While most discussions on successful Electronic Medical Record (EMR) implementation and adoption circle around the proper implementation of clinical workflows, standard order sets, diagnostic codes, and the all important CPOE (Computerized Provider Order Entry), little time is spent on thinking about how the applications actually make it to the users. I have talked to CMIOs this week at HIMSS who mentioned that the improper application delivery actually constituted a significant roadblock or bottleneck towards adoption.
Healthcare organizations have tried anything from Computer’s on Wheels (COWs) to tablets to smart phones and iPhones. Each modality has its own merits and risks. Let’s have a look:

COWs: With large screens and full keyboards, using the system is as easy as using a desktop computer in the office. However, there are some distinct challenges associated with COWs: They are used by many different people. Although the carts are adjustable, users don’t adjust them in the interest of time on the floor and are therefore experiencing ergonomic problems. COWs are wireless, so the 802.11x infrastructure must be 100% reliable with good signal strength. Map out every patient room using the all familiar “Can you hear me now?” method of assessing signal strength in every place the COW might be used. Check with your facilities manager whether the COWs in the hallways would violate any fire security.

Tablets: Overcome some of the bulkiness of COWs. Same challenges with wireless networks though. Check with your users first. Doctors carrying the tablet in one hand and the stylus in the other hand don’t have a hand left to touch the patient. The success of tablets also depends on the specific EMR application you are running. Entering data via the virtual keyboard of the tablet is very time consuming and therefore prone to error. Applications that let users click through selection lists are much more tablet friendly. Consider specialized tablets for the healthcare industry that include scanners and interfaces to diagnostic equipment while maintaining the mobility.

iPhones, SmartPhones: Awesome. Barely larger than a pager with a user interface made for the device. Can’t replace a full application though as many apps are just for vitals, bedside monitor virtualization, results review etc. Smart phones are complimentary to other access modalities – not a full replacement.

iPad: It’s coming. I talked to several EMR vendors at HiMSS 2010 in Atlanta this year, who are already working on their user interfaces to make them friendly for user interaction sans keyboard. Of course, the Citrix Receiver will be able to deliver any windows app or desktop directly to the iPad.

Finally, there are the good old thin clients. These units combine the best of all worlds: Large screen, yet small form factor. Don’t require wireless networks and several incorporate a smart card reader to facilitate two factor authentication. Have one in each patient room, nursing station and several in the hallways (neatly wall mounted and tucked away while not in use) and you have a solution that allows doctors to use both hands on the patient and use a familiar keyboard for data entry. Use desktop and/or application virtualization so that you can eliminate the end point support team. Depending on the EMR application, consider generic windows logon and light or no profiles to speed up logon times to the windows environment. Authentication happens on the application itself in this case. Smooth Roaming capabilities are essential to cut logon time down to a few seconds and provides full mobility on the floor without carrying a device.

Some of the access modalities in your healthcare facility depend on provider preference (yes, doctors do prefer some devices over others and yes, please make your doctors and nurses happy). Use application or desktop virtualization wherever possible to avoid end-point support. Citrix XenDesktop can deliver remarkably high quality application fidelity and image resolution even over longer distances thanks to the bundle of HDX technologies.

What is your experience with EMR implementations and application delivery?

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