Making Mobility Work for Inpatient Providers

Modern mobile devices are more effective than desktop or laptop solutions when 1) information needs to be reviewed or collected in areas where other Internet-enabled devices are too cumbersome to use AND 2) all necessary steps to complete a specific task (chart review, ordering or documentation) can be verified and completed on the mobile device. As voice recognition technology and cloud-based applications accessed through mobile devices continue to improve, mobile devices loaded with relevant applications could transform how independent ordering providers complete inpatient processes.

Here’s one way to view inpatient provider work:

  • All patients
    • Reviewing events and documentation since last encounter or all relevant medical records if this is the initial encounter
    • Speaking with patient and family, examining the patient
    • Coordinating tasks with other team members
    • Adjusting testing or treatment plans (orders)
    • Documenting care provided within the medical record
    • Updating the next provider about the patient’s condition (discharge summary, sign-out)
  • Patients undergoing a procedure
    • Preparing for the procedure (consent, diet, scheduling)
    • Performing the procedure and evaluating the patient after the procedure
    • Documenting procedure before patient is transferred to next level of care
  • Addressing requests from other team members

The items in bold could be addressed by a mobile device. Although ordering workflows can be performed on mobile devices, the current technology seems best suited for “routine” ordering (e.g., common inpatient orders, refilling medications) instead of “complex ordering” (e.g., admission orders, manipulating order details for specific patient characteristics). I will avoid discussing ordering workflows on mobile devices any further.

The most successful applications on mobile devices outside of health care limit what is presented to the end-user to minimize confusion and address specific needs (e.g., completing a financial transaction, identifying the fastest route to a destination). Processes to evaluate a patient for the first time or discharge them to the next care setting may be too complex for integration into existing mobile devices with their limited screen size.

Chart Review

Reviewing a patient’s medical record would appear to be the simplest function to incorporate into a mobile device. The independent ordering provider is looking to see what has been added to the record since the last visit and can scroll through results or documents. The user would use a limited set of commands to adjust what information is being presented.

Initial attempts to shrink all of the medical record into a smaller screen are being replaced by more intelligent data displays (e.g., graphs for longitudinal numerical data, filters to only display relevant documents). The next iteration of this technology could display patient data specific to the user’s requirements (e.g., show blood culture results and antibiotic history to an infectious disease provider seeing a patient with endocarditis, show echocardiogram data with medications for afterload reduction to a cardiologist seeing a patient with congestive heart failure.)

Mobile devices may provide easier access than a desktop or laptop, but the devices’ screen size may limit comprehension of the information reviewed. For some users, the presence of multiple documents or complex test results on a mobile device may trigger migrating to a device with a larger screen to better review of recent patient information.

Documentation

The mobile device has the necessary elements to replace telephone transcription: high availability, microphone connected to voice-to-text technology, and processing power for any tasks that cannot be done in a secure cloud. A health system could suggest security controls to make the documentation process more secure than telephone transcription.

Phase 1: Mobile device as dictaphone (some operative reports, admission documentation)

Initial attempts to migrate clinical users to mobile devices focus on translating voice into text. If there is no information to include from other parts of the chart and the documentation is unique enough to not fit a pre-defined template, this limited functionality should work. Complex surgical cases could meet these criteria. Many hospital admitting teams and consultants may also prefer to use the their mobile device in this way in conjunction with reviewing a patient’s data over a desktop computer. The workflow would be analogous to the clinician flipping through a medical record while dictating a consult over the phone.

Phase 2: Mobile device for free-text documentation elements only (daily notes, sign-out)

Independent ordering provider inpatient documentation for patient care is used for multiple purposes. In addition to “telling the patient’s story,” the documentation serves as the basis for justifying a hospital stay, facility and professional billing. Some of these stakeholders suggest specific documentation elements from other parts of the chart (e.g., laboratory and imaging test results, social history). Rather than repeat this information every day, it would be easier to summon those data through macros to populate a clinical document. If the mobile technology cannot incorporate these macros, the independent ordering provider will need to enter the free-text information using the mobile device and enter the other information from a desktop or laptop. Although not ideal, mobile devices enable users to capture one patient’s information before moving on to the next patient, reducing the risk of missing a detail or entering information on the wrong medical record.

A separate functionality to support independent ordering providers would be to augment or revise existing documentation using voice-to-text. This would reduce the need to re-enter clinical information within the medical record. Clinicians would prefer to update the existing sign-out before handing the information over to the next clinician instead of re-documenting the relevant information into a new sign-out. Members of the same clinical team might use a similar tactic to update an assessment and plan based on interim events rather than re-entering the information into the current document.

Phase 3: Mobile device as intelligent agent to complete all documentation requirements (discharge summaries, history and physicals, consults)

For a mobile device to meet most documentation workflows, the devices applications would need to accurately convert a user’s voice to text, to pull in relevant information from other parts of the chart, and to allow users to bring forward sections of earlier notes to be updated. Higher order functions might include the ability to identify:

  1. Errors within a document – error types include spelling errors, contextual errors (i.e., each word is spelled correctly, but the words do not make sense), and inconsistencies within the document (e.g., right foot instead of left foot).
  2. Errors across documents – the technology would need to identify errors of omission (some documentation elements are missing) and errors of commission (adding documentation elements that should not be entered in this specific record).

Many health care leaders would be interested in reminding independent ordering providers to document specific elements for quality measures or frame a patient’s diagnoses to support higher reimbursement. Apps within mobile devices that incorporate these types of prompts during documentation workflows may help reduce the struggle between hospital staff and independent ordering providers to update documentation after notes have been signed.

Team communication

Mobile devices also enable health care team members to communicate more easily. Applications for non-urgent communications, texting and phone calls could help complete tasks more quickly than having each team member page each other and wait for a response. Increasing access to clinical staff may lead to more interruptions and lower levels of provider satisfaction. Limiting phone calls to those tasks that need to be addressed quickly may help reduce the risk of unintended consequences associated with increased accessibility with mobile devices.

Alternatives to Mobility

Using mobile devices for inpatient providers makes the most sense when the barriers to the desktops are high and the trade-offs when using mobile technology are low. In their current form, mobile devices may meet the needs of some clinicians some of the time, but will probably not address most needs most of the time.

Health systems may decide to invest in technology to lower the barriers to desktop access. Most hospitals have a computer in every patient room. Using smartcards or other rapid login methods may increase the likelihood a clinician will use devices in front of patients. Adding microphones to each computer would minimize the provider’s documentation burden for each patient.

Mobile devices will continue to evolve. The most significant trade-off is the limited real estate to display relevant patient information. Even as mobile devices get larger, it is unlikely that the devices will approach the size of a desktop monitor. Mobile devices connected to smart glasses or other larger displays using augmented reality may help address this limitation.

Conclusion

Mobile devices coupled with relevant applications have the potential to revolutionize how inpatient clinicians complete their work. Understanding the strengths and weaknesses of current application offerings within the existing framework of how independent ordering providers do their work can help health system technical teams and physician leaders push their vendors to make more usable technology to help users develop better clinical care.