design a non-Apple application when the demand is there, he said.

“At this stage we haven't gone down the testing path of deploying it on other platforms, but really that will come down to demand from doctors. They like their iPhones and iPads and the Android market is a little bit disjointed, in that there are lot of different browsers.

“Apple tends to provide the quality hardware and software package all in bundles. We'll probably look at specific devices first up, maybe the Samsung Nexus-type devices."

Dr Turnbull said he was impressed with the idea of giving individual clinicians tablets that can access EMR systems over WiFi so that patient data is always accessible. “As yet, the Mobility Suite doesn’t support real-time collaborative editing of the same document per the challenge, and this is a future area that it and similar EMR systems can explore,” he said.

A much more difficult challenge is to get hospitals on board, he said. “Hospital technology is sadly usually several years behind the times; for instance we have recently only just upgraded from IE6 to IE7 as existing applications are only certified on old browsers and OS versions.

“This makes rolling out innovative web-based applications a tricky prospect as these require very recent browser versions. Implementing new technology and concepts depends on the IT department (many have work scheduled for months or years in advance) and hospital priorities, but it's often easy to at least open a dialogue. The NZ Health Ministry is taking a leadership role in encouraging development of EMR technology so perhaps things might improve in the future.”

Posted in Australian eHealth

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