HIStalk Mobile Interviews Debby Madeira, Nurse Manager, Huntington Memorial Hospital

Debby Madeira is a nurse manager on a medical telemetry unit at Huntington Memorial Hospital of Pasadena, CA.

What’s it like as a nurse trying to care for patients while addressing all kinds of messages and alerts from many sources?

I think that the word that comes to mind for me is chaos. It is near-constant interruption, so it’s very difficult to focus at the task at hand, no matter what that task is.

One scenario that really brought it home for me is that I answered one of our landlines and it was a physician who had been trying to get hold of one of the nurses. He said the nurse wouldn’t answer the phone. She was talking on the phone to another physician, so I said, “Would you like me to ask her to hang up with that doctor?” He said, “No, could you just let her know to call me when she’s done?” 

It’s that you’re instantly able to get hold of everybody, so everybody instantly thinks they should be able to get hold of you. It’s very difficult to finish any task without those multiple interruptions. 

Anything that integrates that and decreases that and makes it more manageable from the nurse’s perspective, to me, is a beautiful thing. Because then they’re able to really focus on the cognitive work that a nurse does. A lot of the work they do is in their head, and that’s really hard to do with those kinds of interruptions.

Is that also true of numeric pagers?

The only paging function that the staff nurses have is the telemetry pagers. Those are being incorporated with the Voalte software, so it’s on their cell phone. Before, they were carrying separate pagers and had that pager, and it was a numeric pager. You couldn’t page it as a traditional pager — it would just get alarms from the telemetry monitoring.

Our charge nurses do carry a separate pager that’s part of our electronic bed management system. That’s a fairly new thing. We’ve only been doing that for a little over six months now. It’s definitely something we’d like to integrate it into whatever cellular device they’re carrying around so they’re not being interrupted by text or numeric pages.

It’s mostly phone calls. We are using text pages, text messages on the iPhones with the Voalte software. I can look at those when I’m able to look at it. You get an alert, but you don’t have to drop what you’re doing to make sure you don’t miss that text page, which is the beauty of getting text messages.

Describe the Voalte system that you’ve installed.

Their name is a really good acronym – VOice ALarms and TExt. It’s a traditional cell phone with traditional voice capabilities. They’re able to do text messaging within the Voalte software. They’re not texting their friends, they’re texting each other related to their work and patient care needs and unit operational needs. They get the telemetry alarms through the telephones as well, so it acts as a telemetry pager. It covers three functions.

Now that we’ve been using it for many months, our IS department is looking at what other things can they integrate onto the device to work with the Voalte software, like our bed management system, some of the documentation, some nursing medical applications like drugs and conversion software — things like that that have been around for smart phones for a long time.

Tell me some of the workflow problems that having the devices have solved.

They just have one device; they don’t have two different devices. Being able to text when you either didn’t deliver that message at all because it was too inconvenient and you didn’t want to bother them with a telephone call, a text message has made a huge difference. It has cut down on voice interruption, but gets messages to the person in a more efficient manner so they can look and say, “OK, my patient needs this,” or, “I’m getting another patient in this room.” That didn’t need to be an interruption with a voice message, but now they’re able to get that text message.

You may not remember everything that you’re asked to do with multiple voice calls that stack up on top of each other. When they’re text messages, you look at your device and you have a reminder right there for you, so that you’re able to follow up on those messages. It cuts up on the interruptions and it serves as a reminder. It really helps to cut down on some of that chaos factor that I feel is a big impact in today’s patient care and nursing environment.

If I were a patient, what would I see and experience differently now that you’ve moved to cell phones?

Nurses here have carried cell phones for some time, so that part’s not new for our patients. But to see somebody receive a text message, open up the phone and read that text message, as well as send a text message while they’re there is kind of a culture shock. The nurses like to explain to patients that this is a device that we use to send messages to each other about what our patients need and how we can help each other.

How do the nurses like having iPhones?

I think they like being able to have the ability to text. I don’t think they see a difference in the actual voice part since they’ve been carrying cell phones for so long already. They really like not having two separate devices — just having a phone and the pager.

Actually, the alarm paging functionality works better on the iPhone with Voalte than it did with the telemetry pagers that we had. The alarm comes over quicker. Just for a while we carried them both to see how it was working, and the alarm comes through Voalte onto the iPhone quicker than it did onto the tele-pagers. They really like that.

What kind of training did you have to provide?

Voalte provided training on how to use their software and some simple instructions on how to use the iPhone. Since we’re not using the iPhone fully, we only need to know how to use it as it relates to using Voalte. It wasn’t too much of a challenge, for most of us here were using other smart phones or iPhones already.

Did you see any improvement in nurse job satisfaction?

We weren’t really measuring it related to that. We’re measuring nurse job satisfaction from a lot of other perspectives.

Having the privilege to be a development partner with Voalte was really exciting. I let the staff make the decision whether we would do that. We’re still the only patient care unit using Voalte right now at the hospital. They were eager to get input from their end users as to what works and what doesn’t work for them. That part has been challenging, but also rewarding because they’re helping shape what communication software they’re going to be using. It will also make work a lot easier for their fellow nurses all over the place that will adopt the technology.

