Mobile Technologies in Healthcare - Amazon S3...Wireless/Mobile Security Challenge `Device (memory, CPU power) and bandwidth restrictions `Sensitive health related information stored

Mobile Technologies in HealthcareImplementation Techniques and Considerations

Ellen DaleyVice President of TechnologyArcStream Solutions

2Proprietary & Confidential to ArcStream Solutions

Mobile technology – the hype vs. the realityDeveloping an integrated mobile solutionAdditional implementation considerations for healthcareReal-life applications – who are the users and what are they asking for? Building a solution that lasts – final thoughts

Presentation Overview


Wireless vs. Mobile

Always Connected,Live Data

Disconnected,Synchronization

Wireless Mobile

<< sync >>


ApplicationServer

Stand-alone and LegacySystems

WebServer

Mobile Middleware(e.g. Sync, transcoding)

Healthcare InformationSystems

(e.g. Cerner, Siemens)

DeviceNetworkMobile IntegrationBack Office

Wireless/Wireline

Gateway

Integration Bus

Security

Device Management

Internet

Mobile Solution ArchitectureTechnology Overview


Cell PhonesVoice & Data

Two- way PagersLaptop / Tablets

PDA/HandheldPocketPC & Palm

Many Different Devices

Smart Phones/Convergent Devices


Device TrendsPocketPC

– Most of the traction within the enterprise space– Healthcare/pharmaceuticals– Sales Force Automation

– Seeing more vendors with PPC devicesPalm

– Multiple vendor devices – from simple tosophisticated

– Used primarily in industries w/ consumer-facingapplications

– Higher Ed– Retail

Tablets– Nothing too hot yet, but gaining some traction

Market Share

Q3 2001

Operating System

.2%Symbian6.4%Others7.5%RIM18%Windows CE68%Palm OS

Source: Gartner 9 November 2001


Palm OS DevicesCost– Inexpensive entry point ($80-$600)– 68% Market share

Capabilities– Palm OS / Single Tasking– OS Designed for Mobile Users

Expandability– Widely available 3rd party software and hardware– Various options dependent on device

Mobility– High battery life

Connectivity– Palm i705, Handspring Treo, Samsung I-300


PocketPC Devices Cost– More expensive entry point ($400-$700)– 18% Market share

Capabilities– OS not designed specifically for mobile devices– Multi-tasking OS increases app options

Expandability– Increasingly more 3rd party software & hardware– Expansion options dependant on device

Mobility– High quality resolution on screens– Limited battery life

Connectivity– Wireless capabilities through expansion, T-Mobile PPC


Tablet / Pen Based Computers Cost

– Expensive entry, alternative to laptop– CE versions cheaper vs WinX

Simplicity/Capabilities– Designed for pen based computing– More than an Information Appliance (IA) or WebPad

Expandability– Widely available 3rd party software & hardware– Various expansion options thru PCMCIA slot

Mobility– High resolution, active screen– Low battery life

Connectivity– Some with integrated 802.11 or thru PCMCIA


Two-way Pagers Cost

– Moderate Entry point + Monthly feeSimplicity

– OS specifically for Wireless devices – Intuitive interface

Expandability- Very limited 3rd party software & hardware- Not currently expandable

Mobility- Low quality screens- Long battery life

Connectivity– Always on


Mobile Phones Cost

– Low entry point + monthly feeSimplicity

– Hard to enter data Expandability

- Very limited 3rd party software & hardware- Often “walled garden” solutions - Limited memory

Mobility- Low quality screens

Connectivity– Always on


New Converged Devices Are Being Introduced Daily

Source: Forrester Research


High Level Summary of Devices

ConsiderationsMarket SharePrice PointDevice Type

Limited Acceptance

Insignificant$100 - $500Other

Microsoft Strategy

Small(WinCE vs

WinX choice)

$1500 - $4000Tablets

Enterprise Adoption

18%$400 - $600PocketPC

Consumer Focused

68%$80 - $600Palm OS


Selecting a Mobile Device

Understand the intended use and specific applications– Evaluate the user population & their needs– Can a single device be mandated? (think IT support)– Can needed applications realistically support multiple OS?

