Physical computing environment

From a large systematic review of all articles published between 1980 and 1997, the following conclusions were reached.

1. Computer use during consultations lengthened the consultation.
2. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre­intervention levels when reminders were stopped.
3. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests.
4. There were no negative effects on those patient outcomes evaluated.
5. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-­patient relationship, cost, time, and training needs.

[1]

Introduction

Wall Mounted Computers

Wall Mounted Computers

Mobile computers

Computers on wheels (COWs)

Mobile computers or computers on wheels (COWS) make a computer available to clinicians at the patient bedside for direct entry of data. Some important considerations are:

• Power supplies: cords can fall off during movement and break. A velcro strap secure and attach the power supply to the cart.
• High quality wheels: skateboard-type polyurethane wheels.
• Large area: for mouse, keyboard, and clip board
• Keyboards: should have clear plastic covers to allow housekeeping staff to be able to easily clean and decontaminate these devices at least once per shift [2]
• Smooth floors: even very small carpet molding causes huge speed bumps
• Maneuverability: integrated devices need to be maneuvered relatively close to the patients and still leave room for the nurse and/or physician to examine and administer care to the patient. The bed side tables, chairs, commodes, IV’s and other stand-based devices clutter the room and present significant obstacles. No matter how spacious the room there’s an amazing amount of clutter right around the bed that prevent getting the medication carts close enough to use the tethered wands. I’ve seen many tethered wands knock over liquid containers over the patient, get caught up in equipment and lines.
• Maintenance: unless oiled, COWS wheels can behave like shopping cart wheels.
• Docking stations: The carts will not be returned to where they were originally intended to be parked. Instead they’ll be left at convenient places. Make sure all of the electrical outlets in the halls and anywhere a cart might get parked are at least waist high rather than in their normal 18 inches from the floor. I’ve seen too many dead carts because clinicians forgot to plug them in where they left them.
• Watch where people take a paper chart and note where they stopped to read. That’s likely where they’ll want to take and use the COWS, CALVES or whatever devices you select. That’s probably where they’ll leave them, too.

Laptops

Some issues with laptops are weight, battery life, screen display, and durability. There is a trade-off between battery life, screen size, and weight; lightweight laptops suffer from inadequate battery life. In addition, larger screens, although they offer more space for electronic charting, are heavier.

There is an issue of security of data stored on laptops. A loss of a laptop compromises patient information [3]. At a minimum, laptops that contain protected health information (PHI) should be required to be password protected. Additional security such as data encryption, the use of biometrics and technology such as smart cards should be strongly considered.

Rolling carts

Rolling carts take up significant space, are heavier, and are less mobile. In addition, the battery charge is still limited. Chargers incorporated into the cart and multiple battery packs increase the time to next charge. [4]

Tablet Computers

Tablet Computers

Handheld computers

While handheld computers are good replacements for small reference books and interactive guides, they are unlikely to be significantly used in an integrated clinical record system. The interface is small and difficult to enter data into. Security is more easily compromised, and wireless connections are slower than their Ethernet counterparts. [5]

Keyboard Infection Control Concerns

There is considerable evidence and discussion of the keyboard as a source of pathogens; particularly the antibiotic resistant Methcillin Resistant Staph Aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE). [6] MRSA may reside on medical surfaces for days to weeks. [7] Multiple precautions can be take to reduce transmission of infection. Physicians and nurses should be educated to the risks posed by the keyboard. Housekeeping staff should have keyboard cleaning techniques added the daily cleaning rounds. Standard housekeeping operating procedure should include cleaning keyboard surfaces every shift (every 8 hours) or at least every 12 hours.