Medbook Application and Medtray

MedBook application & MedTrayMedicine distribution project report2013/2014

Contents

1.BACKGROUND 71.1 Introduction 71.2 Project aim and objectives 71.3 General information about hospital 81.4 Patient Safety as a subliminal issue in health care policy 91.5 To err is human 10

2. CURRENT SYSTEM 11

3. CONCEPT 143.1 Need 143.2 General concept 143.3 Mapping of information flow. 153.4 Different existing concepts 18

4.DESIGN 214.1 Interface of the App 214.2 Appearance 274.3 Making a prototype for a MedTray 334.4 Product value 34

5. SUMMARY 36

6. REFERENCES 36

Team

Jibing WuChina,Beijing

Gina MetssaluTTUBSc Mechanical EngineeringEstonia

Afshin HasaniTTU BSc Mechanical EngineeringIran

Karl AnnusTartu Art CollegeFurniture DesignEstonia

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1.BACKGROUND

1.1 Introduction

This report details a medical design project in cooperation with North Estonia Medical Center (Põhja-Eesti Regionaalhaigla) and Design and Engineering Masters program students at Tallinn University of Technology.

1.2 Project aim and objectives

Our project aim was to find design solutions on the field’s of patients’ safety and/or dignity in hospital.From the field research that we carried out in the hospital, we found several issues that could be improved both the patients and caretakers point of view. Our group concentrated on medication distribution system in hospital departments. We found out that current system with several handwritten lists and papers is not unequivocal for everyone and creates diverse base for human errors. We think that mistakes can best be prevented by designing the system at all levels to make it safer - to make it harder for people to do something wrong and easier for them to do it right.By virtue of their direct patient-care activities and administration of medications to patients, nurses—perhaps more than any other health-care providers—are in an excellent position to prevent, detect and report medication errors. Nurses play an important role in risk reduction. Thats why the main objectives of the proposed project are targeted to designing the nurses working system, although the benefits will rise up at all levels of system.After analyzing current system and background research we worked out one possible solution what we are introducing on the following pages of the report.

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1.4 Patient Safety as a subliminal issue in health care policy

The main topic of this project is patient safety as an important health care policy aspect. Patient safety has been internationally well identified as an important health care problem and research issue, but Estonia lacks a common understanding not only on patient safety, but also on health care main target. There are also no national policy nor strategy document contains a patient safety perspective. At the same time road safety, for example, is topic what is several times more dealt with in Estonia. The patient safety topic is often compared with aviation what is regulated with high level of safety requirements.Institute of Medicine report „To Err is Human“ (1) says that according to estimates from two major studies at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented. As an example we can bring the reference to U.S aviation safety report according to which the average traveler has to fly 438 years in a row to get a partial in a plane crash.

Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (in cluding the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide.

Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. There have been done a research (Eurobarometer research 2009- How people feel patient safety aspects) where Estonia had results :• 45% of respondents considered it likely to get damaged during the hospital stay (EU average

50%)• 39% of Estonians answered that he/she or his/her family member has experienced a deviation

(EU average 26%)• Estonians considered that the most important responsible entity of patient safety are healthcare

professionals and hospitals.

Although the opinion on whether patient safety is a problem in Estonian health care or not polarized, all experts agreed upon that some kind of further action should be taken. Health care in Estonia is not as safe as it should be - and can be.

1.3 General information about hospital

The North Estonia Medical Centre is Estonia’s foremost hospital. Their mission is to provide top-level patient-friendly health care and to promote the development of medicine in Estonia. The hospital is a higher level medical institution. Medical operations are managed through seven clinical divisions – Anesthesiology Clinic, Diagnostics Division, Surgery Clinic, Psychiatry Clinic, Oncology and Hematology Clinic, Internal Medicine Clinic and Follow-up Care Clinic. Hospital provides services in almost all medical specialties (excl. ophthalmology, paediatrics and obstetrics).

Hospital’s main buildings are situated in Tallinn (different locations) and Kose. The hospital is an employer for 3626 people, including 590 doctors, 1352 nursing staff and 862 caregivers. There are over 100 resident doctors in the hospital at any given time. Medical staff are supported by approx. 714 workers.

Hospital is legal person governed by private law and its legal form is foundation. Hospital has been founded by the Republic of Estonia. Hospital’s official name is Sihtasutus Põhja-Eesti Regionaalhaigla.

Picture 1. North Estonia Medical Centre main house in Mustamäe, Tallinn.