Technical Considerations – Battery life!!!– Screen resolution (images vs. text)– Input requirements (text input)– Durability– Expandability (memory & peripherals)– Connectivity (wireless options, mobile options)


Lots of New Peripherals Are Being Introduced Snap on mini keyboardsDigitizer pads (Seiko Smartpad)Folding keyboardVideo output for PPT presentationsHigh Quality video (show movies)IBM Microdrive (1GB)


Power OptionsAs devices have become more popular, more charging and power options are becoming available. A few of these are:

Fuel cell based emergency recharge Quick 9 volt emergency rechargeUSB cables that sync and rechargeSolar recharger


High-Level Development Options

Browser Client Application Client

Palm OS Windows CE

Database


Browser Development : PalmHTML or WML viewingVendors

– AvantGo– HTML Browser– JavaScript available– Provides Dual Deployment (PPC and Palm)

– Palm Browser / PQA– HTML Browser– Some Offline Support

– Plucker– Freeware HTML Browser

Some development can result in database access


Browser Development : PocketPCHTML and XML ViewingVendors

– MS Internet Explorer – HTML 3.2– Supports JavaScript 1.1– Supports SSL, XML / XSL, & cookies – Flash 5.0 viewer available

– AvantGo– HTML Browser– JavaScript available

XML Approach– XSL Style sheets


Application Development: Palm OSMetrowerks Codewarrior C++Forms Development– 80/20 rule– Centers around DB access and UI Applications

– NS Basic– Smaller runtime– Single PRC

– Puma Tech Satellite Forms– Larger Runtime– Can’t compile into single PRC– More powerful with Database

AppForge– Press to compile (Palm / PPC)– Visual Basic– Large Runtime (600k)


Application Development: PocketPCMS eMbedded Visual C++MS eMbedded VB– Currently Interpreted

AppForge– Press to compile (Palm / PPC)– Visual Basic Integrated– Large Runtime (600k)


A Little About JavaStill in infancy for mobile spaceLong development cycle Semi-device dependentSlow – VM decreases performance

Binary Runtime Environment for Wireless(BREW) and J2ME gaining momentum – Primarily for phones

J2ME– KVM on devices available– Not being heavily used


Database Options

Databases are fairly robust on devices now, some offer:– Indexing– Stored procedures– Triggering

Some Key Vendors for Both PPC and Palm are:– OracleLite– DB2 Everyplace– Sybase Anywhere– MS – SQL – MS CE Objects


Connection Types Devices can be connected using various, multiple sources:– IR Sync– Wireless LAN (802.11)– Bluetooth– Network Carriers


IR Synchronization

Ideal option when:

Population is located in multiple/remote locations

Population is synchronizing in a multi-user environment

Population is using a variety of devices

Use of WLAN (802.11) is prohibited


Wireless LAN - 802.11b

Have Wireless LAN Access behind firewallOperates on 2.4GHz ISM Shared Spectrum11 Mbps at 100 ft radius -> 1Mbps at 1000 ftProvides wireless performance and throughput comparable to wired EthernetSupports 10-30 devices per access point, depending on network traffic


Wireless PAN - BLUETOOTH

A short range (Up to 30 Feet), RF communications standard for connecting PDAs, phones, etc.Also operates on the 2.4Ghz ISM shared spectrum 2000 companies including IBM, Toshiba, Motorola, Microsoft and Intel are backing the standardFinally starting to see some devices with BT, which services aresupported will decide ultimate success


Carriers

Carriers are differentiated by:

CoverageCoverage

Hardware costs and characteristics

Speed

Connectivity options


Broad Coverage Wireless NetworksWhat does the network look like

Note – VoiceStream has intermittent coveragein the metro regions of these states, coverage is not complete


Broad Coverage Wireless Networks – Data Everywhere

TDMA(IS-136)

CDMA(IS-95)

GSM

CDMA2000(1evDO)

2001 2002

GPRS

Cdma2000(1XRTT)

Time

Ban

dwid

th

2G 2.5G / 3G Lite 3G

9.6-14.4 Kbps

384 Kbps - 2 Mbps

43–115 Kbps

Data NetworksMobitex, Motient, CDPD,

IDEN…

2000 2003

WCDMA

EDGE

144 Kbps

64-384 Kbps

2004 2005


What can you do with the networks in place?


Packet vs. Circuit

Today, most are carriers are Circuit based

2.5G and 3G introduce Packet based– Always on

– Pay only for data used

– Quick initialization

– Better response time

– Tolerant of coverage gaps

– Spectrum efficient


Wireless NetworksWhat’s Happening and why is it important to healthcare

– Wireless Communication between Physicians and Hospitals over standard Phones and PDA (advanced pager)

– Alert capability and results to patients and doctors

– The availability of the public data networks will alter how applications work

– 2G, 2.5G, 3G

–802.11• Within Hospitals, large care facilities, wireless connection to integrate multiple functions

• Hottest Selling Technology–BlueTooth

• Localized Private Network• Consumes less power, but 802.11 future generations faster

Broad Coverage Networks(Carrier Networks)

Localized Coverage Networks(802.11, etc.)


