Just when you thought it might be safe for your facility to consider jumping into the e-commerce pool, along comes m-commerce. The "m" is for mobile. With the Jaws theme song playing in the background, every CIO is being reminded that he or she better gear up quickly for mobile device access to everything. The Internet has now become simply the transport layer for cell phones, pagers and personal digital assistants (PDAs) to access the wealth of information on the web. While the advertising and media focus is centered on mobile access to stock quotes, sports scores, weather and horoscopes, it won't be long before the physicians, executives and others in your organization are asking for wireless access to your healthcare databases. And you won't be able to use HIPAA as an excuse.
The technology has arrived and with it, new learning curves. New acronyms abound: WAP, WML, HDML, PQA, UP, ECC, WTLS, CDPD. New terms: web clipping, micro-browser, mobile IP, transcoding are popping up daily to deal with the rapidly developing mobile access toolkit. Plenty of companies, new and old, are touting their solutions - Palm, IBM, Symbian, Aether, 724 Solutions, Transmeta, Oracle, Sybase, Microsoft, EDS and many more. As is generally the case with new technologies, there are no clear winners in the race to establish standards.
Fortunately, the wireless crowd has not ignored the success of the Internet and its underlying technologies. Whether your wireless device of choice is a phone, a PDA or a pager, odds are the language it understands will be a variant of HTML (HyperText Markup Language), the language of the wired web. This means that you are creating web sites to serve wireless device needs. Not the same site that you already have, mind you. You will need an additional site or sites that serve up HTML-like information in a format specific to the device being used. WinCE devices will show what you have today but it won't look right. Palm's require basic HTML (i.e. no script language) in little bites. Phones require WML or HDML in littler bites.
Web clipping is a technology created by Palm for its Palm VII wireless PDA. With Palm holding about 80% of the PDA market, web clipping is emerging as a de facto standard. Web clipping enables the Palm VII to send and receive small chunks of bare-bones HTML to and from the Internet. The received HTML cannot contain any scripting language (JAVA, VBScript, etc.). The Palm VII utilizes the Bell South Mobitex pager network for its wireless capabilities. A monthly subscription to Palm.net is required. Pricing varies based upon kilobytes transmitted (or a subscriber can choose an unlimited use plan). The pager network has an advantage over cellular technology because of the lack of interference with telemetry and other hardware inside hospitals. Palm's security approach is outstanding with 163-bit encryption, message integrity checking and unique device IDs per Palm device. There is a minor security issue with data that resides in the Palm browser's history cache but the Palm can be "locked" to prevent unintended user access.
Microsoft's WinCE devices, conversely, serve up the web using a shrunken version of the Internet Explorer browser software displaying standard HTML, with full client side scripting support. This means that existing web sites can be viewed on a WinCE device. Be prepared for lots of scrolling, however, until the new Pocket Internet Explorer is released this summer. The wireless connectivity requires a CDPD (Cellular Digital Packet Data) modem and an account with Bell Atlantic or some other carrier. Pricing varies based upon usage and you have to be careful about cellular interference inside the hospital. Security is built upon SSL (Secure Sockets Layer) which is the same technology in use today for secure e-commerce transactions.
WML (Wireless Markup Language), HDML (Handheld Device Markup Language) and WTLS (Wireless Transaction Layer Security) are standards espoused by the WAP (Wireless Application Protocol) camp. WAP is currently supported on Internet enabled phones. These phones are just starting to appear with additional costs from Bell Atlantic of about $10 a month. While a phone is a great verbal communication device, its 3 to 4 line by 11 to 12 column display makes it hard to use in healthcare's text-based world. The word "hemoglobin" barely fits on 1 line! Not to mention that phones are data-input challenged. Pressing the number keys 1- 4 times each for entering letters gets old fast. Of course the phone manufacturers are not sitting idly by letting Palm grab the whole PDA market. Check out the new device from Symbian code-named "Quartz." Its being hyped as the Holy Grail of mobile devices we all have been waiting for. And don't expect the Internet enabled phone market to really take off until something like Quartz appears.
