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Getting
Around With Hand-helds |
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By Bill Briggs, Senior Editor ,
Health Data Management |
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., Santa Clara,
Calif. 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 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, 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 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 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.
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 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, 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.
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.
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.
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.
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
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