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Mobile Technologies in HealthcareImplementation Techniques and Considerations
Ellen DaleyVice President of TechnologyArcStream Solutions
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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
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Wireless vs. Mobile
Always Connected,Live Data
Disconnected,Synchronization
Wireless Mobile
<< sync >>
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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
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Cell PhonesVoice & Data
Two- way PagersLaptop / Tablets
PDA/HandheldPocketPC & Palm
Many Different Devices
Smart Phones/Convergent Devices
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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
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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
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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
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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
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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
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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
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New Converged Devices Are Being Introduced Daily
Source: Forrester Research
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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
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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)
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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)
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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
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High-Level Development Options
Browser Client Application Client
Palm OS Windows CE
Database
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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
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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
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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)
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Application Development: PocketPCMS eMbedded Visual C++MS eMbedded VB– Currently Interpreted
AppForge– Press to compile (Palm / PPC)– Visual Basic Integrated– Large Runtime (600k)
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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
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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
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Connection Types Devices can be connected using various, multiple sources:– IR Sync– Wireless LAN (802.11)– Bluetooth– Network Carriers
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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
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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
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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
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Carriers
Carriers are differentiated by:
CoverageCoverage
Hardware costs and characteristics
Speed
Connectivity options
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Broad Coverage Wireless NetworksWhat does the network look like
Note – VoiceStream has intermittent coveragein the metro regions of these states, coverage is not complete
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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
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What can you do with the networks in place?
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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
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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.)
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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
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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
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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
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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
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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
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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
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Manageability
Key features include:
Remote software distributionRemote kill of a devicePassword managementFull end-to-end network managementTotal device monitoring
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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…
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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
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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
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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
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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
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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
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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
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Thank You!
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Speaker Bio
Ellen Daley is the Vice President of Technology at ArcStream Solutions.You can contact her at edaley@arcstream.com
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