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1.5 To err is human

Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. A number of studies have been done to investigate why deviations occur at all.More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Thus, mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right. Health care organizations must develop a “culture of safety” such that their workforce and processes are focused on improving the reliability and safety of care for patients. Safety should be an explicit organizational goal that is dem onstrated by strong leadership on the part of clinicians, executives, and governing bodies. This will mean incorporating a variety of well-understood safety principles, such as designing jobs and working conditions for safety; standardizing and simplifying equipment, supplies, and processes; and enabling care providers to avoid reliance on memory.

A large percentage of medical errors are associated with medications. The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following working definitions specifically for medication errors:

Medication error: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, or systems including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

Common causes of medication errors:

Ambiguous strength designation on labels or in packaging Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes and suffixes in drug names)Equipment failure or malfunctionIllegible handwritingImproper transcriptionInaccurate dosage calculationInadequately trained personnelInappropriate abbreviations used in prescribing Labeling errorsExcessive workloadLapses in individual performanceMedication unavailable

2. CURRENT SYSTEMFor the field research we observed the daily routine of the hospitals workflow. Workflow in hospital is the set of tasks what are grouped chronologically into processes and every task needs the set of people or resources to accomplish a given goal.

We noticed that one important issue what distract caretakers daily workflow is the information technology in hospital practice.Health IT, what must promise many benefits for improving quality and efficiency of health care service, seemed to be poorly functioning. Including unnecessary pauses and rework, delays, established workarounds, gaps where steps are often omitted, and a process that participants feel is illogical. Huge amount of time is spent on data entry to computers and its supposed to be only small detail of the many tasks that nurses are required to complete.

Picture 2. Nurse’s notebook, where she writes down doctors orders during morning wards round

Picture 4. Nurses workdeskPicture 3. Nursing file

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Health care is a service industry that relies heavily on good information. In closely following and taking care of patients, nurses are guardians of a rich source of information, but we found that some of this important information was documented in the nonofficial/ unrecordable notes or transferred as a conversations. The official report information seemed to be more overall assessments of patient care and includes only required information.

Current system at PERH hospital has both the paper and electronic records, and due to user-hostile interface of both of these, there are used self created medication management system, with notebooks, handwritten lists, tables and notes.

As we concentrated our interest on drug distribution system, then we examined how information moves from doctors order in medical treatment plan until its execution.

In the morning ward rounds nurse makes quick notes about doctors orders (Picture 2).

Everything has to be put down to the nursing file (Picture 3). Nursing file is a document what proofs the provision of nursing care to the patient, which consists of the following components:

• general information about patient• medical history• the plan of nursing• monitoring the condition of the patient• the treatment plan• consultations

Doctor signs all orders in this document. This is meant to be as a main working tool for nurses- for getting and gathering information.

Picture 5. “PAPKA”

Picture 6. Medicine list and timetable on the wall of medicine cabinet

There are some parts of information what are obligatory to be inserted digitally (Picture 4), but not all the information, what is recorded on paper files. There is reluctant attitude towards inserting information digitally - it is task that nobody wants to do it willingly.

Because of searching information for every single patient from nursing files is inconvenient and time consuming, there are created so called “PAPKA” system- the piece of paper for each patient what is editable with pen and eraser (Picture 5).

There are gathered main information, what nurses needs more often- the quick and easy overview of all patients all together. Left side is for patient general information: name, ID code, doctors name, ward and place nr.Middle section is for marking down patients treatment plan for oral medicaments.Right section indicates intravenous medicaments.There are also remarks about patients menu preferences, date of operation and other main issues what are necessary to keep in mind.

Some departments then creates one more handwritten list with overall information about medicaments what must be daily prepared and distributed (Picture 6).

All together makes a large number of paper records, what with opportunities of modern information technology are inadequate and poorly managed. Handling of these kind of paper files are time consuming and involves lot of workforce.Also there are need for physical space to storing them (Picture 7).

Picture 7. All patients files are kept in these covers.

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3. CONCEPT

3.1 Need

As a result of observing current medication administration system and taking under consideration background research what we presented in previous paragraphs, our team recognized a need to redesign this system at all levels to make it safer - to make it harder for people to do something wrong and easier for them to do it right.In health care system there should be a working culture what can prevent possible mistakes, doesn’t carry along errors what emerged in previous steps throughout all the process and avoid reliance on memory. In the situation where patients to nurses ratio is enormous, there should be avoided all the unnecessary working tasks.Another issue is the under-usage of information technology possibilities in hospital practice.