So what should you do? Well if you have learned anything from the Internet development craze in the late 90's, experience says that you should not wait around for your competitors to do it first. So pick a device platform or two, a vendor partner to help develop it, put together an internal team to lead the project and start learning. Consider these pilot applications, for example:
- The physicians on staff or with admitting privileges need mobile access to their patient census with the ability to view results, orders, and meds. Perhaps they could enter visit charges, place and revise orders, enter prescriptions, etc.
- The hospital administration staff needs the ability to quickly and wirelessly lookup summary information on patients when responding to patient complaints or concerns.
- The home health nurses need to view their schedules, get directions to their next visit, and record their progress notes and visit charges.
Here are just some of the challenges and opportunities you will face:
How do you justify the cost to upper management?The per user costs will range from $1,000 of startup and $30 - $50 per month for wireless access. The costs to build the application will vary. In today's tight labor market it may be best to look for a WASP (Wireless Application Service Provider) that can offer an end-to-end solution including user startup, application development, training and help desk support for a monthly fee.
Regardless of the expense, the cost of not going wireless could be substantial. It is inevitable that physicians will soon demand wireless access to your facility's information infrastructure. If those physicians can wirelessly access your close competitor's clinical system, in-house pharmacy and lab but not yours, which facility do you think they will prefer to admit patients to?
What group of users will make for a good pilot project?As is generally the case, you will want to select a group of potential users that are committed to the new technology (i.e. gadget lovers) and are creative enough to see the long-term potential while patient enough to put up with the usual problems all new technologies have. As you will see when you visit the industry web sites listed at the end of this article, physicians are falling in love with PDAs. Because of this phenomenon they may be a good group to start with. Select some top admitters to your facility, build a working group, meet often and use an iterative development approach to keep them interested.
Where do you find the technology experience and tools?The device vendor's web sites provide many of the tools and information you will need to get started. Since the underlying technologies are similar to those behind any web projects you have underway, look to those project teams for help also. If you are in a hurry, get external help.
What will you need in the way of infrastructure?If you have high speed connections to the Internet with necessary firewalls and security, you are all almost there. Creating a wireless format web site on your current web server will work perfectly. You will most likely need to add security technology (e.g. SSL) and server side application management software.
What application challenges will you face?Providing wireless access to your existing systems will be relatively easy if they are already client/server or better yet, web (Intranet) based. You will be able to easily get to the underlying SQL database and format the data for PDA viewing. Cedars Sinai Medical Center, for example, recently deployed Palm VIIs with read-only access to patient information, email, a physician directory, paging access to their medical library. Because Cedars had an Oracle and Web based system already in place, it was only a matter of days to develop wireless access.
However, if you are like most facilities and have not made the switch to client/server, your job will be tougher. Your options are to wait for your vendor(s) to provide a solution on the wireless platform of choice or look for a third party solution provider that has developed wireless connectivity to the various vendor systems. For those who have a vendor supplied client/server system in place there is still a reliance on the vendor to provide an input interface to the client/server database.
If the prospect of wireless access to healthcare information conjures up an image of Star Trek's Dr. McCoy with his Tricorder, do not fear. We are still have a way to go to achieve that kind of power. But with the way technology is changing, it is not as far as you think. Give it a try. Won't it feel great to look back over your career and say to the next generation that you were part of the wireless revolution?
For more information on the wireless world, check out these sources:
Industry Followers- InfoWorld, February 28, 2000
- www.pdamd.com
Technology Vendors
- www.palm.com
- www.phone.com
- www.symbian.com
- www.microsoft.com
Brian Wells (bpwells@intehealth.com) is currently the President and Chief Technology Officer of InteHealth Incorporated, a company he founded in 1997. InteHealth's focus is the development and support of software products and WASP services that integrate legacy systems with today's leading edge wireless and e-commerce technology. Prior to founding InteHealth, Brian was the CIO at GMIS Inc. Brian also spent 9 years at SMS developing and supporting IBM mainframe HIS applications. He has an MBA from Villanova and a Computer Systems degree from RIT.