Palm-based Wireless Computing to Improve Access to Health Information and Coordination of Care James J. Cimino, M.D Department of Biomedical Informatics Columbia University New York Presbyterian Hospital Broward General Medical Center Grand Rounds July 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

Where We Want to Go

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 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 Hospital Clinical Information Systems Architecture Clinical Database Medical Entities Dictionary Database Monitor Medical Logic Modules WebCIS... Radiology Laboratory Discharge Summaries Research Administrative Alerts & Reminders Database Interface Reformatter

WebCIS Web-based front end to legacy database Medical Entities Dictionary (MED) –Translation –Class-based queries Patient  Department  Report header  Details Summary reports Links to health resources Infobuttons Patient lists

New York Presbyterian Hospital Clinical Information Systems Architecture Clinical Database Medical Entities Dictionary Database Monitor Medical Logic Modules WebCIS... Radiology Laboratory Discharge Summaries Research Administrative Alerts & Reminders Database Interface 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-list  Department  Report headers  Details

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 s 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 Details  Department  Header  Details 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) controlintervention

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