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Getting Around With Hand-helds
Caregivers are beginning to turn to personal data assistants and other hand-held devices for easy, ubiquitous access to online health care data.
By Bill Briggs, Senior Editor
Mark Snyder,
M.D., never enters a patient exam room without his personal data assistant. The
orthopedic surgeon at Cincinnati-based Wellington Orthopaedic and Sports
Medicine enters patient histories into the PDA using preprogrammed templates
and drop-down menus. He later transfers the data to the organization’s personal
computer-based practice management system through a process called “hot sync.”
When placed in a cradle linked to a PC, the PDA automatically synchronizes all
data on the PC and PDA.
Snyder’s goal
is to improve patient care by gathering data that conforms to national
standards developed to aid in the process of outcomes measurement for total
joint replacement.
“In total
joint replacement, we have to prove that procedures are necessary and
beneficial,” he says. “In the past there were always attempts to collect
clinical data, and in recent years to collect outcomes data,” but those efforts
often fell short.
The right kind
of automation, Snyder contends, can help providers derive real benefits from
data collection. In early 2000, Snyder and a colleague began to collect,
manipulate and transfer patient care data via PDAs. Snyder’s PDA is a Palm,
made by Palm Inc.,
That’s a
marked improvement in a field where patient monitoring is a lifelong process,
but also one in which outcomes data collection hasn’t been the norm.
“Early
detection of problems can prevent catastrophic outcomes later,” Snyder says,
noting that only about 25% of the nation’s orthopedic practices collect
outcomes data. He attributes
Snyder is
among the first physicians to apply PDAs and other hand-held or pocket-size
devices in the patient care setting. More common uses for these hand-held
devices in health care include: scheduling and time management; serving as a
reference source for drugs; and, increasingly, generating electronic
prescriptions.
PDAs are in
more extensive use, industry observers say, by a growing number of physicians
and other caregivers who use them for their original purpose: as electronic
planners and address books. Experts disagree on whether the use of PDAs in
health care will evolve past these fundamental applications.
Many of the
same experts, however, agree that proliferation of PDAs in health care can help
break down barriers between clinicians and greater use of I.T. in general. And
the hand-held market’s potential already is fueling development of more
sophisticated PDAs and other small devices, such as “Web phones,” which combine
mobile phone technology and small screens capable of displaying e-mail messages
and stock quotes retrieved via the Internet.
Projections
The hand-held
market’s enormous potential has hardware, software and service vendors
salivating. Some 20% of physicians will be using hand-held devices for daily
transactions by 2004, predicts a report by WR Hambrecht & Co. Transactions
include writing prescriptions, checking lab results, dictating notes and
capturing charges. That level of use will translate into sales of $2 billion
for hand-held companies, estimates Josh Fisher, health care research analyst at
the San Francisco-based investment firm.
WR Hambrecht’s
projections are based on its estimate that, as of October 2000, 15% of
physicians used hand-held devices for reference purposes such as scheduling and
checking drug dosages. “It’s early, but we think use of PDA and hand-held
technology will be a huge trend,” Fisher says.
The key to
attaining such growth levels will be whether physicians and other clinicians
continue using PDAs only as reference tools and address books or expand into
transactions, Fisher says. “When they move to transactions, it will be a whole
different ballgame,” he says. “That’s where the opportunity is for more profits
and revenues.”
That pivotal
point in health care PDA evolution, however, is anything but a guarantee, many
experts say. “There will be a huge jump in the adoption of PDA technology,”
says Briggs Pille, vice president of e-architecture at FCG Doghouse,
The variety of
devices and applications in the market is an indication that users—and
developers—are far from consensus on the ideal apparatus.
“The market is
still spreading its wings,” he says, calling those currently using such devices
the “gadgeteers.” The devices are not in the mainstream yet and won’t be unless
there is a convergence of all the right technology into fewer appliances, he
contends, but not necessarily a single type of device.
The proof,
Pille and WR Hambrecht’s Fisher say, will be in the functions PDAs and other
hand-held devices perform. And Pille preaches caution when digesting research
estimates. “It’s been reported that 85% of physicians are using e-mail.
However, what percentage of those caregivers are using
e-mail to conduct business is not entirely clear,” he notes.
Other
observers are skeptical that complex transactions can be conducted on PDAs,
regardless of the caregiver’s desire. “Many physicians are using them, but I’m
not sure PDAs are robust enough for the data physicians need,” says Michael
Palmer, partner in charge of e-health in the
Many PDAs run
on the Palm OS operating system, which has limited memory capacity of two to
eight megabytes. Others use the Microsoft Windows CE operating system, which
features up to 32 megabytes of memory. Windows CE devices now are marketed
using the brand Pocket PC. Physicians today largely use PDAs for accessing
reference material such as an electronic Physicians’ Desk Reference, reading
online journal articles, and conducting simple transactions.
