The importance of screen real estate in a clinical setting

90 day ROI on all-in-one touchscreen PC's for office nurse workstations.

The Heartland Clinic of Platte City (10 minutes north of Kansas City International Airport) has been using Cerner's PowerChart for over 2 years in a nearly paperless environment. We initially started with notebook and tablet PC's with the nurses and the physicians carrying their machines into the patient exam rooms.  That quickly went by the way-side as we discovered patients wanted to see what we were doing and we needed to review lab results, digital images and other patient information with the patient.  The small screen devices just could not meet this need nor did we have a good place to set the devices without interrupting the visit.

Inexpensive PC's with wireless NIC cards (the rooms were not wired) replaced the mobile devices and very soon after that we installed 21" swivel monitors that hit the sweet spot with the patients, nurses and physicians.

Total cost for these inexpensive devices was less than $1,000 and we've been using them to complete the majority of our encounter notes in the exam room at the point of care as well as leveraging them to look up and deliver patient educational material from a variety of online resources.

We all saw productivity enhancements (less clicks, screen manipulation, etc.) with the larger screens.  If they were inexpensive we feel that 27 or 30" swivel monitors might be even better.

Similarly I, along with others, have found attaching a separate monitor to our laptops have improved the functionality and productivity by reducing the manipulation of windows on smaller screens and enabling the frequent side-by-side comparison of data.

  I've found that it's very beneficial to have one screen in landscape and the other screen in portrait mode. Many applications (like the New York Times Reader) are designed for landscape while others (USA Today and most web sites) are more functional in portrait mode.

The same thing is true with our electronic medical record.  Cerner's PowerChart is split into a section called the "Organizer" consisting of messages, tasks, patient lists, schedules, etc.  It works best in landscape mode as shown.  Opening a patient chart creates a new window that is independent of the organizer.  Using 2 screens it's quite obvious that most sections of the chart fit the portrait arrangement better than the landscape and in my office this is the way I set up the application when not seeing patients.

Lately I've been watching our nurses who are using the notebook computers given to them.  Day in and day out they have to juggle many parts of the patient's chart, the web (for accessing insurance information, locations of clinics and facilities to which we refer patients and other productivity applications). It seemed logical that they too would benefit by additional monitors. 

However, when we attempted this we discovered that there were enough quirks in how remote hosted applications (like our EMR) treated two screen arrangements and often they couldn't put the second screen on the right (the preferred arrangement for Windows applications).  Secondly there wasn't enough space to accommodate large second screens and all of the cords were a nuisance.

I was impressed with the iMac that I was using at home but there were cost constraints (as well as push back from our IT department) that prevented experimenting with iMac nursing workstations.  Instead we tried HP's new Touchsmart 600's and received permission to purchase one of them to test.

Within minutes of setting it up one of our better nurses who admits to being computer phobic was jumping all over the Aerosnap and other Windows 7 features including the touch screen functionality for web page and windows arrangements. Her response triggered us to purchase several more refurbished units for under $900.

This device, like the iMac, has a wireless mouse, keyboard and NIC card and due to it's vertical positioning actually increased the usable space around the machine on the nursing island while at the same time nearly tripling the effective screen real estate.

We started calculating the time saved by counting how many times during a routine phone interaction the nurse had to open close or manipulate a window to answer various questions.  The other party at times would want specific visit, lab, insurance and past patient data that necessitated jumping around to different sections of the chart.


In addition the nurses usually had to  bounce back and forth between patient's charts and their message center in the organizer section of the application.

On average a minimum of 5 window changes were required to complete that interaction.  Each of these changes added 5-10  seconds to close or bring to the front the desired window and then locate the data.

The very large screen devices with the Aerosnap feature enabled the nurses to have most of the needed windows open on the screen with minimal manipulation and the number of screen changes plummeted to a little over 1, a savings of 25 - 30 seconds per phone interaction.

Each nurse said that in the course of a day they fielded close to 50 phone interactions (this despite having nearly 80% of our patients using our web portal and saving nearly 8 hours of phone conversations a week per nurse).  This means in the 1st day of setting these devices up we were saving each nurse an average of 25-30 minutes a day in wasted PC manipulation.  Based on our average wage our calculated ROI on these devices is well under 90 days.


In short, you just can't have enough screen real estate and productivity gains is proportional to the amount of that real estate.

Incorporating photograph in an routine exam room visit

I've been incorporating photographs in PowerNotes for nearly 2 years and after a wide variety of experiments am now refining the process to where nearly 50% of my notes have images in them without adding any time to the documentation at the point of care in the exam room. This blog reports on the technique and methods that allow this value added process in a primary care ambulatory setting using existing tools, devices, features and functions in PowerChart 2007.19 code.

