Dec. 7, 2006 | TECHNOLOGY UPDATE: Even though adoption of electronic health records (EHR) and other clinical IT remains fairly anemic, at least one aspect of health-IT has taken giant steps forward in the last few years: the use of mobile and wireless technology where choices are proliferating.
"This really is the third generation of wireless in healthcare," says Neil Martin, M.D., chief of neurosurgery at the David Geffen School of Medicine at the University of California, Los Angeles. Doctors and other healthcare professionals have progressed from pagers to basic cell phones and now to data-enabled "smartphones."
Remember personal digital assistants (PDAs) with docks or infrared beams for synching? That is soooo Y2K. Even Wi-Fi cards for laptop computers have started to seem dated.
"We've seen evolution from cradle synching," says Mireille Gotsis, a Redmond, Wash.-based healthcare industry manager for Cingular Wireless (Atlanta). Physicians have been trading in their old, disconnected PDAs for modern PDA smartphones with cellular integration and built-in Wi-Fi and Bluetooth wireless functionality for use within the clinical environment.
"Now everyone is looking at the shiny, new devices that provide those integrated capabilities," Gotsis says. "You try to reach the physician or the clinician wherever they are."
And practitioners want to be reached. "As a neurosurgeon, I'm all over the hospital," Martin says. "I guess I'm the ultimate mobile professional." And he needs more than vmail. Martin needs access to images when consulting on patients in critical care.
An MRI or CT scan viewed on a PDA or smartphone may not be diagnostic-quality for a radiologist, but for a neurosurgeon or other specialist helping to treat life-threatening emergencies, the resolution is just fine, according to Martin. He says that a smartphone screen just happens to be about the size of one square of a 12-image MRI film, which is good enough for him.
"We're not looking for tiny things when we're called about changes to patients in intensive care," Martin says. "The issue is not: Will you miss some tiny details? The issue is: Can you access the information when you get called from the ER? There's got to be a real-time way to get the information."
With his all-in-one mobile device, Martin can look at EKG wave forms from afar, not just lab reports, allowing him to alert the operating room that a patient is on the way. "It shortens the decision cycle," Martin says.
"It eliminates unnecessary trips to the hospital," he says. In congested southern California traffic, that is an important plus.
As the hardware has progressed, so has the network infrastructure behind it. It has been possible for years to connect a cell phone to a computer modem and get dial-up Internet access from just about anywhere, but anyone who has cable or DSL Internet service at home knows how painfully slow a 56-kilobit-per-second (kbps) dial-up connection can be.
Three years ago, it used to take 30 seconds to transfer an image over cellular airwaves. By next year, Martin expects download time to shrink to a mere 3 seconds, thanks to a new generation of wireless broadband technology. "Now the technology that we envisioned years ago is feasible," says Martin, who also is chief medical officer and co-founder of Global Care Quest, a mobile healthcare software developer in Aliso Viejo, Calif.
He says that the networks of Verizon Wireless and Sprint Nextel have been upgraded tremendously, based on a data-transmission protocol known as Evolution Data Optimized (EVDO).
Late last month, Sprint upgraded its broadband network by debuting EVDO Revision A in the San Diego area, and the company announced plans to add 20 additional markets by year's end and to have the fast data exchange available nationwide by the third quarter of 2007.
Revision A of the technology increases download speed slightly, to about 450-800 kbps, but accelerates upload speed to 300-400 kbps, roughly six times faster than the previous range. Peak download speed might "burst" as high as 3.1 megabits per second and uploads to 1.8 Mbps, according to Verizon and technology partner Nortel. Verizon has not said when it intends to move to Revision A.
"That's going to give us DSL speed over a cellular network," Martin raves.
For its part, Cingular has high-speed data networks in 52 metropolitan areas using a protocol known as Universal Mobile Telephone System/High Speed Downlink Packet Access (UMTS/HSDPA). These networks deliver sustained download speeds of 400-700 kbps, with bursts topping 1 Mbps.
Something as fast as home DSL certainly can't compete with a well-developed hospital network, but speed is relative. In the hospital, physicians would stop using wireless devices if it took a several seconds to pull up an image. "If you're sitting in a restaurant a half-hour from the hospital, taking 10 seconds doesn't seem so bad," Martin says.
