palm-based wireless computing to improve access to health information and coordination of care
DESCRIPTION
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?. - PowerPoint PPT PresentationTRANSCRIPT
Palm-based Wireless Computing to Improve Access to Health Information
and Coordination of Care
James J. Cimino, M.DDepartment of Biomedical Informatics
Columbia UniversityNew York Presbyterian Hospital
Broward General Medical Center Grand RoundsJuly 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?
• 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
Physician Team
Intra-teamCommunication
Nursing Team
Inter-teamCommunication
Intra-teamCommunication
Interaction with ClinicalInformation System
InformationResources
InformationNeeds
Hand-Held Devices Choices
• Linux– Sharp
• PalmOS– Palm, Handspring, Sony
• PalmOS+Phone– Kyocera, Samsung, Handspring
• PocketPC– Compaq
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
• Mobile• Personal• Replace multiple devices• Replaces paper resources• Nomadic data capture
Wireless Handheld Solutions Disadvantages
• 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 HospitalClinical Information Systems Architecture
Clinical Database
Medical Entities Dictionary
Database Monitor
Medical Logic Modules WebCIS
. . .. . .Radiology LaboratoryDischarge
Summaries
Research
Administrative
Alerts & RemindersDatabaseInterface
Reformatter Reformatter Reformatter
WebCIS
• Web-based front end to legacy database• Medical Entities Dictionary (MED)
– Translation– Class-based queries
• Patient DepartmentReport headerDetails• Summary reports• Links to health resources• Infobuttons• Patient lists
New York Presbyterian HospitalClinical Information Systems Architecture
Clinical Database
Medical Entities Dictionary
Database Monitor
Medical Logic Modules WebCIS
. . .. . .Radiology LaboratoryDischarge
Summaries
Research
Administrative
Alerts & RemindersDatabaseInterface
Reformatter Reformatter Reformatter
PalmCIS
PalmCIS Architecture
NYPH Clinical Data Repository
NYPH Secure Server
Secure
Internet Intranet
Wireless Device
Wireless Network
Secure
PalmCIS Client
• Kyocera QCP 6035 Smartphone or Treo 650• EudoraWeb browser• SprintPCS wireless service• End-to-end SSL encryption
PalmCIS Server Application
• 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-listDepartmentReport headersDetails
Security
• 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)
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)
Navigational Issues
• Trade-off: data per page versus click-to-data ratio• Minimum required information versus fewest clicks• DetailsDepartmentHeaderDetails 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
Impact of Shortcuts
• Improve efficiency
• Reduce back clicks
• Optimize traversal paths
Log Files(control)
Log Files(intervention)
control intervention
Impact of Shortcuts
• Improve efficiency
• Reduce back clicks
• Optimize traversal paths
• Benefits– Facilitate access to
information– Assist in answering patient-
specific questions– Serve as reminders of what to
look at and patient problems
Log Files(control)
Log Files(intervention)
Virtual Whiteboard
• Identify team members and roles• Permit messaging between team members• Asynchronous communication• Palm-based and desk-based
Cost
• 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