Key Points for describing need :• prevent errors• save time• storing as much information as possible• convenient access of information• user-friendly interface for IT solutions• common operating environment for all levels of system• the integration of different working processes

3.2 General concept

We found an opportunity for improvements. Our idea was to use benefits of info technological solutions, so that they are not inconvenient for users and maintain the benefits of existing system. We wanted to create a system that is as handy to use as notebook and pen, but is times more efficient.We took an iPad as a convenient tool with lot of possibilities and features as a base to our new system. We started creating a interface what is connected to a “smart” medicament distributing tray and at the same time allows to record digitally any kind of information at all levels of communication line. As far as we collect all the data in digital way its easy to transform it to all forms what are necessary in hospital system.

3.3 Mapping of information flow.

To start with, we mapped out the information flow during the daily routine in one hospital department (Picture 8).

We marked down all the key factors into a simple and clear order and got a blueprint what shows all the process and touch points (Pictures 9 and 10).

Picture 8. Current information flow map

Picture 9. Key figures

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As one of our main targets was to reduce error possibilities, we marked down the type of errors and the touch-points for them to possible rising up (Picture 11).

Picture 11. Current information flow and error points

Doctor saying instructionsNurse writing everything

down to notebook

Nurse writing everything down to nursing �le

Nurse writing everything to the “PAPKA”

Doctor signs

Nurse prepears medicines in medicine cabinet

Nurse brings medicines to the patient Patient takes medicines

- mishearing- misinterpretation- writing error- timing error- medicine error- memory error- controlling error

Possible mistakes:

Explanations of error types on map:

Mishearing:• misunderstanding of speech. Can hear wrong name, dose, type, quantity etc• can not hear properly because of some kind of disturbing factor

Misinterpretation:• can interpret the heard information wrongly

Writing error:• misunderstanding handwriting• cant write so quickly• somebody might disturb and then there can be blanks

Timing error:• cant write so quickly• some information can be skipped due rush• to save time, nurse may not write everything down and hope to relay on her memory

Medicine error:• disturbed when distributing medicines• open and prepare wrong medicine box• wrong amount• medicine mix up• patient mix up• mix up different time doses (morning pill amount goes to lunch blug etc)

Memory error:• don’t remember the order• dont remember on time

Controlling error:• doctor controls (signs) only nursing file, not PAPKA what is the main working document

Picture 10. Processes and touch points blueprint

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3.4 Different existing concepts

There are several existing high tech solutions for automated medicine dispensing systems worked out. We analyzed the pros and cons for all of them and tried to sort out good features.

Cerner’s RxStation

Cerner is innovative health care company that has developed quite unique automated medicine dispensing cabinet: RxStation. This cabinet allows hospitals to eliminate a source of potential human error. This cabinet is connected to each patient’s electronic medical record (EMR). When clinicians go to the cabinet to retrieve medications, they open the patient’s EMR and select the medication to be administered. A drawer on the RxStation cabinet containing the appropriate medication at the appropriate dose opens, allowing the clinicians to retrieve the medication. The tray and bin with the correct medication illuminates and unlocks. All other bins and trays are secured. RxStation consists of different modules that can be modified, added or removed to tailor it’s use for a given health system (2).

Picture 12. Cerner’s RxStation

Automated Kanban System

Southwest Solutions Group have created another solution for better hospital inventory management. It is called A Two-Bin Automated Kanban System. It uses spacesaver’s Frame WRX and StockBox products. They say that Kanban helps to balance between not running out of medical supplies and managing inventory overhead cost.One main component of this system is StockBox (Picture 13) that uses RFID technology to automate medicine replenishment process.All the medical inventory is kept in open trays in Frame WRX (Picture 14).

Picture 13. StockBox with RFID technology

Picture 14. Frame WRX

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HD Medi ATDPS

The Automatic Tablet Dispensing and Packaging System (ATDPS) is a fully-automatic, drug-specific, and patient-individual dose packaging system for strings of transparent sachets. The system can dispense, pack and print sachets for single or multiple doses, as well as mixed doses with all the important dose administration information. A maximum of 3600 drugs doses can be processed per hour for automatic dispensing to more than 1800 beds. The Special Tablet System (STS) is incorporated and allows the inclusion of special tablets in the production run.The system is compatible with all standard hospital information and patient administration systems. Authorization is conveniently handled using RFID (a unique radio frequency code) and provided that a user has appropriate access rights, the production can be managed. The trays used for the STS are also labeled with a RIFD chip, ensuring that only the right STS tray is accepted by the ATDPS (3).

KirbyLester

Kirby Lester provides systems that feature the latest technology like built-in work-flow software, pharmacy management system interfacing, on-screen drug imaging, order history and tracking, reports, and other features previously only available on more expensive and complicated systems. Kirby Lester systems not only help improve counting accuracy and reduce labor time, but they also help to reduce and eliminate dispensing errors.