What kind of things are you hoping to have the product include?

As I mentioned, the bed tracking system for at least the charge nurses — and actually for me too since I’m carrying one of the iPhones as well – it would be lovely to have that in our hand and not be tethered to a desktop computer. Also, the charge nurses carrying their separate pager.

Some simple documentation functions that are in our HIS system — they would like to be able to do that using the iPhone.

They’ve asked for things like Epocrates so that they have drug information at their fingertips. Conversion software that some of them are already using on their own smart phones that they’re playing around in their pocket so they can do temperature conversion and other metric-type conversions.

Actually, I have this whole list in my office. We’ve sent it to both IS and Voalte, the things we’d like to be able to see integrate with so that everything they might need to use from a techie perspective they can access from the phone because it would make it so much more efficient for them.

We take digital pictures of patient rooms. Right now, we’re using standard digital cameras — go plug it into a photo printer and print the picture out and the picture goes in the chart. We haven’t advanced to the point where our images are digital in the electronic record. We have a hybrid electronic medical record, and so one of the things that we’re really pushing for is for them to be able to use iPhones as their digital camera.

So instead of one for the entire unit of 32 beds and eight nurses, charge nurse, and four nursing assistants, everyone would have a digital camera in their pocket and would be able to take the pictures appropriately. Then, hopefully, wirelessly send it to a photo printer. Eventually with a dream that the pictures would be digital and be able to be imported directly into the patient’s electronic medical record. That’s one of the things that would save a lot of time and frustration for the nursing staff, so that’s high on their list right now.

You mentioned that you have a hybrid electronic medical record. What systems do the nurses actually use other than the Voalte system as far as other software?

We use Meditech. We’re looking at a 2-3 year timeline for either changing to a different vendor or going to Meditech’s most current product. Physicians are still writing orders and not doing computer order entry. There are some tools and forms that are not available in our version of Meditech, so they have to print it out and fill it out by hand. The physicians are still writing their notes by hand.

The nurses do the majority of their documentation electronically in Meditech. Most of the order entry and resulting is done within the system. There are just a few things that it’s not able to do as regulatory requirements have changed.

If you look out down the road, let’s say three to five years, in terms of the technology available for nurses to use, what would you like to see?

I think mostly I would like things to be seamlessly and transparently integrated. I don’t want them to have to stop one thing and close it to move to something else. I’d like them to not have to duplicate anything because that keeps them at the bedside with their hands on the patient, and also their minds working to benefit the patients. And right now there’s a lot of fragmentation, a lot of non-integration, a good amount of duplication, so I’m not sure I could envision a software or piece of technology equipment that would do it.

Whatever it is I would like it to be integrated. That decreases duplication. So if they’re assessing something with an electronic device like a portable, non-invasive blood pressure machine. I would like that blood pressure, after it’s validated by the nurse, to directly go into the medical record so they’re not taking that piece information off that machine and then manually entering it into the system. And then everything they do to be very seamless and integrated.

Any final thoughts?

I just want to really praise Voalte. I’ve been a nurse for a very, very long time, and although I’m pretty tech-savvy and enjoy using it to make my work and my personal life more productive and creative, I really, really praise them wanting to be development partners. We, being the frontline nurses that are not seen as the purchase decision makers, often do not get to participate in product development.

So, it’s really been fun from that perspective, both as managers and staff, to work with Voalte to develop this product that nurses will be using instead of it just being managers or just IT people just educators who are usually the people who have more input into designing things. It’s been great for frontline people to be able to participate in that and really influence product development.

  • Great interview- speaking to those on the front line always yields positive results. Voalte has a great niche that they are carving-out. Their success will depend upon the features and functions they add as they are competing with Meaningful Use investments. Their other relative competitors haven’t really added innovative features, directly, for some time (ex: Cisco, Ascom, Polycomm/Spectralink) except for Vocera. Vocera has their own issues.

    Voalte also pays attention to training and installation (unlike their competitors from my experience). They also are in the feedback loop with their product in real-time via their product.

  • Thanks, Mr HIStalk, for helping bring us back to the real “meaningful use” of HIT…improved patient care!
    When technology can provide nurses and other bedside caregivers with real-time data at the point of care while improving, rather than interrupting, clinical workflow the adoption rate of technology by clinicians will skyrocket!!

  • Great to see nurses benefiting from technological innovation that is relatively simple but highly effective. They are often an underserved population in the healthcare system and continue to struggle with the same workflow and information challenges that other clinicians face in the clinical setting.
    It raises a couple of questions in my mind – why is that a separate application more efficient at sending out alerts?
    It also presents a challenge to sites and facilities that have placed an outright ban on cell phones because of research such a this
    http://ccforum.com/content/11/5/R98
    and the inevitable urban legends and random “incidents” that are mis attributed to a cell phone.
    The smart phone is becoming an integral part of many people’s lives and integrating functionality is important as Debby put it because it means ” just carry one device”. This has been a target for a number of years. The iPhone bridged the divide on usability making the functionality easy for *everyone*. Watch for more innovation and tools to arrive at the smart phone.

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