Basically the process involves using virtually any camera, transmitting the images in real-time to a secure network folder that is accessible by PowerChart running on Citrix application servers, loading those images into the Multimedia Manager, Clinical or PowerNotes during the visit.  Here's what it looks like:

We've been testing a variety of cameras to determine whether there is an optimal camera and have concluded that virtually any image capturing device will work and the one chosen should be dictated by the nature of the image and potential downstream use.  The iPhone works as does the inexpensive point-and-shoot cameras, mid-level and high end cameras.  All have their advantages and disadvantages but they all work (more about this later).

The critical component for fast, secure and seamless incorporation of images in the point-of-care documentation process is a wireless SD card.  We found that physically having to connect the cameras using USB cables and/or removing the SD memory cards and inserting them into the local device was problematic on two major levels.

1. First, the active of manipulating the camera, cable or chip detracted significantly from the patient-physician interaction and interrupted the flow of the encounter as well as added time to the encounter. 
2. Second, enabling USB and SD imports increased the security risk of the in-exam room computers unnecessarily.
3. There's an Eye-Fi app for the iPhone so smart phones can be used securely as well and this allows the smart phone to direct the photographs in a secure fashion to the same secure as the cameras with the Eye-Fi cards although it seems to take marginally longer (1-2 minutes at most).

We are having significant success using wireless Eye-Fi SD cards widely available at different price ranges ~$40 - $100 primarily dependent on size and speed.  These cards look like any SD camera memory card except they have wi-fi capability in which images are encrypted and routed wirelessly to the desired location.  The cards come with an Eye-Fi Center application that installs on any PC or Mac allowing the user to specify which Wireless Access Points to connect to (up to 32 private/secure SSIDs may be specified for each card) and the target network folder to which the pictures will be routed. All of the cards can be managed by the same application as shown below:

Net result:  A picture is taken in the exam room > camera begins immediately to transmit the picture without any intervention by the physician > physician and patient continue their interaction without being disturbed > image is usually available to PowerChart's drawing tool within 30 - 120 seconds (there are many variables that vary the copying of the image from the camera to the network folder).  The physician can then incorporate the image in the note that (in our case) is being compiled at the point-of-care in front of the patient.

We're using images for anything that is difficult to describe or will need to be followed (rashes, lesions, wounds, physical findings like edema, varicose veins, etc.).

It's fun, the patient's love it and it has certainly enhanced the physician/patient/exam room experience without adding time to the visit or taking attention away from the clinical condition/event that prompted the visit.

The Active Challenge - 300 in 60

Yesterday I finished my Active Challenge and here's the video of that event. Since I'm turning 60 this year I decided to play 60 holes of golf in one day; WALKING and carrying my own bag AND breaking 300 (5 strokes per hole). Enjoy and find out whether I completed it and whether I met my goals.

iPhone, iPad and application licenses

Just discovered that Skyscape's (http://www.skyscape.com) applications that many of us physicians used have to be uninstalled on the iPhone before they can be installed on the iPad.  Alternatively the physician is free to purchase them again to use on both the iPhone or the iPad even though the likelyihood of them being used at the same time is remote.

This is simply not right and as of now I'm recommending that all physicians who use Skyscape products refuse to purchase separate copies for each device they use. The license should be to the individual, not the devices.

Technology to the rescue?

So reviewing this morning's news a couple of interesting articles caught my attention. One, a discussion of Foursquare which provides a social networking app tying into their GPS devices that quickly allow people to "check in" to bars, restaurants, shops and other venues ostensibly to share tips and receive points. The complete article by Rob Pegoraro can be read in his Fast Forward column on the Washington Post.

The second, another release from Duke on a "New smoking cessation therapy proves promising."

And then this add on 7A of this morning's USA Today about a GPS enabled ESCORT radar detector.

What if you put all of these together in a medical application? A GPS enabled, location specific inhaled glucose delivery system for insulin dependent diabetics. Would know what restaurant you walked into, calculate the average carbohydrate load of the items on the menu, adjust the inhaled insulin device so that you could eat or drink your fill without raising your blood sugar and then guide you safely around any police checks?

It's getting pretty freaky but let's take it one step farther and have all of this available as an implant. Now go back and remember the Cyborgs from the old Startrek shows?

Are we there yet?

We are the problem ... and the solution

We Are the Problem ... and the Solution

An article by Reed Ablelson in this morning's New York Times illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs.  It is apparent that large changes are coming. The question is not if but when and by whom?

