This article is reprinted with permission from Health Data Management. Health Data Management is a comprehensive, credible source of information on every aspect of health care information technology. The monthly magazine provides in-depth analysis of the latest trends in using automation to make health care delivery more efficient.
Bill Briggs is a Senior Editor at Health Data Management.
Caregivers are beginning to turn to personal data assistants and other handheld devices for easy, ubiquitous access to online health care data.
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 HotSync. 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., Santa Clara, Calif. The PDA-based software that manages the data was developed by Pendragon Software Corp., Libertyville, Ill. The result of Wellington Orthopaedic's hand-held initiative is that 92% of the practice's patients today receive very thorough and up-to-date follow-up, Snyder says.
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 Wellington's success rate "not only to our energy and enthusiasm but also to the ease of using a PDA."
Snyder is among the first physicians to apply PDAs and other handheld or pocket-size devices in the patient care setting. More common uses for these handheld 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.
ProjectionsThe hand-held market's enormous potential has hardware, software and service vendors salivating. Some 20% of physicians will be using handheld 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 handheld 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 handheld devices for reference purposes such as scheduling and checking drug dosages. "It's early, but we think use of PDA and handheld 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, Denver, a subsidiary of Long Beach, Calif.-based First Consulting Group. "What is not so clear, though, is the adoption rate of using PDAs for specific, significant applications."
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 handheld devices perform. And Pille preaches caution when digesting research estimates. "It's been reported that 85% of physicians are using email. However, what percentage of those caregivers are using email 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 Boston office of Accenture, formerly Andersen Consulting.
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., San Mateo, Calif., Express Scripts Inc., Maryland Heights, Mo., and Allscripts, Libertyville, Ill., provide software for PDA-based prescriptions. For example, a pediatrician might always select from a list of the same 10 to 20 drugs every time he or she prescribes eardrops, Palmer explains. The PDA will display a list of the drugs and identify those on a particular payer's drug formulary.
"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 handheld 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 handheld 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 handheld 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 HotSync 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, Wellington's initial investment was less than $1,000 for software and two PDAs. Several members of the practice's staff also use the PDAs and assist in collecting patient data, Snyder explains.
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.
IntroductionsThat 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 handheld devices and systems. Many institutions are reluctant to make the investment, instead leaving the purchase of PDAs and other devices--like handheld 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 handheld 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 handheld devices cost $300 and up.
Itching to ProvideMany 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 handheld 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 TrendIn 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 handheld 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 handheld level, observers say.
SecurityIn addition to the existing network security issues in any automated health care setting, handheld 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 handheld 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.