The most
common such transactions involve prescriptions, which can be tailored to a
physician’s specialty.
A growing
number of companies, including iScribe Inc.,
“The doctor
picks the drops and the system knows if it’s on the formulary; then the pharmacist
is no longer in the middle of the process,” Palmer says. The PDA then can be
placed in its cradle or docking station, from which it sends the prescription
to a printer to be faxed to the pharmacy, or sends it electronically to the
pharmacist’s fax number.
While many
PDAs use docking stations, some are designed as wireless devices that enable
real-time synchronization and transmission of information.
The process
has potential, Palmer adds, because it’s the first connectivity among payers,
physicians and pharmacies. “It avoids phone calls and callbacks, and in our
anecdotal studies, doctors find they get 20% fewer phone calls about their
prescriptions.”
The real test
of value is the next phase, Palmer says: To get more complex transactions on
the devices, including test orders and access to patient lab results, while the
physician conducts hospital rounds.
WR Hambrecht’s
Fisher agrees that cost and labor efficiencies brought by hand-held automation
will depend on the ability to conduct higher-level data transactions on PDAs
and other devices. But he believes the current, basic uses of the devices
portend greater things to come.
“The most
compelling evidence that this is a true trend is that doctors, for the first
time, are beginning to buy and use PDAs for managing contacts and looking into
drugs,” Fisher says. “By itself, that’s not much of a business, but as time
goes by, doctors likely will want to use these devices for more functions, such
as capturing charges, reviewing lab orders and dictating notes.”
Who uses them?
For now, the
list of caregivers using mobile technology includes physicians, and to a lesser
degree, nurses, therapists and other ancillary staff.
In addition to
physicians in general practice, specialists and surgeons, mobile technology is
reaching into more mobile fields of health care, including home health and
emergency services.
Caregivers in
the latter settings tend to use laptops and notebook computers because they
enter data and prefer devices with keyboards. Some industry observers, though,
believe next-generation hand-held devices, which more closely resemble PCs,
will help ambulance-based and other mobile caregivers make the transition to
the smaller, more portable PDAs.
Most
caregivers that use hand-held devices, however, do so for reasons other than
data entry, experts say. PDAs in particular are easy to use, create value and
save money, Fisher says. “The devices save physicians time spent flipping
through drug reference manuals and enable them to easily check schedules,” he
says. “These are the things that make their daily lives easier.”
Physicians
have other motives as well. “Doctors want to be perceived by patients and their
peers as being on the cutting edge,” Fisher says, “as keeping up with changes
in medicine and technology.”
But it’s time
savings and access to data that most caregivers seek when turning to hand-held
devices. For Snyder at Wellington Orthopaedic and Sports Medicine, it was a
combination of the two.
“We’ve done
time studies that show it takes less than five minutes per patient to enter
patient data into a PDA,” he says. “Plus, it fully integrates with the visit
and improves face-to-face communication,” Snyder adds.
Using the PDA
demonstrates to the patient that their information is being recorded for future
reference. Not only is Snyder’s patient data entered more accurately through
templates and other forms, it also now takes his research assistant less than
two minutes to “hot sync” a full week’s worth of data into the practice
management system. That enables her to spend more time analyzing data and less
time rounding it up from traditional paper-based sources, Snyder adds.
Wellington
Orthopaedic also expects to save money with the PDA-based system compared with
other options, Snyder says. “Normally, the data acquisition process is
extremely expensive,” he says. Between hardware and software, the cost for
mobile systems of the wireless local area network variety can top $25,000, he
adds.
By contrast,
Although
learning to use a PDA usually takes only a few minutes, Snyder and his research
assistant needed to invest time in the beginning to troubleshoot and work out
the system’s kinks. Both the hardware and software companies were extremely
cooperative during the implementation process, he adds.
For Snyder,
PDAs have made the data entry process easier and more complete. The next phase
for Wellington Orthopaedic, he says, is to develop macros—or miniature
applications—that will enable physicians to directly populate the practice’s
electronic medical records system, from Medic Computer Systems Inc., Raleigh,
N.C.
Data
collection is not the prime goal for all health care organizations, though.
Some have considerably more fundamental targets, such as introducing new
doctors to mobile technology.
Introductions
That was the
plan at the Naval Medical Center in Portsmouth, Va., says Brian N. Bowes, M.D.
Until November, when he transferred to the Marine base in Quantico, Va., Bowes
helped spearhead a program to bring Palms to Naval Medical Center staff.