I was struck by how much blame each of us carries in this dilemma.  Most physicians in this country are payed by what they do, not what they produce.  As a result we are all under pressure to bring in enough income to pay our nurses and staff.  Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 - $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient ... a lot simpler and a lot more profitable.
This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992.  These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010.  The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year. Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now.  At some point this house of cards crumbles.
We patients are also to blame.  In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable.  Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures.  Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).
And it’s worse when we’re healthy!  We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone.  If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address).  Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.
So what are we to do? Well, for one we need to act because no one else is going to. For my own part I have resolved to be a role model for my patients.  I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits.  In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit.  We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.
As patients it is usually less expensive to do the right things.  First, change our lifestyles to maximize our genetic potential.  We do need to stop smoking.  We do need to move rather than sit.  There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight. We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is.  The complications from vaccinations are infinitely smaller than the complications from any of the diseases.
When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice.  It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories.  Make sure the physicians making decisions are aware of this.  If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term).  If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary  in our lives to decrease the need for those medications.
We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.
We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.
We need to care for others and not be responsible for hurting others.
Finally, we need to begin rewarding those politicians who make hard decisions.  We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems.  The center will and we need to begin rewarding those who work with others and not those who are obstructionists.
The bad news?  It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim.  But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.

 

 

 

Posted via web from Dr. Voran's Posterous

The Ideal Exam Room: A Primary Care Physician's Wet Dream

There's a certain irony in that the more specialized a practice gets the more technology available to help the physician. A retinal subspecialist is a good example where they have in office orbital CT scanners and a host of other extremely expensive tools available for the physician's use at the time of the visit.  On the other side of equation the primary care physician who has to deal with the entire body and mind is often left with only with devices that haven't changed much in 100 years. Yet they are expected in the usual 10-15 minute visit to interview, examine the patient, derive a diagnosis and treat the patient.  
The stark reality is that it is the primary care physician, with the greatest informational needs that should have most of the tools.
We're all familiar with the tricorder used in Startrek where Bones could scan a person in the field as well as the exam room, view the images and make a diagnosis.

 
What's silly is that by the time a patient is seen by the subspecialist the diagnoses have already been made (usually by several other physicians who have sequentially seen the patient at an ever increasing cost).  By the time the patient gets to the highest technology it is used only to confirm the diagnoses and to complete the definitive treatment.

It's my opinion that if technology was available at the front lines many diseases would be diagnosed, caught and treated long before they require subspecialised therapy or treatment.


There are many devices such as a dermatoscope, tonopen, digital ophthalmoscope, otoscope, not to mention digital scales are available but outside the reach of most primary care physicians.  Yet, if each exam room was equipped with these digital devices AND connected to their electronic medical records many diseases that now are missed could be diagnosed earlier, more accurately and treated at a much lower cost than they are now.

On the pure information front, I find the time cost of logging into multiple systems (our own EMR and those of nearby hospitals, reference labs not interfaced without our system, imaging centers, online reference sources such as UpToDate, ePocrates, MDConsult and a host of other tools that I wind up using in the exam room prevents me from exploiting them in the typical 10-15 minute appointment. Even though we’ve equipped the PCs in each exam room with 21” swivel monitors we find there’s a lot of visit time that could be saved if the all of the information needed at the time of the visit didn’t need to be navigated to.


When not seeing patients I usually grab all of the computers to which I have access, splay them up in front of me (including one of the units from the nearest exam room).  Productivity increases dramatically.  Most information resources are at my fingertips in parallel rather than serially if restricted to a single machine or reduced screen real estate.  This is exactly why traders in most brokerage houses sit behind multiple displays in order to work.  Time is money and faster, better (well, maybe) are made if one doesn’t have to waste time navigating to that information.


So what am I saying?

I am confident that if we would put the most technology possible into the hands of front line physicians who have to address the broadest spectrum of patient concerns we might be surprised at how much more efficient, productive and cost effective healthcare would be.

So one day I see myself practicing in a room with all of the tools at my and my patient’s fingertips.  Any questions could be quickly answered, the record would not have to be populated with vague text but actual images of the pathology observed, sophisticated imaging and testing could be accomplished at the point of care before the patient left the room. The patient and I would have a very good understanding of the next steps rather than waiting for all the ordered tests to come back as the patient is sent across town for them, paying higher and higher prices the closer we get to the definitive diagnosis.

And then I wake up only to have had a wet dream.  I have to return to the small,  cramped, jail-cell exam room with the one computer and a variety of relatively low-cost analog devices and try to answer difficult questions. Often having to disappoint the patient by sending them on to another person or facility to eventually get to their answers.

Posted via email from Dr. Voran's Posterous