Picture 15. Kirby Lester’s KL 100 pharmacy robot

Picture 16. HD Medi ATDPS

4.DESIGN

Based on key-points of need, we decided to approach the problem from several angles and started to create two mutually complementary solutions:• MedBook application - easy to use interface for safer, quicker and more effective information

administration• MedTray- what is connected through the dock to the MedBook app and supports nurses in

medicine distribution, helping prevent errors and save time.

4.1 Interface of the App

According to our blueprint we mapped out the App structure (Picture 17).

Picture 17. App structure

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Picture 18. MedBook app’s patient page

Picture 19. Automated reminder

History

Contact

Current Info

Patient InfoNotice

-Medicine -Food

Changing operation room 5min ago

Building X in construction yesterday

NameSexAgeTeleAdress

Cloth washing is done 1hour agoPhoto

NameRelasionTeleAdress

Ward1

Ward2

Ward3

Ward4

Ward5

Name

Name

Name

Name

Name

Name

Patient FoodMedicine Tests03.01.2014 Fri

Ward6

Ward7

Ward8

Visual map

Recording

Department/Unit

Building/Floor

OperationTestTemperature

Edit

08:00

10:00

12:00

14:00

16:00

18:00

20:00

22:00

Get test result

Taking blood test

Reminder

History

Contact

Current Info

Patient InfoNotice

-Medicine -Food







Recording


Taking medicine

Top menu

Top menu contains four basic parts: • “morning tour” section which is later changeable to “patient”• medicine section• tests • food

Additional feature is calendar, quick button to home page and login profile, search bar.We realize the importance of contact between nurse and doctor so we added contact feature and date.Left barWe use left sidebar structure and expanded menu, because it’s simple and very easy to control your logical location in the app. The buttons are designed in a way for easy understanding the relationship between each branch. When each button is pressed the visual map can help nurse avoid mistake.Right barRight bar are quick access to clock reminder, notes taking, printing, save, setting and refresh. It can be dragged to the right to appear a board for above function.ContentIn the content there are basic information section about patient and their contact member. Notice section keeps update the recently important issue about patients messages and condition. Current information section contains medicine and food, it could be adjusted by finger for roll up and down to view all the information.

Picture 20. Food choosing window

Name

History

Contact

Current Info

Patient InfoNotice

-Medicine -Food






Ward1

Ward2

Ward3

Ward4

Ward5

Name

Name

Name

Name

Name


Ward6

Ward7

Ward8

Visual map

Recording

Department/Unit

Building/Floor


Food

Breakfast

Lunch

Dinner

Save

Name

Edit

A: Pulled Pork Sandwich,Steamed CarrotsB: Cream Style Corn,Biscuit

A: Rosemary Roasted Potatoes,Sauteed CabbageB: Sauteed Zucchini & Tomatoes Dressing

A: Chicken Breast TampicoB: Shrimp & Sausage Jambalaya

In history section there is possible to change from calendar look to graph look, which improves the understandability and easy edit by clicking. It can show operation time, test time and temperature at the same time (Picture 18). So the nurse can have better knowledge of the patients condition whether it’s getting better or not.

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We also add automated reminder (Picture 19) as backup during morning tour rush hour to reduce mistake as well as nurse’s stress of recording everything correctly in such a short time.

By clicking pencil button it will pop up a small window where the information is editable. For example if you want to edit food, it brings up a check list (Picture 20). Its very easy and timesaving to do just a few click and save. It automatically goes to the general system so kitchen gets all the information at the same time.

Under food page (Picture 21), left bar gives the basic information about a day. Notice will show if there’s patient left who hasn’t chosen the food yet or any problem occur. When all is correct then “send” button will highlight so nurse can send all the list to the kitchen.Food list is arranged by ward, when a patient is not allowed to eat (for example in case of scheduled operation), it will automatically appears cross and it is not active for choices.

Because there are other organizations involved in the food distribution, then it’s possible to create food lists also as a order for all the units and all patients, dinner, supper, etc (Picture 22). By clicking the triangle it is possible to arrange all the information in a way as it needs to be - date, building, department etc. It’s automatically calculates the total amount of certain types of food for a certain time.

In the Medicine page (Picture 23) we use intelligent searching function at the top. If you insert “a”, then the database automatically provides the most possible choices. It turns to blue when it’s been chosen.Also there is possibility to search by category. By clicking on the second bar, the drop list will show all the general categories, and further it changes to the sublists. When item is chosen then it will turn to blue and the left column appears with its content.The list gives a warning when the medicine runs out of stock. By quick clicking there is possible to place an order for them from center pharmacy. Also you can add “favorites” to the search list. When patient list is chosen it will give all the information about certain medicine.

