The 2011 HIMSS Analytics Guide to Evaluating Mobile Cart Technology

Updated: April 1, 2011

As a testament to the old adage, as more things change, the more they stay the same, the healthcare information technology (IT) industry has been impacted by a number of legislative issues, including the passage of the American Recovery and Reinvestment Act (ARRA) since HIMSS Analytics released the last update of this guide in 2009. According to the 22nd Annual HIMSS Leadership Survey in 2011i, half of healthcare organizations identified meeting the meaningful use criteria established by the HITECH Act as part of the ARRA as their top IT priority in the next two years, replacing a focus on clinical systems. Meeting these meaningful use criteria will allow organizations to qualify for the stimulus money directed at reinvesting in their technology to achieve electronic health record (EHR) capability in 2011. And, since the meaningful use criteria are focused on seeking to bolster health IT to improve the delivery of healthcare in the US, there is still very much a focus on patient safety and quality of care in the industry. According to respondents to the 21st HIMSS Leadership Survey, respondents were most likely to report that improving patient care/quality of care would be the key business issue that organizations were trying to achieve in the next 12 months. Capturing data at the patient bedside is a key component of ensuring that patient data is captured into the medical record promptly and accurately, thus improving patient safety and quality of care. A number of solutions currently exist in the market that allow for clinicians to capture data in this manner. According to the HIMSS AnalyticsTM Database, the use of carts and other technologies used at the point of care, for the most part, has increased in the past two years.ii (see Figure One). Because the market is so broad, the remainder of this white paper will focus on the carts market. Mobile Technology Penetration Wireless Carts Wireless Laptops PDA Slate Tablet PCs Convertible Tablet PCs Number Figure One 2008 26 percent 29 percent 26 percent 15 percent 6 percent 5,166 2011 45 percent 38 percent 21 percent 11 percent 11 percent 5,283

Todays mobile carts are more sophisticated than ever. In comparison to earlier generations of carts, they have become smarter, more innovative and lighter. They are also highly adaptable and packed with diverse features and functionalities. Mobile cart technology has become so influential that clinical workflows are being impacted by its
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capabilities and flexibility to meet the needs of hospitals and the needs of individuals who use these cartsiii. Despite the continuing advancement of cart technology, there are still barriers to utilization. One of the key barriers users of mobile carts continue to face is longevity of the battery. As it pertains to smart mobile carts, the term mobility conjures images of freely moving from bedside to bedside without hindrance. Batteries can be heavy and oftentimes have a length of life that may need to recharged mid-shift, both of which can impact clinical workflow. Battery technology has developed considerably in the past few years. Generally, most of the current mobile smart cart providers tout battery life spanning from six to eight hours, with a recharge time of four to six hours, depending on the type of battery and how its incorporated within a specific work area. Sealed Lead Acid, Lithium Ion or Nickel Metal Hydride are some of the options available on the market at this time. A number of mobile cart providers are introducing different types of battery technology into the market; technology thats used in other industries successfully (i.e. automotive industries) in hopes of improving usage time and minimizing the recharge deficiencies. One type of battery mentioned recently is Lithium Ion Phosphate which only requires one hour of recharging. Battery life is one of many criteria that a healthcare organization needs to take into consideration when evaluating a comprehensive solution that will work for the clinicians and care providers at their organization. Reduced battery charge time can translate to additional time the mobile cart can be used for direct patient care, which can have a positive impact on cost of ownership.

Vendor Evaluation
User Needs Assessment Carts enable clinicians to access data at the time care is provided to the patient. All clinicians who will use carts, including physicians, nurses and others, such as therapists and pharmacists, need be included in the initial decision making process. Additionally, representatives from each of the departments and/or units that will use the technology must be included in the decision making process. A list of items that clinical users should consider when evaluating cart solutions is included below. Clinical Workflowdoes the cart support data access and capture at the point-ofcare, while allowing clinicians to access all information needed (in a readable format) to provide patient care; what device to clinician ratio is required to facilitate appropriate care. This is becoming more of an issue as the adoption and demands of mobile carts continues to increase. Power sourcedoes the cart have a battery that can support patient care activities across an entire clinical shift, does the unit have a battery gauge that displays battery life, how long does it take to charge the battery, is the battery easy to access and change (the device to clinician ratio will increase if units have reduced battery lives). Another question to consider is the type of battery being used. Vendors in this market use a variety of different battery technologies.

