Using Technology at the Bedside Stephen Lapinsky Mount Sinai Hospital & University of Toronto Toronto, Canada

Using Technology at the Bedside

Stephen Lapinsky

Mount Sinai Hospital & University of Toronto

Toronto, Canada

One ICU patient generates up to 236 variable categories

Morris, Crit Care Clin 1999, 15:523

Humans capable of managing 5 to 9 variables adequately

Miller, Psychol Rev 1956, 63:81

Data overload - Data overload - patient informationpatient information

Textbooks

Journal articles

Review articles

Association Guidelines

Hospital protocols

Pharmaceutical company information

Electronic Medical literature

Data overload - Data overload - reference informationreference information

Data overload -Data overload - communicating info communicating info

Inefficient data access and communication between healthcare staff

dangerous expensive

New Technologies

Information Access in HealthcareInformation Access in Healthcare

Electronic patient record

Decision support systems

Handheld computers

Electronic journals

Electronic books

Wireless communication

Electronic imaging

Automated Paging Alert System

Software “agent” scans hospital database

Filters: eg. Location = ICU Hgb < 70 g/L or 20% drop

Generates automated pageOngoing evaluation:

- time to intervention- satisfaction:

physiciannurse

Hospital Wireless Communication

In-hospital wireless telephone using 1.9 GHz

3-line function

Forward to paging or covering nurse

Physicians: call/page on rounds instantly accessible

Nurses: link to call-bell

Digital Wireless Area NetworkIEEE 802.11b Wireless LAN at

11 Mb/s

Wireless cart allowing bedside access to: hospital system (eg. labs) PACS radiology Internet searches Order entry

Potential for: video transmission wireless handhelds wearable computers

Handheld Computers

Handheld Computers in the ICUHandheld Computers in the ICU

Widespread usenon-medicalmedicine

Why ?

- 10% US physicians

- 40% of residents

Handheld Computers in the ICUHandheld Computers in the ICU

Widespread usenon-medicalmedicine

International compatibility

Why ?

Roles for Handheld computersRoles for Handheld computers

• access to patient information • access to medical reference information

• tracking educational experience

• scheduling, contacts

• non-synchronous communication

C:\My Documents\Lilly\palmsprings\Emulator.exe

Evaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical CareEvaluation of Palm Computers in Critical Care

Study 1: Qualitative evaluation of handheld computers in the ICU

Study 2: Comparison between “paper” and electronic medical reference database

Study 3: Evaluation of Surgical Procedure logging using handheld devices

Study 4: Evaluation of handheld Pharmacopoeias

Study 5: Ontario Critical Care Information Network


Study 1:Study 1: Qualitative evaluation of handheld Qualitative evaluation of handheld computers in the ICUcomputers in the ICU





Data entry & transfer: on admission update on rounds IR beaming between staff

Reports Daily report Discharge summary IR beam to HP Laserjet 6P

Methods

Results


6 month study period: June - November 1999

24 palm handheld users (84 user-months):

3 Focus group meetings at 2 month intervals

2

34

15Attendings

Medical trainees

Resp therapists

Other (pharmacist, nurseeducator, research fellow)

Results


Physical attributes of Palm IIIx

Patient Management database

Medical reference database

Suggestions: hardware & software

Suggestions: process



Study 2:Study 2: Comparison between “paper” and electronicComparison between “paper” and electronic medical reference databasemedical reference database




Methods

Paper database:Critical Care Handbook of the

Massachussetts General Hospital

Study 2

Comparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databasesComparison of paper & electronic databases

Methods

Paper database: Critical Care Handbook of the

Massachussetts General Hospital

Palm database:Electronic version of the Mass Gen handbookMount Sinai ICU handbookSearchable databaseTreatment guidelines


Methods

Crossover study:3 weeks control (paper), 3 weeks handheld

Subjective assessment:Survey, interview

Objective assessment: Test clinical ICU scenarios, time-constrained

Standardized on a separate group of trainees

Results:No significant difference





Study 3:Study 3: Evaluation of Surgical Procedure logging Evaluation of Surgical Procedure logging using handheld devicesusing handheld devices



Surgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging SystemSurgical Procedure Logging System

69 General Surgery residentsData entry on PalmInternet download of procedure data

Procedure data entry

Message broadcasting- from departmental administrators to all Palm users, during routine synchronization

Internet synchronization with a central database

Customized surveys- get feedback from trainees, directly into a central database


Customized drop down lists

“Surgeon” list specific for the selected hospital

Categories generate sub-categories and procedures based on the American Board of Surgery structure


Data accessData access

Trainees can access their individual database via a secure web site

Procedures may be reviewed on the Palm

Procedural data is downloaded via the Internet using secure synchronization to a central database.


ReportsReports

Allow evaluation of

- individual trainees

- teachers

- hospitals

- trainee years

- etc






Study 4:Study 4: Evaluation of handheld Pharmacopoeias Evaluation of handheld Pharmacopoeias


Comparison of features & content Pharmacopoeias

Mobile Micromedex Epocrates qRx Dr. Drugs A2Z Drugs Lexi-Drugs Moby Drugs & Interactions PDR

Comparison of Handheld PharmacopoeiasComparison of Handheld PharmacopoeiasComparison of Handheld PharmacopoeiasComparison of Handheld Pharmacopoeias

Results:

Essential parameters:

- Physicians identified 9

- Pharmacists identified 14

Content:

A2Z 9/9 13/14

FunctionalityCostUpdates






Study 5:Study 5: Ontario Critical Care Information Network Ontario Critical Care Information Network

Dr. B. KashinDr. H. Clasky

Dr. T. RogoveinDr. D. McRitchie

Dr. S. LapinskyDr. T. StewartDr. R. WaxDr. S. Fischer

INFORMATION DATABASE

• content determined by user’s needs

• evidence-based management guidelines

• regularly updated according to feedback

InternetSynchronisation

from office, home, ICU

Palm Handheld Reference Resource

• mobile, point-of-care access to medical information

• optimal formatting to facilitate rapid data retrieval

• hyperlinked text, tables, images, calculators

online feedback re: online feedback re: content, formatcontent, format

Does the handheld resource work?

- videotaped "think aloud" analysis of the technology in action

Do community intensivists find the content and technology helpful?

- Surveys downloaded to users’ handhelds- Moderated focus group meetings

Does the network improve resource use?

- Clinician performance pre/post with a computer-controlled human simulator

- Comparison of ICU mortality, duration of mechanical ventilation and length of stay, patient transfers

Evaluation

Centre of ExcellenceCentre of Excellence

ICU Information

Database

Peripheral Peripheral HospitalHospital








Centre of ExcellenceCentre of Excellence

Feedback, surveyssuggestions

Reference Information

C:\My Documents\Palm presentation\Emulator.exe