Patient FoodMedicine Tests

Notice

Friday 3.01W ard 1 Patient Food A Food B Remark

******

******

******

******

W ard 2 Patient Food A Food B Remark

******

******

******


******

******

******


******

******

******

******


******

******

******


******

******

******

******


******

******

******

******


******

******

******

******

Food A

Food B

03.01.2014 Fri

Breakfast

Lunch

Dinner

Shrimp & Sausage Jambalaya

Chicken Breast tampico

Picture 21. Food page Picture 23. Medicine page


Drug Detail

Penicillines

Cephalosporins

Macrolides

Tetracyclines

Fluoroquinolones

Aminoglycosides

Tuberculosis

Fungal infections

Viral infection

Malaria

Otheranti-infectives

All

amoxicillin

amoxil drops

ampicillin caps

ampilicin susp

penicillin v potassium

dicloxacillin

+

Short cut

Patient List

Distribution

Medicine List

Add shortcut Order

a

amoxicillin

Patient FoodMedicine Tests

Notice

Friday 3.01

Food A

Food B

03.01.2014 Fri

Breakfast

Lunch

Dinner

Shrimp & Sausage Jambalaya

Chicken Breast tampico

Picture 22. Food page

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4.2 Appearance

Step 1. Dock stays in medicine storage room. It also has a charging function.

Picture 24. “MedTray” iPad dock

Step 2. If placed to the dock, overall medicine distribution list opens. As there are need for distribution several times a day, then system automatically recognize a right time and shows a list for medicines what needs to be prepared.

Picture 25. “MedTray” dock with iPad

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Step 4. System lights up holes for these patients who needs medications in this distribution time (Picture 27).

Step 3. Placing the tray ontop of the lightpanel (Picture 26).

Picture 26.

Picture 27.

Step 5. Holes are filled with paper cups (Picture 28).

Picture 28.

Picture 29.

Extra feature: we are using different colored cups for marking patients in ward (Picture 29)- we would like to suggest that in ward there are different places marked with different colors - bedsheets, cupboards, pijamas of patients or something else. Then its another proof that right medicine cup goes to right patient.

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Step 6. Barcode reader window opens (Picture 30).

Picture 30.

Picture 31.

Step 7. Front camera reads barcode and detailed drug information appears (Picture 31).

Step 8. According to prescriptions right holes lights up. Amount of light dots indicates how many bills are needed to this cup (Picture 32).

Step 9. After all necessary cups are filled, all lights are closed. Next step is inactive if there are some missing bills (Picture 33).

Picture 32.

Picture 33.

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Picture 35.

Picture 34.

Step 10. The same procedure repeats with next medicaments from list until all needed are distributed (Picture 34).

Step 11. Medicaments are ready for distribution (Picture 35).

4.3 Making a prototype for a MedTray

Picture 36. Picture 37.

Picture 38. Picture 39.

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4.4 Product value

Med Book application would be working-tool for nurses that would be easy to useand due to this inserting and editing information would be easy and convenient. They would not need to do unnecessary tasks.If we compare “before” and “after” information flow maps, then it shows that most of the errors would be eliminated from the system after using MedBook together with MedTray. Not to mention the time what it would save and digitally recorded material what would be available for all levels of health care system.

Benefits:• preventing errors• saves time• information is quickly editable and controllable• device is handy to use and portable• information is recorded digitally- allows easy transfers to other systems• information is in one common environment- available for all levels of system• all the records are quickly available and creates possibilities to quick analyses


down to notebook

Nurse writing everything down to nursing �le

Nurse writing everything to the “PAPKA”

Doctor signs




Possible mistakes:


down to iPad

Doctor signs




Possible mistakes:

Picture 40. Previous information flow map Picture 41. New information flow map

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5. SUMMARYThe implementation of modern information technology affects health care system heavily. The use of information technology in health and medical treatment improves the quality of service, as well as giving it the opportunity to significantly reduce the cost, which is related to the medical service.At the moment most health care institutions use different information systems, which are not able to exchange information with each other smoothly yet, but it is improving every day.As long as the use of a computer for everyday work is troublesome additional commitment for nurses there is amount of information what remains unsaved.We are sure that if the interface of device is convenient, then users will soon see it rather than the helping tool then a tedious extra duty.

6. REFERENCES

1. http://www.iom.edu2. http://www.cernerrxstation.com/ 3. http://www.hdmedi.eu/en/products/packaging