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4/23/2012
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Hospital Computer Kiosks Effective, But Value Questioned

Patient kiosks expedite routine healthcare in California emergency departments, despite nurses' perceptions that they impede workflow, researchers say.

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Is A Personal Health Record In Your Future?
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Two different reports on the same clinical trial--one in a peer-reviewed journal, the other on the California Healthcare Foundation website--illustrate how even an effective health IT application might create workflow problems.

The purpose of the randomized study, conducted by researchers from the University of California at San Francisco (UCSF), was to determine the efficacy and safety of using computer kiosks in emergency departments (EDs) to expedite workflow and shorten waiting times for patients. Three EDs in California participated in the trial, following a successful pilot of the kiosk strategy at an urgent care center, involving women with uncomplicated urinary tract infections (UTIs).

Women who presented at the EDs with UTI symptoms were asked to provide a urine sample, then go to the kiosks and fill out online questionnaires. In the process, the computer randomized the patients who met criteria for uncomplicated UTI into either a control or study group. Patients who were selected for the study group immediately received an antibiotic prescription and instructions and were sent home. The control group of patients had to remain in the waiting room after using the kiosk until an emergency physician could see them.

Of the participants, 17% met the criteria for uncomplicated UTI and were randomized to either group, and 69% of these women had a positive urine culture for UTI. The median amount of time spent in the ED was 89 minutes for the study group (who received expedited care), and 146 minutes for the control patients (who had to wait to see an ED doctor). Both groups had a similar time to illness resolution, number of return visits, and satisfaction with care.

[ Practice management software keeps the medical office running smoothly. For a closer look at KLAS' top-ranked systems, see 10 Top Medical Practice Management Software Systems. ]

The conclusion of the study, which was published last year in Academic Emergency Medicine, was: "An interactive computer kiosk accurately, efficiently, and safely expedited the management of women with uncomplicated UTI in a busy, urban ED. Expanding the use of this technology to other conditions could help to improve ED patient flow."

Recently, the California Healthcare Foundation (CHCF), which funded the study, posted a follow-up report on the foundation's website. Authored by Ralph Gonzales, MD, one of the study coauthors, and Sara Ackerman, PhD, a medical anthropologist, the report described several problems in the implementation of the kiosks.

For one thing, it turned out that the proportion of patients with suspected UTIs who were referred to the kiosks ranged from 20% to 84% at different sites.

One reason for the differences was that some triage nurses resisted referring eligible patients to the kiosks. The nurses felt that the kiosks disrupted their workflow; also, the majority of patients they referred did not receive expedited care, either because they did not have uncomplicated UTIs or because they were randomized to the control group. As a result, these nurses didn't see the point of the experiment. In addition, the machines themselves were prone to breakdowns, which made the nurses' task harder.

John Stein, MD, lead author of the Academic Emergency Medicine paper and an associate professor of emergency medicine at UCSF, doesn't believe that any of this detracts from the value of the study's conclusions. In an interview with InformationWeek Healthcare he said, "we were successful in proving the kiosks' utility. We were able to show dramatically increased efficiency in care" without sacrificing quality. Moreover, he pointed out, the results of the study have prompted two of the EDs to consider reinstating the kiosks "for regular daily care."

Despite the nurses' complaints, he maintained that the kiosks did not impede the overall ED workflow. Noting that the UTI patients were a small percentage of ED visitors, he said that during the study period "the overall rates of time to discharge and time to admission were unchanged."

The main problem with the kiosk implementation, Stein stated, was that it forced the nurses "to do something different." As for their perception that some patients were irritated if their care were not expedited, he noted that in the patient satisfaction surveys there was no difference between patients who received fast-track care and those who didn't.

Nevertheless, he added, more study in a typical ED workflow is clearly warranted because the trial was conducted in an artificial research environment. As for whether kiosks can actually shorten overall ED wait times, he said, "All we did was to show that kiosks had the potential to improve efficiency without decreasing the quality of care."

The 2012 InformationWeek Healthcare IT Priorities Survey finds that grabbing federal incentive dollars and meeting pay-for-performance mandates are the top issues facing IT execs. Find out more in the new, all-digital Time To Deliver issue of InformationWeek Healthcare. (Free registration required.)

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RGONZALES000
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RGONZALES000,
User Rank: Apprentice
4/28/2012 | 1:33:41 AM
re: Hospital Computer Kiosks Effective, But Value Questioned
As the lead researchers in these two studies, we would like to clarify what we see as the main results of our studies to prevent any misperceptions that we are inferring that nurses served as an obstacle to successful implementation of the kiosk program. We do not believe nurses are to blame for the failure of the kiosk program to become fully adopted in these EDs. In fact, quite the contrary. Although the kiosk program was found to be accurate and safe based on controlled research conditions, it did not actually improve efficiency as promised. Ineligibility for expedited care (due to clinical criteria or randomization to the control group) created additional work for staff to re-insert women who returned to the front desk into the queue for regular care. This was frustrating for ED triage staff, since it added an extra, seemingly futile, step to the already complex, time-sensitive, and high-stakes sequence of tasks they performed. NursesG«÷ feedback gave us critical insight into the reasons for this failure. We view the honest responses from nurses and physicians in our evaluation to be a valuable starting point for developing better design and implementation strategies for this promising technology, specifically the lessons weG«÷ve learned are summarized on page 5 of the case study.
betts
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betts,
User Rank: Apprentice
4/24/2012 | 4:34:48 PM
re: Hospital Computer Kiosks Effective, But Value Questioned
The denigration of nurses' input is disturbing, at best. Being a nurse who has practiced in multiple arenas of care (ICU, CCU, PACU, ED, HHA, Hospice, etc), I can vouch for the fact that if nurses are saying it impacts their time, researchers and hospitals need to listen and act, rather than, one more time, overlooking the obvious impact to THE PATIENT--ie, impacted ED flow means poorer patient care.
justaskjul
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justaskjul,
User Rank: Apprentice
4/23/2012 | 6:50:24 PM
re: Hospital Computer Kiosks Effective, But Value Questioned
I've seen a lot of success in kiosks on the practice management side, more-so than on the clinical side. A patient comes into the office and instead of verifying all their information verbally with a human body, they walk up to the kiosk and check themselves in -- update demographic information and even swiping cards for co-pays and other payments as well as even signing up for the practice's patient portal.

Clinically, I think it can help efficiency in some instances, like the example above or perhaps an OB patient who needs to come in every few weeks for the same repetitive visit or a hypertensive patient who is coming in for their BP check.

Julie C.
InformationWeek Contributor
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