Transcript 2005-Broward-Palm-based Wireless Computing to Improve Access

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?
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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
Interaction with Clinical
Information System
Information
Resources
Information
Needs
Inter-team
Communication
Intra-team
Communication
Physician Team
Intra-team
Communication
Nursing Team
Where We Want to Go
Information
Resources
Infobuttons
Physician Team
Virtual
Whiteboard
Nursing Team
Hand-Held Devices Choices
• PocketPC
– Compaq
• Linux
– Sharp
• PalmOS
– Palm, Handspring, Sony
• PalmOS+Phone
– Kyocera, Samsung, Handspring
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 802.11
• Wireless WAN
– Omnisky (EarthLink), Palm.Net
– SprintPCS, Verizon
Wireless Handheld Solutions
Advantages
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Mobile
Personal
Replace multiple devices
Replaces paper resources
Nomadic data capture
Wireless Handheld Solutions
Disadvantages
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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
Medical Logic
Modules
WebCIS
Clinical Database
Database Monitor
Alerts & Reminders
Database
Interface
Medical Entities
Dictionary
Administrative
Research
Reformatter
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Radiology
Reformatter
Discharge
Summaries
Reformatter
Laboratory
...
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
Medical Logic
Modules
WebCIS
Clinical Database
PalmCIS
Database Monitor
Alerts & Reminders
Database
Interface
Medical Entities
Dictionary
Administrative
Research
Reformatter
...
Radiology
Reformatter
Discharge
Summaries
Reformatter
Laboratory
...
PalmCIS Architecture
Secure
Secure
Wireless
Network
Wireless Device
Internet
Intranet
NYPH Secure
Server
NYPH
Clinical Data
Repository
PalmCIS Client
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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
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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
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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)
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
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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
Log Files
(control)
Log Files
(intervention)
control
• Reduce back clicks
• Optimize traversal paths
intervention
Impact of Shortcuts
• Improve efficiency
Log Files
(control)
Log Files
(intervention)
• Reduce back clicks
• Optimize traversal paths
• Benefits
– Facilitate access to
information
– Assist in answering patientspecific questions
– Serve as reminders of what to
look at and patient problems
Virtual Whiteboard
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Identify team members and roles
Permit messaging between team members
Asynchronous communication
Palm-based and desk-based
Add Task
Get Task
Cost
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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
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Elizabeth Chen, PhD
Jianbo Lei, MD, MA
Larry McKnight, MD
National Library of Medicine Training Grant