“We got a
grant to buy 30 PDAs in May 1999,” he says. “The plan was to incorporate them
into graduate medical student education and to improve medical care. We wanted
to establish the devices in doctors’ training so they’ll be up to speed with
technology down the pike.”
The medical
center physicians use PDAs to store reference materials, medical algorithms,
flow sheets and frequently used pager numbers. Bowes declined to name the
source of the grant, but noted the point was somewhat moot: The Navy now is
supplying all new doctors with PDAs along with their uniforms upon entering
Officer Candidate School.
When combined
with physicians who purchased PDAs on their own, the total number of users at
the medical center is about 60, Bowes adds.
Funding of
mobile technology is one of the key issues in expanding the use of hand-held
devices and systems. Many institutions are reluctant to make the investment,
instead leaving the purchase of PDAs and other devices—like hand-held PCs and
cell phones—to the physicians. And many have already purchased their own PDAs,
says Palmer of Accenture.
“As usual, the
question is who pays for it,” Palmer says. “With PDAs, right now it’s the
physician; and that could continue. But as hand-held devices become more
complex, doctors will more frequently be asking who pays for it.”
Fisher of WR
Hambrecht says physicians should expect to foot some of the bill.
“There are two
schools of thought,” Fisher says. “One is that doctors won’t pay for the
devices. On the other hand, there are those who believe doctors should have a
stake in the game. The theory is to make them pay something, but ensure they
get a good return on their investment.”
Fisher
suggests a small monthly subscription charge of $50 to $100 for transactions,
including electronic prescribing, lab orders and charge capture. WR Hambrecht
estimates that subscription charges for such services now range from $100 to
$200 per month, and new hand-held devices cost $300 and up.
Itching to provide
Many
consultants say that there are willing third parties that are itching to
provide the devices to establish a link to physicians. For example, drug
companies are likely sponsors, Palmer says. “They have a huge desire to be in
the physician’s hand.”
The pharmacy
benefit management firms have the same desire, says Pille of FCG Doghouse.
“For companies
like Express Script and iScribe, their objective is to capture physician
mindsets,” he says. “The main way is through ‘point-of-prescription’ software,”
which the companies will provide along with the devices themselves."
At the other
end of the device sponsorship spectrum are hospitals, consultants say. “It’s
rare,” Palmer says. “Hospitals have not been eager to invest in hand-held
devices. There is no apparent problem that such devices are going to solve.”
Palmer does
qualify his observation, noting that some institutions are using mobile
technology in very targeted ways at the department or care unit level. Wireless
local area networks are more common in the hospital setting, although they also
are catching on in physician group practices.
Bucking the trend
In any case,
money is tight and few hospitals are willing to make the investment, some
consultants say. One institution that’s bucking the trend, though, is Memorial
Health System in Savannah, Ga.
Memorial
Health began providing Palms to 25 of its 350 physician employees in a pilot
program that began in November 2000, says Steve Stanic, vice president and CIO.
The delivery system includes a 600-bed hospital, home health services and a
managed care organization.
“We wanted to
make a commitment to the technology to make it easier for physicians to
practice medicine,” Stanic says. Memorial Health executives concluded that
hand-held devices would be the most efficient medium physicians could use when
making their rounds.
Currently,
doctors use PCs on carts for data entry. Physicians in the PDA pilot program
use a Web browser format in conjunction with browser-based software from
McKesson HBOC Inc., San Francisco.
The result is
a Web portal that combines data from the institution’s five administrative information
systems that can be synchronized when linked to the PDAs.
Phase two,
Stanic says, will be to integrate new PDAs with Memorial Health’s wireless
system from Proxim Inc., Mountain View, Calif.
The new PDAs
will be iPAQ devices from Compaq Computer Corp., Houston. “‘Hot syncing’ is
wonderful, but we want real-time access to data.”
Whether
wireless or synchronized, mobile access to patient health data raises the
security flag. Most systems are password protected, but few employ encryption
all the way down to the hand-held level, observers say.
Security
In addition to
the existing network security issues in any automated health care setting,
hand-held devices face the added risk of being lost or stolen, says Pille of
FCG Doghouse.
“People
typically are storing some files on hand-held devices,” he says. “So suddenly
you have potentially thousands of devices with data on them. That’s a big
concern.”
Security
concerns, however, will not quash the fast-growing PDA market. But because
mobile technology is so new, the winners among hand-held devices are difficult
to pick, industry observers say.
Many agree
that the technology will not reduce to one type of device, and instead likely
will include several winners. A major challenge will continue to be how to
integrate such devices into broader information systems in health care
organizations.
Pille and
others say that the Palm operating system is making great strides to compete
with Microsoft’s Windows CE operating system . While the Palm operating system paved
the way for PDAs, only time will tell if the Palm OS or Windows CE wins the
long-term battle for market share.