Fast and flawless medication delivery—a groundbreaking eQuality project centered on this imperative has put Toronto East General Hospital (TEGH) at the forefront of electronic order entry among Canadian hospitals. Working with HP and HP Partner Compugen, TEGH built an innovative new system for Electronic Medication Administration Record (eMAR) and Computerized Provider Order Entry (CPOE). At the heart of the system are mobile carts equipped with HP Compaq Ultra-slim Desktop PCs—a hardware solution that overcame power and durability challenges commonly encountered with other platforms. The hardware and software deployment for TEGH’s eQuality project won the Showcase Ontario Diamond Award of Excellence. The solution streamlines workflows, eliminates transcription error and strengthens patient safety—all while laying the groundwork for electronic documentation initiatives of the future.
"There are two big stories here," says Robert Lee, TEGH manager of the CPOE project and former manager of clinical informatics. "One story is the complete reworking of our technical environment, with HP and Compugen providing backbone solution support. The other story is the development of the CPOE and eMAR applications, which involved a big change in clinician workflows. Both stories are about patient safety."
Bringing clinicians with computers to the bedside Two and a half years in the making, the CPOE and eMAR project replaced a medication order entry system that was paper-based, time-consuming and vulnerable to error. "We had standardized nursing stations where the computers were at a distance from the patients," Lee recalls. "Clinicians were writing things "
CPOE enables clinicians to enter their orders directly into the electronic patient record on a computer instead of writing in a paper chart. This allows immediate transmission of information anywhere in the system. Universal access allows multiple health-care providers to access a chart at any time. eMAR incorporates a person’s medication orders with an automatic schedule for nurses, prompting them when to administer medications. Previously, orders were rewritten onto paper with specific times outlined. At the point of care, clinicians scan barcodes on patient wristbands to ensure the medications are given to the correct patient.
"It’s all about bringing clinicians with computers to the patient’s bedside, to improve the quality of care," Lee says.
The WOW factor: building a new platform
TEGH tackled the twin challenges of revamping its workflows and its technical environment: What hardware platform would work best? How could they obtain sufficient battery life? How could they make it all affordable? A device assessment working group including physicians, nurses, pharmacists, ergonomists and infection-control specialists considered options. Compugen consulted closely. "Compugen was extremely helpful as our local vendor to provide us with devices to help us evaluate technologies," Lee says. "Therefore, we understood our options and how to define requirements for the clinical devices."
These requirements included long battery life so the mobile carts could function through an eight-hour hospital shift without needing a recharge.1 The PCs had to withstand spills and stand up to the industrialstrength cleaners used for infection control. TEGH had, in the past, successfully used notebook PCs on mobile carts in some settings. In benchmarking visits to peer institutions, the TEGH team saw notebooks used in CPOE and eMAR systems. "We found that in a clinical setting, an ideal solution would need to be durable to withstand spills and hospital-grade cleaners, yet prove cost effective," Lee explains. "We decided we needed something very redundant and powerful because the Cerner software application we use is complex and has to be installed locally in some situations."
The ideal PC for the mobile carts, it turned out, was the HP Compaq Ultra-slim Desktop PC. The device delivers strong processing power, a lengthy lifecycle, stable hardware and software images, and a form factor that fits the size demands of a mobile cart. The device also is ENERGY STAR® qualified and cost effective. "The HP Compaq Ultra-slim Desktop PC was one of the highest-rated ENERGY STAR® devices we could find; it paired nicely with the battery technology we were investigating, and it has a four-year lifecycle," Lee says.
The solution still required customization. TEGH worked closely with the HP Configure to Order Program (CTO) and Compugen to design and equip two types of cart, called respectively "med carts" and "Workstations on Wheels," or "WOW." To build these, TEGH took a standard medication cart and mounted the HP Compaq Ultra-Slim Desktop PC at the back of the column, away from possible spills. In the WOW, the CPU is fully encased except for the on/off button. A network interface card facilitates communication over the wireless network. An HP Compaq 19-inch diagonal LCD Monitor sits at waist height, along with a keyboard and mouse covered in washable material. The flat surface that may have traditionally accommodated a notebook PC is free to serve as a work space. Because each PC links to numerous USB devices—badge reader, fingerprint reader, keyboard, mouse, a device for wireless barcode scanning of patient wristbands—TEGH deployed an external hub tied to battery power. Further, it converted the WOW devices to DC power.
"That’s extremely unusual, because a desktop by its very nature is AC-powered," says Rob Nolk, the IT manager responsible for the hardware roll out for the CPOE and eMAR applications. "By making them DC-powered, we were able to increase the length of the battery charge."
Pack Service or under contract with Compugen. "TEGH is forward-thinking about introducing cutting edge technologies all over the hospital," says Ron Rotman, Compugen account executive. "They leverage their strong relationship with Compugen and HP to take a hands-on approach to evaluating "
Workflow changes, staff training ease future electronic initiatives
One of the biggest end-user groups of the new CPOE and eMAR system is hospital pharmacists. Valerie Leung, TEGH clinical manager for pharmacists, describes how CPOE has streamlined workflows, sped medication delivery and improved decision making. "Clinical pharmacists are able to fulfill their orders from any location, whereas before we relied on paper prescriptions that were brought down by porter to our central pharmacy team," she says "That cuts a good amount of time from delivery to the patient. In addition, information about whether a medication was given or at what time, is now available electronically. Before, we did not have access to all that information, which helps us make good decisions about appropriate therapies."
Doctors and nurses too see major benefits. The system advises on medication choices for a particular illness and raises alerts concerning dosages, allergies and drug interactions. It protects everyone from the notoriously bad handwriting of doctors. Physician Pieter Jugovic, who helped develop the CPOE system, notes that order sets are now up to date and standardized, where before outdated paper versions might linger with varying medical terminology. With the touch of a few keys, he can start orders from anywhere in the hospital without hunting for a chart. He can even follow patient progress from home. "I have remote access," he says. "Reviewing orders, trending results and planning patient management are a breeze. Order sets are based on medical evidence and best practice, and are easily updated. This ensures we consistently give our patients the best care possible."
Because of its workflow changes, the project required extensive workforce training. Accomplishing that has laid the groundwork to ease all future electronic initiatives. Next up on TEGH’s technology plan is more electronic clinical documentation. "One major hurdle we overcame with this project is clinicians’ familiarity with the technology," Lee notes. "Now, they’ll use the same device whether administering medication or doing documentation. Mobility is key; entering a patient history, for example, should be done as close as possible to the receipt of information. HP and Compugen have enabled us to reliably and costeffectively bring computers to the bedside. The intended result is to continually provide improvements in the quality of patient care."