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W hile innovative technologies have on a touch screen. The questions are based on a
transformed and improved almost every aspect of diagnostic algorithm that rules out complications
health care, most new technologies must undergo or more serious conditions. If any of her answers
significant change after the initial introduction, indicates a potential complication, she is instructed
case study
and many are abandoned altogether. To find to wait as usual to be seen by the clinician. If she
out what determines the success and spread of is deemed appropriate for rapid prescription, a
technologies, a developing field of research called clinician reviews her illness and medical history,
science and technology studies conducts in-depth selects one of several recommended antibiotic
qualitative research on the interaction between the regimens, and personally hands the prescription
technical and human aspects of an innovation. to her after confirming her responses to kiosk
questions. If the patient has insurance, the clinic
The following case study explores this interaction submits a bill for a level 2 office visit.
through the story of a computer kiosk designed to
expedite care in acute care settings for women with During a study of the kiosk, 162 women accessed
urinary tract infections (UTIs). the module, and 35% received computer-
assisted treatment. Fully 98% of users found the
The UTI Kiosk Design program easy to use and 95% said they would
Dr. Ralph Gonzales and his team at the University recommend it to friends/family. The average time
of California, San Francisco (UCSF) designed and for patients to complete the kiosk module and
implemented the free-standing, touch-screen kiosk receive treatment was about 20 to 30 minutes
in an urgent care clinic located at UCSF Medical versus a typical two-to-three-hour wait to be seen
Center. The kiosk enables English-speaking by a clinician. Since the kiosk module (with some
patients with minimal computer skills and all minor modifications to screening questions) was
levels of literacy to receive a rapid diagnosis. fully implemented, about 40% to 50% of women
with suspected UTIs were eligible for computer-
The kiosk process works as follows: When a assisted treatment. (In the study, the kiosk module
woman signs in with a suspected UTI, she is was validated against clinician diagnosis and urine
offered the kiosk as an alternative to waiting culture.)
for a physician. Based on established telephone
treatment algorithms, women eligible for Dissemination at ED Sites
computer-assisted treatment are 18 to 64 years With good results from the initial pilot, the
of age, have had a previous UTI, have pain when study team created a plan to test kiosks at four
urinating, and no complicating features. emergency departments. They started by recruiting
the support of local leaders or champions, a
If the referred patient opts for the kiosk, she is strategy that is generally agreed to be essential
asked a series of questions and enters her answers for new health care IT projects. All sites received M arch
2012
Figure 1. UTI Kiosk Experience in an ED: 1 month
financial support that was linked to an agreement that a
minimum proportion (70%) of eligible patients would be
referred to the kiosk during the three-year study period.
Women with Decline to
At three of the four ED sites, physician and UTI symptoms participate
(n=50) (n=4)
administrative leadership buy-in was quickly established.
Local opinion leaders and front-line staff expressed
enthusiasm about the kiosks potential to expedite UTI
care and offer new services for patients (chlamydia and Kiosk Ineligible
(n=46) (n=34)
contraception modules were to be added later).
Kiosks with the UTI module were then placed in waiting Varying Referral Rates
rooms and check-in areas at three hospital EDs, and Several months after the initial launch at the three active
front desk staff and triage nurses were given in-service sites, the research team noticed that referral rates differed
presentations and clear instructions to refer all women considerably among sites, and that these rates were highly
with suspected UTIs to the kiosk. variable over time at some sites and more consistent at
others. The goal for kiosk referrals was 70% of eligible
At the fourth site, however, there were approval women, but the proportion of patients with suspected
difficulties. Although ED project leaders supported the UTIs who were actually referred to the kiosk varied
kiosk test, nurses and staff were concerned that it would over the course of the study from 61% to 84% during
offer expedited care to some people at the expense of measurement periods at one site, 13% to 20% at another,
lengthening the wait times of others. Because fairness and and 34% to 65% at a third.
equity were thought to be built into the hospitals triage
process, any perceived unfairness of the UTI program was Moreover, eligibility for the expedited UTI care pathway
controversial. At this site, senior administrators created was not as high as expected. While 40% to 50% of
a lengthy approval process, and during the interval, staff women who completed the UTI module in the urgent
enthusiasm and knowledge of the project waned. The care clinic met eligibility criteria for expedited care, only
UTI module was not implemented in this ED during 10% to 20% of women in the EDs did so. Clinicians
the study. surmised that this might be due to ED patients being
An implementation evaluation was conducted near the Nurses also reported that patients sometimes expressed
end of the project period to examine reasons for the frustration with ED staff after spending time answering
apparent disconnect between the sites initial support for questions on the kiosk with the hope that they would
the project and inconsistent use of the kiosks. Individual be fast-tracked, only to be returned to the front desk
interviews were conducted with research team members and to hours of waiting. This had a corrosive effect on
and site staff, and observations were made of ED activities relations between nurses and patients, although overall
at each of the four sites. patient satisfaction obtained in telephone follow-up was
good and did not differ between expedited and control
groups.
About the F o u n d at i o n
The California HealthCare Foundation works as a catalyst to
fulfill the promise of better health care for all Californians.
We support ideas and innovations that improve quality,
increase efficiency, and lower the costs of care. For more
information, visit us online at www.chcf.org.