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 - patient information

zTextbooks zJournal articles zReview articles zAssociation Guidelines zHospital protocols zPharmaceutical company information zElectronic Medical literature Data overload - reference information

Data overload - communicating info

zInefficient data access and communication between healthcare staff ydangerous yexpensive

zNew Technologies Information Access in Healthcare Electronic patient record Decision support systems Handheld computers Electronic journals Electronic books Wireless communication Electronic imaging

Automated Paging Alert System zSoftware “agent” scans hospital database zFilters: eg. yLocation = ICU yHgb < 70 g/L or 20% drop zGenerates automated page zOngoing evaluation: - time to intervention - satisfaction: physician nurse

Hospital Wireless Communication zIn-hospital wireless telephone using 1.9 GHz z3-line function zForward to paging or covering nurse zPhysicians: ycall/page on rounds yinstantly accessible zNurses: ylink to call-bell

Digital Wireless Area Network zIEEE b Wireless LAN at 11 Mb/s zWireless cart allowing bedside access to: yhospital system (eg. labs) yPACS radiology yInternet searches yOrder entry zPotential for: yvideo transmission ywireless handhelds ywearable computers

Handheld Computers

Handheld Computers in the ICU yWidespread use xnon-medical xmedicine Why ? - 10% US physicians - 40% of residents

Handheld Computers in the ICU yWidespread use xnon-medical xmedicine yInternational compatibility Why ?

Roles for Handheld computers access to patient information access to medical reference information tracking educational experience scheduling, contacts non-synchronous communication

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

zData entry & transfer: yon admission yupdate on rounds yIR beaming between staff zReports yDaily report yDischarge summary yIR beam to HP Laserjet 6P Methods

Results Evaluation of Palm Computers in Critical Care z6 month study period: June - November 1999 z24 palm handheld users (84 user-months): z3 Focus group meetings at 2 month intervals

Results Evaluation of Palm Computers in Critical Care zPhysical attributes of Palm IIIx zPatient Management database zMedical reference database zSuggestions: hardware & software zSuggestions: process

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

Methods zPaper database: Critical Care Handbook of the Massachussetts General Hospital Study 2 Comparison of paper & electronic databases

Methods zPaper database: Critical Care Handbook of the Massachussetts General Hospital zPalm database: Electronic version of the Mass Gen handbook Mount Sinai ICU handbook Searchable database Treatment guidelines Comparison of paper & electronic databases

Methods zCrossover study: 3 weeks control (paper), 3 weeks handheld zSubjective assessment: Survey, interview zObjective assessment: Test clinical ICU scenarios, time-constrained Standardized on a separate group of trainees zResults: No significant difference Comparison of paper & electronic databases

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

Surgical Procedure Logging System z69 General Surgery residents zData entry on Palm zInternet 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 Surgical Procedure Logging System

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 Surgical Procedure Logging System

Data 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. Surgical Procedure Logging System

Reports Allow evaluation of - individual trainees - teachers - hospitals - trainee years - etc Surgical Procedure Logging System

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

zComparison of features & content zPharmacopoeias yMobile Micromedex yEpocrates qRx yDr. Drugs yA2Z Drugs yLexi-Drugs yMoby Drugs & Interactions yPDR Comparison of Handheld Pharmacopoeias Results: Essential parameters: - Physicians identified 9 - Pharmacists identified 14 Content: A2Z9/913/14 Functionality Cost Updates

Evaluation of Palm Computers in Critical Care z Study 1: Qualitative evaluation of handheld computers in the ICU z Study 2:Comparison between “paper” and electronic medical reference database z Study 3: Evaluation of Surgical Procedure logging using handheld devices z Study 4: Evaluation of handheld Pharmacopoeias z Study 5: Ontario Critical Care Information Network

Dr. B. Kashin Dr. H. Clasky Dr. T. Rogovein Dr. D. McRitchie Dr. S. Lapinsky Dr. T. Stewart Dr. R. Wax Dr. S. Fischer

INFORMATION DATABASE content determined by user’s needs evidence-based management guidelines regularly updated according to feedback Internet Synchronisation 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: content, format

zDoes the handheld resource work? - videotaped "think aloud" analysis of the technology in action zDo community intensivists find the content and technology helpful? - Surveys downloaded to users’ handhelds - Moderated focus group meetings zDoes 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

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Centre of Excellence Feedback, surveys suggestions Reference Information