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About the series
As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.
H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.
The continuum of care requires continual communication and information sharing to tie it together, and that involves computerized equipment that clinicians and patients understand, are familiar with and will gladly use. The proliferation of cellphones, their morphing into miniature computers and the addition of wireless tablet computers have become a ready base for health-related information interchange.
The challenge for health care CEOs is to bring that potential into the particular realm of care delivery, surrounding it with reliable infrastructure and fostering policies on IT support and data security that keep a beneficial but strongly decentralizing force from getting out of corporate control, experts say.
Unlike desktop computers and laptops on wheels, mobile devices take the user angst out of connecting and locating information sources, says Michael Kurliand, R.N., information services strategy consultant with Children's Hospital of Philadelphia.
"There's a big convenience factor, and you get a product in your hands that is very innovative and relatively on the cheap," Kurliand says. "It's easy to integrate, and you become very intimate with it in a short period of time."
A smartphone or tablet is engaging to clinicians "because it's intuitive, it's got the good battery life, it's got the accessibility, fairly good speed; it brings everything to your fingertips," says David Collins, who heads up mobile health activities with the Healthcare Information and Management Systems Society.
In contrast to interfaces for electronic record systems, which take some time to get to know and love, the intrinsic enthusiasm for mobile devices has required reining in physicians' ambitions to use them beyond what may be practical or supportable.
An interdisciplinary committee for mobile-health policy — deciding not just device issues, but also the clinical issues of working them into health care operations — is the first step in developing a sensible rather than haphazard approach, says Collins.
Fundamentals like security measures, wireless networks and integration with the existing information technology can be hashed out at the start. "So when Dr. Jones says, 'Hey, I want to use m'damn tablet and I want to use it now,' [the answer is] 'Yes sir, we understand, we hear you, but here are our limitations — we've got this thing called HIPAA; we've got to consider the actual bandwidth and connectivity; we've got to consider integration to the electronic health record."
Ample bandwidth, and ability to get reliable connections at any location and time of day, are pivotal once a health care organization commits to mobile approaches, says Kurliand. "When we're exchanging information that way now, it's critical they get it in a certain amount of time and there are no dead spots. Because if I'm a clinician and I need to respond to an emergency situation, I need to get that message in two or three seconds or less. We have to build a network infrastructure that can support that."
Children's Hospital has built antennae on tops of buildings to bring in signals from the major cellular phone companies and invested in infrastructure that covers every cranny, including elevators. A crew audits reception annually throughout the hospital. But even that's not enough.
An additional investment has to be made in a system to prioritize messages, says Joe Christina, enterprise systems architect at Children's. Normally reception standards make a "best effort" to send some things while favoring others, like routine phone calls. But clinical priorities differ from consumer norms, and certain transmissions of images, video and urgent messages have to be waved through ahead of other traffic, Christina says.
Facilities usually have a Wi-Fi network already, and that creates options for mobile reception, says Hank Fanberg, director of technology advocacy at Dallas-based Christus Health. "Smartphones nowadays have the capability to connect to a wireless network or a cellular network, so we're going through the exercise: Do we need a cellular network within our facilities? Is the wireless network sufficient?"
Support for mobile devices also has to cover surrounding communities as patients are engaged in their ongoing care, Fanberg says. Christus is piloting consumer uses of mobile technology to keep in touch with discharged patients (See case study). Christus research showed that not everyone has a computer at home, but "even those at the lowest rungs of the socioeconomic scale all had a cellphone."
With Medicare and other payers starting to penalize providers for patient relapses and readmissions, communication with those patients post-discharge is paramount. Do they understand what they need to do? Are they hearing but not comprehending?
Christus Health is counting on the ubiquity of cellphones to text, tweet, swap pictures, email and call as needed to inform and stay in touch with patients while facilitating clinical updates soon enough to head off problems, says Fanberg. One pilot project under way is focused on cellphone-based disease management, and another involves sending patients home with computer tablets for post-discharge follow-up.
Typically a patient gets a home visit once a week, and in some cases is provided special monitoring equipment. With cellphone systems, a mid-level clinician can get timely data from patients using a familiar possession; clinicians can react in near real time, asking questions and alerting the doctor if warranted. "It's that ability to intervene faster, sooner, more conveniently, in the patient's home or wherever they happen to be," says Fanberg.
Investments in the infrastructure and array of mobile devices require an analysis of benefits versus costs, but that should be "not just from a financial perspective but from a clinical perspective, as well," he says. "We really believe that by leveraging these devices, we will have better clinical outcomes." And the financial outcomes will follow from that.
Health care CEOs bombarded with requests to use all manner of mobile devices should ensure that the basics of improving clinical workflow are served before allowing any old gizmo or app, says Kurliand.
That means emphasizing first "the lowest common denominator" — affecting the most people and processes--instead of proposals "only applicable to a small number of workflows, a small number of specialists, or it's something they only occasionally do," says Kurliand.
One broadly useful app, he says, turned out to be taking pictures that can be sent directly to an EHR. For example, a nurse can take a picture of a wound, which can be compared with previous pictures and also for caregivers to see in coming days. Before, nurses had to describe the wound or draw a picture, which made it difficult for others to figure improvement, saysChristina. "In terms of continuity of care, this is a hugely forward [development] in that, 'You can see what I saw, 48 or 72 hours ago,' and make a quick determination of, 'Is it getting better?' "
IT vendors focus on what's new and possible, "but you have to focus on the nuts and bolts, the real basic moves around how these things fit into your workflow and then work up from there and [ask] what does a mobile workflow look like?' " Kurliand explains.