3 Models of Data Delivery to Devices

Traditional Sync Approach– Synchronize directly from enterprise applications to native device application

(Calendar, Email, Tasks, etc.)– “Conduits” are built for two way synchronization of data– Cradle or Wireless synchronization

Web Based Approach– Deliver content specifically formatted for particular devices easily– Shorter development cycles– Support for both offline and connected modes possible

Merge/Replication Approach– Synchronize directly from staging database to custom databases on device.– Sync is handled by database engine– Cradle or Wireless synchronization


Traditional Sync ApproachSynchronize directly from enterprise applications to native device application (Calendar, Email, Tasks, etc.)“Conduits” are built for two way synchronization of dataCradle or Wireless synchronization

MobileMiddleware

(Transformation)

Email/CalendarServer

EnterpriseData Systems

NativeCalendar

NativeEmail


Web Based ApproachDeliver content specifically formatted for particular devices easilyShorter development cyclesSupport for both offline and connected modes possible

MobileMiddleware

(Transformation)

WebServer

EnterpriseData Systems

HTML

WML

HDML

Others


Merge/Replication ApproachSynchronize directly from staging database to custom databases on device.Sync is handled by database engineCradle or Wireless synchronization

DataTransformation

Email/CalendarServer

EnterpriseData Systems Custom

DatabasesStaging Database


Mobile Integration“Future Proof” Hype:

Device Agnostic – ability to remain independent from any one or series of devicesRealities – Lowest Common Denominator

Network Agnostic – ability to be independent of network provider or carrier technologyRealities – Less of an issue as mobile application architecture become more web based.

Customization/Flexibility – ability to modify solution for particular need setRealities – Lots of integration


Clinical Systems

Data

Financials/Practice Management

CPOE/Decision Support

Application IntegrationMobile Workers

Clinical Staff

Admin Staff

Support Staff

• Scheduling• Billing

Wireless Infrastructure

• Labs• Pharmacy

• EBM References• Clinical DataRepository

Mobile Solutions: Complex Integration


Manageability

Key features include:

Remote software distributionRemote kill of a devicePassword managementFull end-to-end network managementTotal device monitoring


Security

Mobile solutions introduce a unique set of security concerns– Sensitive patient information on unprotected or misplaced

device– Interception of wireless transmissions

Current security measures focus on:– Encryption– Authentication of the user– Tamper proofing devices


Wireless/Mobile Security Challenge

Device (memory, CPU power) and bandwidth restrictionsSensitive health related information stored on the device Communication link includes public lines (e.g. Internet & Wireless Networks)End-to-End connection requires multiple networks and protocolsLack of physical security mechanisms raises eavesdropping and tampering risks

Security is only as strong as it’s weakest linkEnd-to-End Security is required


Presentation OverviewMobile technology – the hype vs. the realityDeveloping an integrated mobile solutionAdditional implementation considerations for healthcareReal-life applications – who are the users and what are they asking for? Building a solution that lasts – final thoughts


Handheld Solutions Should Be Process Oriented

Determine user information needs

Understand workflow process

– Document process steps and components

– Information use within and between processes

Develop a mobile workbench “vision” that can beexecuted in phases

Understand how mobile solution within a largermulti-channel delivery environment


Information when and where you need it- regardless the medium of access

Hospital

PhysicianOffice

RemoteClinics

T1

WLAN

IR

DSL1xRTT

Sync

RAS

External

Understand the Multi-Channel Delivery Environment


Mobile Information WorkbenchInformation Integration

Integrated information from multiple systems will follow an end-user’s workflow.Functions will be accessed seamlessly and not through separate point applications.





A Best-of-Breed ApproachOften times, an organization will need to resolve how to best combine the following for a “best-of-breed” integrated solutionHIS vendors with mobile solution extensions to existing systemsNew vendors (or 3rd parties) with strong mobile capabilitiesAdditional information from backend systems that have no mobile solution available – internal or outsourced development

Design the functionality to provide the highest-value solutionto your end users and then use the best of breed approach to

build out the solution, leveraging existing resources where possible


Accessing Data in a Healthcare EnvironmentLeveraging an existing Clinical Data Repository (CDR)Leveraging a existing desktop based patient portalBuilding a staging database specific to mobile solution (often using HL7)Leveraging existing vendor mobile solutionsUsing API’s to access data from backend systems


Understand Regulatory Requirements (HIPAA)Considerations for Mobile Technology

Confidentiality• Authorization

• Access Control

Integrity• Data Validation

• Audit Trails• Log Files

Secure Transfer• Encryption

Availability• Backup

• Disaster Recovery

HIPAA Insurance ReformHealth Insurance Portability and Accountability Act

Privacy & SecurityPrivacy & Securityof Patient Dataof Patient Data





Why are hospitals adopting mobile technology?

