Palm-based Wireless Computing to Improve Access to Health Information

and Coordination of Care

James J. Cimino, M.DDepartment of Biomedical Informatics

Columbia UniversityNew York Presbyterian Hospital

Broward General Medical Center Grand RoundsJuly 7, 2005

What are we trying to fix?

• Errors!• Information-related causes of errors:

– Lack of access to patient information– Lack of access to health knowledge– Poor communication and coordination of care

How do we study causes of errors?

• Surveys• Focus groups• Observation• Use of clinical information systems

– Observation with “think aloud’– Logfile analysis

What did we find?

• Information needs are 1/3 each:– Patient information– Institutional or administrative information– Health knowledge

• Information needs and resources are context-specific• Information needs are frequently unresolved• Team members can’t identify each other• Communication is delayed and inefficient

Proposed Solution:

• A wireless, handheld device that:– Connects to the clinical information system– Provides local knowledge resources– Provide context specific on-line knowledge– Supports communication among team members– Does not depend on infrared or wireless Ethernet

Where We Are

Physician Team

Intra-teamCommunication

Nursing Team

Inter-teamCommunication

Intra-teamCommunication

Interaction with ClinicalInformation System

InformationResources

InformationNeeds

Where We Want to Go

Physician Team

VirtualWhiteboard

Nursing Team

InformationResources

Infobuttons

Hand-Held Devices Choices

• Linux– Sharp

• PalmOS– Palm, Handspring, Sony

• PalmOS+Phone– Kyocera, Samsung, Handspring

• PocketPC– Compaq

Palm Platforms

• Palm VII+ all-in-one device/service- connection time, not HIPAA-compliant

• Palm Vx with Omnisky+ add-on, all-in-one service, “always on”- not HIPAA compliant, out of business

• SmartPhone+ all-in-one-plus-phone, HIPAA-compliant- smaller screen, connection time

• Treo 600/650+ all-in-one-plus-phone, WiFi, color, camera- cost, connection time

Client Application Choices

• Platform dependent– PalmOS SDK

• Platform independent– Web-based

• WCA, AvantGo, EudoraWeb, Internet Explorer

Wireless Communication Choices

• Wireless modem– External modem– Integrated modem

• Expansion card slot– Wireless network card

• Wireless LAN– IEEE 802.11

• Wireless WAN– Omnisky (EarthLink), Palm.Net– SprintPCS, Verizon

Wireless Handheld Solutions Advantages

• Mobile• Personal• Replace multiple devices• Replaces paper resources• Nomadic data capture

Wireless Handheld Solutions Disadvantages

• Screen size

• Input methods

• Connection time

• Transmission speed/quality

• Local storage

• Security

• Device-specific thick clients

• Limited Web-browsing

• Device cost

• Wireless service cost

New York Presbyterian HospitalClinical Information Systems Architecture

Clinical Database

Medical Entities Dictionary

Database Monitor

Medical Logic Modules WebCIS

. . .. . .Radiology LaboratoryDischarge

Summaries

Research

Administrative

Alerts & RemindersDatabaseInterface

Reformatter Reformatter Reformatter

WebCIS

• Web-based front end to legacy database• Medical Entities Dictionary (MED)

– Translation– Class-based queries

• Patient DepartmentReport headerDetails• Summary reports• Links to health resources• Infobuttons• Patient lists

New York Presbyterian HospitalClinical Information Systems Architecture

Clinical Database

Medical Entities Dictionary

Database Monitor

Medical Logic Modules WebCIS

. . .. . .Radiology LaboratoryDischarge

Summaries

Research

Administrative

Alerts & RemindersDatabaseInterface

Reformatter Reformatter Reformatter

PalmCIS

PalmCIS Architecture

NYPH Clinical Data Repository

NYPH Secure Server

Secure

Internet Intranet

Wireless Device

Wireless Network

Secure

PalmCIS Client

• Kyocera QCP 6035 Smartphone or Treo 650• EudoraWeb browser• SprintPCS wireless service• End-to-end SSL encryption

PalmCIS Server

• Apache server• Thawte SSL Web server certificate

PalmCIS Server Application

• Web-based• C, CGI, HTML• User interface: pull-down menus, links• Security: authorization, authentication, signon

management, session management, logging• Data Access Modules (DAMs) for patient data• Medical Entities Dictionary (MED) for translation• Patient-listDepartmentReport headersDetails

Security

• End-to-end Secure Socket Layer• ID-specific IP address• Host IP address restrictions• ID and Password• SecurID• Timeout• System logs• Login failures generate e-mails• Screen lock (potential)

PalmCIS Login

PalmCIS Patient Selection

PalmCIS Laboratory Results

PalmCIS Radiology Results

PalmCIS Summary Reports

PalmCIS Microbiology Reports

PalmCIS Cardiology Reports

PalmCIS etc…

Information Resources

Infobuttons

• Information needs arise while reviewing clinical information

• Needs can be predicted based on context– Task– User– Patient– Patient data

• Queries to on-line information resources can resolve needs

• Match concept of interest to class(es)

• Identify context based on class(es)

• Retrieve question(s) for context

• Sort by “priority”

• Return HTML page of links (URLs)

PalmCIS Infobutton: Culture Result

PalmCIS Infobutton: Sensitivity

Navigational Issues

• Trade-off: data per page versus click-to-data ratio• Minimum required information versus fewest clicks• DetailsDepartmentHeaderDetails is inefficient• Can previous path predict future path?• Log files used to identify most-common paths• PalmCIS keeps track of user’s path• Provide list of shortcuts to next likely report

PalmCIS Shortcuts

Impact of Shortcuts

• Improve efficiency

• Reduce back clicks

• Optimize traversal paths

Log Files(control)

Log Files(intervention)

control intervention

Impact of Shortcuts

• Improve efficiency

• Reduce back clicks

• Optimize traversal paths

• Benefits– Facilitate access to

information– Assist in answering patient-

specific questions– Serve as reminders of what to

look at and patient problems

Log Files(control)

Log Files(intervention)

Virtual Whiteboard

• Identify team members and roles• Permit messaging between team members• Asynchronous communication• Palm-based and desk-based

Add Task Get Task

Cost

• Treo 650: $500• Sprint PCS: $60/month• Annual cost: $970/user• Server equipment extra• Personnel extra

Research Issues• Usability study

– PalmCIS– Shortcuts– Infobuttons

• Understanding whiteboard functions• Structured note entry• Where are handhelds better than desktops?• How do we study usefulness and impact?

– Usage logs– Increased access to information resources– Faster access to clinical data and alerts

Next Steps

• Redesign of clinical data presentation– Create efficient, task-specific views– Based on experience to date

• Complete integration of Virtual Whiteboard and note writing with WebCIS

• Explore use of Wi-Fi• Design randomized controlled trial• Get funding for larger deployment

Conclusions

• Secure, usable, wireless, handheld access to patient information and health knowledge is feasible

• Cost is not a big factor if replacing cell phone, PDA and beeper

• Integration into workflow and educational processes is biggest challenge

• Understanding appropriate “niche” functions is critical to success

• Answers are not obvious - research is needed

Acknowledgments

• Elizabeth Chen, PhD• Jianbo Lei, MD, MA• Larry McKnight, MD• National Library of Medicine Training Grant