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Storage areasis there sufficient room in the care environments for cart storage and charging, to eliminate congestion in hallways and other patient care settings. Storage componentsis it necessary for users to store additional equipment, such as medication, on the cart to eliminate multiple trips to retrieve items stored in an alternate location. Attachmentscan necessary equipment, such as a bar code scanner or patient monitoring devices, be easily integrated into the cart; is it possible to upgrade the cart for future needs (e.g. RFID technologies). Mobilityis the cart compact enough to maneuver efficiently in patient care settings (within hospital rooms or clinic settings), is it easy to transport the cart from one unit to another, so that injuries to staff can be avoided. Ergonomicsdoes the cart have height adjustable monitors, sufficient workspace and placement of handles that facilitate movement from one bed to another to reduce neck strain and other workplace injuries.

As the decision process evolves, users and biomedical engineers should be given opportunities to suggest which equipment to evaluate, as well as ample opportunity to evaluate equipment. This includes creating a test environment in which the user can view data on the device in question, in their own environment. Finally, users should rank the features and functions they require into absolute, need to have and nice to have categories, which will help create a means for prioritizing the features and functions that are necessary. Business Requirements As the end user, clinicians are critical to the selection process. This does not mean that the business and/or technical requirements needed to properly use and support the carts should be overlooked. As such, IT and biomedical personnel also need to play a critical role in the decision making process, with a focus on support issues. Some of these issues are outlined below. Maintenance and supportwhat is the vendors position on maintenance, how does an organization replace a device that is being maintained so as not to impact workflow, does the service provider offer convenient customer service hours, and/or a loner policy. Infection controlhow is the device secured (i.e. sealed monitor, keyboard skin) to prevent spread of infection, how long does it take to sanitize the device, can the machine be sanitized by clinicians, or housekeeping staff, or does this need to be done by other staff members. Privacy and Securitycan these devices be secured to conform with the organizations security policy; will the information that comes up on these devices be shielded from the view of other patients/clinicians; are biometric security functions accommodated.

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Infrastructuredoes the organization have room to store, and/or charge devices not in use, does the infrastructure facilitate the wireless capabilities needed to support 24/7 access to critical information, what physical limitations need to be considered in the devices footprint. Integrationdoes the cart integrate with the applications for which it is intended to be used, does it support the IT application platforms in place throughout the organization. Standardsdoes the cart meet current ISO 14971 standards, IEC 60601-1, and UL standards and certification.

Organizational Culture The purchase of carts is a strategic decision that can greatly impact the usability of core software systems, thus increasing patient safety and quality of care. However, a wellintentioned strategy can be undermined if it is out-of-sync with the organizations culture. As such a few key questions should be asked during the decision making process to ensure the purchased carts fall in line with culture expectations. Risk tolerancesome organizations prefer to purchase the latest technology, while others wait until technology is more proven. The former are more likely to try technology that hasnt been road-tested, whereas more risk-averse organizations tend to wait until a product is proven to make an investment. Key organizational goalswhat is the organizations primary goalimproving patient safety/quality of care, improving its competitive position in the market, improving the working conditions of clinicians, improving patient satisfaction or all of the above. Personnelare key clinical users accustomed to using technology or are they likely to balk at having to adopt new technology, would the personnel adapt best to a big bang approach or would they adjust better to a gradual introduction of cart technology. Process focusdoes the organization have a culture experienced in continuous process improvement, six sigma, or other process improvement methodologies that will enable it to effectively change workflows so that carts are optimally implemented into the care delivery process. Executive leadershipare the senior executives of the organization committed to using technologies to improve patient safety and clinical outcomes, and to lead these efforts.

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Vendor Attributes After narrowing down the options, it is necessary to select a vendor. There are numerous companies in the market who offer mobile cart solutions. Healthcare organizations need to determine which characteristics are important when choosing a vendor. Items to consider when selecting a vendor include: Longevitydoes the vendor have a long record of service and success in the market or are they a recent entrant; does the vendor have a consistent and strong financial record. Community impactdoes the vendor have ties to the community (i.e. corporate headquarters or distribution center). Industry involvementdoes the vendor participate in industry trade organizations and professional societies. Customer servicemany vendors differentiate themselves with extended warranties, tailored customer service and maintenance offerings, extended hours for access to a representative; does the company use off-shore customer service resources; how is the vendor rated by companies that track service performance. Architectural/packaging flexibilityvendor willingness/ability to modify solutions to meet the organizations unique needs, can the device be further modified in the future to accommodate your organizations future strategic goals. Product portfoliowould you prefer to use a company that specializes in a single type of technology, such as carts, or would you prefer to work with a company that can offer a full range of mobile devices. Type of companydoes your software vendor work with a preferred partner or would you prefer to work directly with the vendor or make the purchase through a solutions reseller. Previous relationshipis the vendor one that your organization has experience working with in the past, was that experience positive or negative. Reference sitesis the vendor able to direct you to other customers that reflect your environment (i.e. same devices, software application vendor, hospital department/unit). Greendoes the vendor practice environmentally-friendly (green) manufacturing processes. Contractdoes the vendor provide a contract that is fair and balanced.

