Palm-based Wireless Computing to Improve Access to Health Information and Coordination of Care

1. 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

2. 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

3. How do we study causes of errors? • Surveys • Focus groups • Observation • Use of clinical information systems • Observation with “think aloud’ • Logfile analysis

4. 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

5. 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

6. Where We Are

7. Where We Want to Go

8. Hand-Held Devices Choices • PocketPC • Compaq • Linux • Sharp • PalmOS • Palm, Handspring, Sony • PalmOS+Phone • Kyocera, Samsung, Handspring

9. 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

10. Client Application Choices • Platform dependent • PalmOS SDK • Platform independent • Web-based • WCA, AvantGo, EudoraWeb, Internet Explorer

11. 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

12. Wireless Handheld Solutions Advantages • Mobile • Personal • Replace multiple devices • Replaces paper resources • Nomadic data capture

13. 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

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

15. 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

17. New York Presbyterian HospitalClinical Information Systems Architecture Medical Logic Modules WebCIS Clinical Database PalmCIS Database Monitor Alerts & Reminders Database Interface Administrative Medical Entities Dictionary Research Reformatter Reformatter Reformatter . . . . . . Radiology Discharge Summaries Laboratory

18. PalmCIS Architecture Secure Secure Wireless NYPH Network Clinical Data Internet Intranet Repository Wireless Device NYPH Secure Server

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

20. PalmCIS Server • Apache server • Thawte SSL Web server certificate

21. 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

22. 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)

23. PalmCIS Login

24. PalmCIS Patient Selection

25. PalmCIS Laboratory Results

26. PalmCIS Radiology Results

27. PalmCIS Summary Reports

28. PalmCIS Microbiology Reports

29. PalmCIS Cardiology Reports

30. PalmCIS etc…

31. Information Resources

32. 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

33. 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)

34. PalmCIS Infobutton: Culture Result

35. PalmCIS Infobutton: Sensitivity

36. 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

37. PalmCIS Shortcuts

38. Improve efficiency Impact of Shortcuts Log Files (control) Log Files (intervention) control intervention • Reduce back clicks • Optimize traversal paths

39. Improve efficiency Impact of Shortcuts Log Files (control) Log Files (intervention) • 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

40. Virtual Whiteboard • Identify team members and roles • Permit messaging between team members • Asynchronous communication • Palm-based and desk-based

41. Add Task Get Task

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

44. 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

45. 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

46. 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

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