Improve clinical processes or workflow efficiencies

Attract and retain staff

Improve clinical data capture and documentation

Facilitate clinical decision support

Improve quality of care and patient satisfaction


So Many Applications – where are the real opportunities?

Labs

Pathology

Pharmacy

Patient Records

Charge CaptureAlertsAlerts

Other MobileWorkflow Apps

(e.g. eprescribing)

ReferenceApplications

Decision Support

Operative NotesClinic Notes

Clinical SystemExtensions

Order Mgmt/CPOE

MedicationAdmin Record

Medical EquipmentData

NursingAssessments


Physician Opportunities The value of the opportunity can differ between hospital salaried and private practice physicians:

Centralized reference materials

– Today, the most common use of PDA’s among physicians

– Clinician discretion vs. hospital provided and/or “approved”

Clinical systems information (patient-centric)

– Labs, medications, radiology impressions

– Historical information when pertinent

– Threshold and opt-in alerts capabilities


Physician Opportunities cont…Computerized Physician Order Entry (CPOE)

– Wireless connectivity a necessity

– Still much debate over which device to use (PDA vs. tablet)

– Separation of simple and complex order types

Coordinate the workflow with nursing

– Don’t want to chase down nurse or assistant

– Send alerts to notify status of new order

Alerts for verbal orders requiring signatures

– High value to medical records management

– Ability to electronically sign-off on orders


Electronic charge capture

– Higher priority among private practice and hospital administration

– Consistent in showing significant ROI’s

Dictation

– Ensures accurate and compliant documentation

– Device is a smart recording instrument; on-device speech to text still 5+ years out

Task/ to-do list to help manage patients through shift changes

– Healthcare CRM paradigm, managing patients in a similar fashion to corporations and their customers

Physician Opportunities cont…


Nursing Opportunities Because nurses typically are floor based, a wireless laptop cart device often times fulfills a majority of their device needs, additional mobile opportunities include:

Input of vitals and I&O’sElectronic medication administration records (MAR’s)

– Bar-coding for verification being piloted (VA’s), issues around compliance

– Should interface with medication distribution type systemsTask/ to-do list to help manage patients through shift changesViewing output of medical devices

– EKG, ventilator, oximetry


Materials Management Opportunities One of the first uses of mobile technology was the barcode inventory device. Healthcare is expanding this solution to include the clinician capture of patient charges

Streamlining processes for both clinicians and MM staff– Get rid of the inefficient and resource intensive sticker system– Improve the process of patient charge capture – Robust functionality for materials staff including par counts

and other inventory functionality


Emergency Department Opportunities Hospitals who have not invested in a specific vendor solution are using mobile technologies to manage ED workflow issues:

Building a ED-centric workflow – Details about where patients are, how long they have been

waiting, what action is necessary, and who is caring for them– Identify where bottlenecks are and how staff is loaded– Keep workflow moving by pushing pertinent, up to date

information to physician via PDA (e.g., lab results, radiology reports)

Extended from existing HIS systems for true workflow integration– Registration and patient information– Clinical results and order entry





Final Thoughts

What information do I need to distribute to make my users most effective?

– For smaller form-factor devices, this is usually a subset/extension of information

– Otherwise consider using a tablet or laptop with wireless connectivityHow do I integrate my data in a way to increase the efficiency of my user’s workflow?

– Base functionality upon user information needs– Avoid point solutions when at all possible

How do I develop my architecture in a way to be easily accessed from all locations/sources?

– Browser based solutions offer most flexibility– Consider a how solution is accessed across multiple channels


Final Thoughts

How can I distribute information to my users be in locations with limited network access? What is the future of wireless?

– Most healthcare data needs real-time access - mobile solutions add significant complexity

– Stay with wireless solutions when at all possible, consider IR for connectivity for limited network access

Which device type(s) should I support? Do I need to remain device agnostic?

– Base your device upon the solution requirements, device agnosticism helps to protect against future technology changes

How do I secure and support these mobile solutions?– Security and management cannot be an afterthought, design these

directly into any solution prior to deployment


Thank You!


Speaker Bio

Ellen Daley is the Vice President of Technology at ArcStream Solutions.You can contact her at [email protected]

Documents

Mobile Technologies in Healthcare - Amazon S3...Wireless/Mobile Security Challenge `Device (memory, CPU power) and bandwidth restrictions `Sensitive health related information stored