One of the most important factors in finally choosing to work with a vendor is whether or not you feel they fully understood the needs that are unique to your organizationand that they can deliver the solution that will meet those needs. Ideally, unless your organization has a large appetite for risk, you should ensure this solution has been rolled out and is in use at other organizations of similar size and scope.
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Decision Making Process

After the initial evaluation and selection process has been undertaken, a final decision needs to be made. Below are a few steps an organization should take prior to making a final decision. Road Testset up an environment in which the users can test multiple solutions in as close to a real environment as possible, this may involve actually integrating the technology into the clinical workflow. This process should highlight any issues not addressed during the initial discovery phase. Peer to Peer Networkingmake sure end users have the opportunity to experience the software in person. These users should test the technology at a minimum of one reference site. All concerns and/or issues raised at this on-site meeting should then be addressed in a post mortem meeting. Have IT, biomedical, and clinical users participate in this meeting. Clinician Buy Inobtain sign-off from the lead clinician for the department/unit for which the devices are intended for use. This should not only include the type of devices, but number of units purchased (i.e. clinician to device ratio); the devices should also support clinical workflows envisioned by the clinicians. If IT or biomedical disapproves the recommended choice, have a plan in place for reevaluating the solution, or move to negotiations with the second choice vendor if it meets the requirements of the evaluation teams. Final Recommendationlet the final recommendation for device use come from the end user team of clinicians. At that time, the IT and biomedical departments can ensure they are comfortable providing the support necessary for the device; the IT department also needs to ensure the carts are compatible with the organizations software solutions. Recognize that not every department will want the same solution. Communicatemake sure all parties involved understand what their roles will be relative to the purchase of the final solution, including support issues and training. The role of the vendor post purchase should also be clearly defined, both with the vendor and with appropriate staff.

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After the Sale

After a final decision has been made, it is important to ensure the purchased solution is implemented to meet the goals that were established for purchase. Thus, it is critical that a comprehensive training program be put into place. It is also important to ensure the vendor is available post implementation to provide on-going support and maintenance. Training Training programprovide the staff with a hands on training environment where they can practice with the new technology using fake patients; make sure super-users and/or representatives from the vendor are available 24/7 during the first days of the roll-out. On-going trainingprovide continual training for both new hires and current users; some organizations require mandatory assessments to test that clinicians actually have the skill set required to use the cart successfully; e-learning courses should be established to help the users retain their competency in using the devices so that these courses can be completed at any time.

Customer Service Supportinvestigate the hours in which the vendor has support available to you, what type of on-going training program does the vendor offer, talk to other users about the companys reputation for support services. Maintenancehow quickly can the vendor replace/repair a unit that is no longer functional, does the vendor offer a maintenance plan that identifies a regular maintenance program in the hopes of preventing more costly maintenance later. User satisfaction surveysdoes the vendor survey their user base frequently for satisfaction, and do they publish the results. User group supportdoes the vendor provide or support a user group to facilitate information exchanges for using and designing their products and services.

The next page contains a checklist of items healthcare organizations are encouraged to take into account when making a decision regarding mobile device technologies. These items should be taken into consideration as early in the decision making process as possible so they are well integrated into the overall strategy and not considered as an afterthought.
i

HIMSS, 21st Annual HIMSS Leadership Survey, sponsored by Citrix Systems www.himss.org HIMSS Analytics Database, updated January 17, 2010 iii Ackridge, Jeannie (Aug 1, 2010). Carts roll with flow of healthcare challenges, Healthcare Purchasing News, www.faqs.org/periodicals/201008/2109413421.html#ixzz1C4SjBDyg
ii

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Cart Evaluation Checklist

25 Items to review for to make sure that you purchase carts that meet your organizations needs
Extended Customer Service Hours Ability to Integrate with Key Software Application Systems Bar Code Scanners (as desired) Battery Gauge Battery is Easy to Charge/Replace Battery Life/Charging Time Battery Minimizes Downtime/Maximizes Productivity Battery Size and Weight Biometric or Proximity Security Capabilities Compatibility with Organizations Hardware Platforms Compatibility with Organizations Wireless Network Competitive Maintenance Options Disinfection Requirements Ease of Movement on Different Floor Surfaces Ergonomic Keyboard (Lighted for Night Time Use) Footprint is Compact Enough to Fit in Patient Care Areas Footprint is Compact Enough to Reduce Storage Needs ISO and UL Standard Compliance Height-adjustable Workstation Keyboard Skins for Infection Control Medication Drawers (as desired) Sealed Devices for Infection Control Sufficient, Well-Placed Workspace Screen Size is Large Enough to Read All Information Well-Placed Handles

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