One challenge is easing the transition between wide-area networks like cellular broadband and local-area networks such as a Wi-Fi hot spot, Gotsis says. She mentions a Seattle-based company called NetMotion Wireless that has developed a mobile virtual private network (VPN) specifically for healthcare and public-safety usage to smooth the handoff between wireless WAN and LAN environments.
Earlier this year, Cingular launched Office Reach a product that connects wireless devices to existing PBX telephone systems, enabling a cell phone to work like just another internal phone extension. "We've seen quite a bit of interest there," Gotsis says.
Soon, cellular data networks will be able to detect a user's presence on a VPN. If a user is busy updating records, that person is not immediately available for another appointment. "This really helps with the scheduling of a homecare nurse," Gotsis says.
Cingular also is testing an Internet-based technology called IP Media Subsystem (IMS), which will enable the simultaneous transmission of voice and data; for example, someone in a hospital could send images and test results to a remote, consulting physician. If the doctor has a nearby computer with Bluetooth connectivity, the cell phone could function as a modem while the doctor is talking.
Region-by-region introduction of this is planned starting in 2007, Gotsis says.
Laying the groundwork for such future innovations, the University of Chicago Hospitals installed a comprehensive wireless infrastructure, covering about 95 percent of its campus -- including the hallways, stairwells and elevators in its older buildings -- on multiple frequencies.
Even cell signals are now as strong deep inside aging buildings as they are in the university's gleaming, new children's hospital. "We also found that our pagers and radios work flawlessly," says vice president and chief information officer Eric Yablonka.
"Mobility within the building is critical," Yablonka explains. The hospital has replaced its old paging system with wireless IP phones for those on the move. The floors are quieter and clinician response is quicker. "And the nurses love it," Yablonka adds.
Campus security is wireless-enabled, and some other building functions such as lighting and HVAC could go wireless if management wanted to make the switch, Yablonka says. The infrastructure is secure and robust enough that Yablonka is comfortable providing wireless Internet access to patients and visitors on a segmented part of the network that does not compete with critical hospital systems.
"This is a disruptive, enabling technology," he says. In this case, disruptive is a positive in that it challenges old, inefficient ways of doing things.
That is exactly the way it should be, suggests Intel senior healthcare strategist Ron Ribitzky, M.D. "Mobility by itself is not a panacea for the delivery of data," Ribitzky said in a recent Webcast organized by ambulatory electronic medical records (EMR) vendor Allscripts. Mobility merely enables delivery.
"If we don't understand the business proposition, it will not work," Ribitzky says. What is the desired outcome of IT investment? It could be financial, it could be clinical quality improvement, or it could be workflow optimization to enable outcomes measurement.
In his view, mobility has three components: tagging, moving, and connecting. Tagging is the ability to identify and account for what is moving, Ribitzky says. "The key point is to enable people to connect to the data from wherever they are."
For Albert Einstein Healthcare Network, part of Jefferson Health System in Philadelphia, the goal of IT was more accurate charge capture and better communication between more than two dozen sites.
Each of the 60 clinicians carries a Hewlett-Packard iPaq PDA loaded with an Allscripts e-prescribing module and linked to an IDX scheduling system. Built-in wireless connectivity permits charge capture at the point of care.
The practice created "exploding sets" that open up custom templates and populate multiple data fields as a physician clicks on a particular procedure or order. "We are much less likely to miss [charges for] procedures that are being done," explains medical director Julie Massey, M.D.
The prescribing component connects in real time to payer formularies, provides interaction alerts, and can learn physician "favorites" to save time in the future. The system also gives practitioners routine clinical reminders for specific types of patient visits.
Massey reports that physicians initially were reluctant to take over charge capture from office staff, and it often takes a couple of months for new doctors to program their preferred medications into the system. "Once they get over that learning hump, physicians love it," Massey claims. They no longer have to fill out paper encounter slips, and the bills are submitted electronically so claims are cleaner.
And there's another side benefit of the mobile devices. "Our kids, in particular, just love us carrying around our iPaqs," says Massey, a pediatrician.
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