Mobile Healthcare

Unless you’ve been comatose for a while, you’ve certainly heard about the Apple iPad. The device has already been crowned the de facto device for everything from e-reading to creating a new wave in healthcare unlike anything we’ve ever seen. Of course this is all speculation as the device hasn’t been officially released yet.

Many people have speculated that the iPad will be a great device for healthcare. Whether or not that will be the case remains to be seen. One thing is for certain: everyone is banking on the iPad being a big hit in healthcare. Based on the success of the iPhone as a favorite among physicians and nurses, this certainly isn’t a wild prediction. Will this success translate to the pharmacy? Good question.

I spent some time yesterday talking with some good people over at Pharmacy OneSource about pharmacy technology, clinical decision support, data mining, and a whole bunch of other interesting items. During one point of a conversations the history of Pharmacy OneSource came up. Part of that history includes the merger of Pharmacy OneSource with HealthProLink (HPL) sometime in late 2005.

The mention of HealthProLink (HPL) brought back fond memories of a time when pharmacy informatics was really starting to take off and I was infatuated with the Palm Pilot <insert flashback sequence here>. HPL was a set of software tools for collecting and quantifying pharmacist intervention data as well as ADR/ADE information. In addition, the application offered access to several clinical calculators and a fairly robust reporting system. I was part of the implementation team for HPL when I worked at Community Medical Centers – Fresno and used it daily for a couple of years.

This was also a time when Palm Pilots were all the rage and every pharmacist I knew carried one in their lab coat pocket. The Palm OS was a stroke of genius because of its minimalistic approach to the user interface. Anyone could pick up a device using the Palm OS and figure out how to use it in a matter of minutes. They were a model of simplicity and functionality. In addition, several development environments were available for application development as well as several “readers” and database applications. This led to the development of hundreds of medical references, medical calculators, free and commercial peripheral brains and countless ways to track patients, labs, and medications available for devices running the Palm OS. It is the only time in my career as a pharmacist that the entire profession embraced a new technology and used it to their advantage. The literature was full of “studies” using handheld devices for documenting clinical interventions^1-4, carrying individually created documents and “peripheral brains”^5,6 performing pharmacokinetic calculations, accessing drug information and performing drug interaction checking.^7-12 The entire handheld movement was quite impressive to watch.

From Implementation Science 2009 Sep 25;4:62:

Abstract:

BACKGROUND: Health information technology and electronic medical records (EMRs) are potentially powerful systems-based interventions to facilitate diagnosis and treatment because they ensure the delivery of key new findings and other health related information to the practitioner. However, effective communication involves more than just information transfer; despite a state of the art EMR system, communication breakdowns can still occur. 123 In this project, we will adapt a model developed by the Systems Engineering Initiative for Patient Safety (SEIPS) to understand and improve the relationship between work systems and processes of care involved with electronic communication in EMRs. We plan to study three communication activities in the Veterans Health Administration's (VA) EMR: electronic communication of abnormal imaging and laboratory test results via automated notifications (i.e., alerts); electronic referral requests; and provider-to-pharmacy communication via computerized provider order entry (CPOE). AIM: Our specific aim is to propose a protocol to evaluate the systems and processes affecting outcomes of electronic communication in the computerized patient record system (related to diagnostic test results, electronic referral requests, and CPOE prescriptions) using a human factors engineering approach, and hence guide the development of interventions for work system redesign. DESIGN: This research will consist of multiple qualitative methods of task analysis to identify potential sources of error related to diagnostic test result alerts, electronic referral requests, and CPOE; this will be followed by a series of focus groups to identify barriers, facilitators, and suggestions for improving the electronic communication system. Transcripts from all task analyses and focus groups will be analyzed using methods adapted from grounded theory and content analysis.

Although the information in the article is only a design concept, it is still worth reading. Concepts like these could be useful for many outpatient as well as many inpatient alerts; labs that are outside normal parameters, results from blood tests, incorrect antibiotic choice following culture results, etc. With the advances in mobile technology, especially mobile communication devices, this is worth serious consideration

The Palmdoc Chronicles:” I’ve had a Palm Pre for about 2 months now and I can declare that the device has seen tremendous improvement with firmware updates (pushed OTA) and a steadily increasing amount of useful applications in the Palm App Catalog and the unofficial Homebrew scene.

How usable is it as an smartphone for doctors? Well I can say it pretty much does replace your old PalmOS device as it is. One of the cool features of the old Palm PDAs is the ability to keep snippets of information in the Memos (Notes) in various categories for instant recall. These notes may be protocols, clinical pearls or practically any bits of information which you want to look up while rounding for instance.

WebOS’ builtin “post-it” type Memos is ok if you are keeping about 10-20 notes but pretty useless if you are talking about 300-500 notes or more. There are several solutions at hand which overcome this limitation.”

“After three months of rumors, details surrounding Epic Systems’ partnership with Apple for a mobile phone-based electronic health record (EHR) application have come to light: Just a few days ago, Epic System’s iPhone application, called Haiku, became available on Apple’s AppStore. Haiku provides authorized clinical users of Epic’s Electronic Health Record with secure access to clinic schedules, hospital patient lists, health summaries, test results and notes. Haiku also supports dictation and In Basket access. Haiku works on both the iPhone and iPod touch,” according to the app’s description on the AppStore.”

This is a very interesting turn of events as rumors regarding Apples new tablet entering the healthcare arena have been swirling around the internet. Could Haiku be the precursor to what we’ll see with the Apple tablet? I sure hope so.

Source

I read an interesting blog today. In the blog the author states that:

An Apple tablet would be the ultimate UI for electronic medical records. With a touch-screen display like the iPhone, using the EMR during an encounter would be simplified. For example, selecting an evaluation and management (E&M) code could be as easy as “dialing in” the code with a swipe of a finger.

Using the iPhone’s intelligent keyboard technology, the device could have a very sophisticated automatic coding tool. Some EMRs can already auto-generate E&M codes based on information collected during the patient encounter. Combine this with the iPhone’s keyboard word suggestion tool, and physicians could rapidly select codes. Additionally, just as the iPhone adapts its keys and layout for different applications, the Mac Tablet could display a unique keyboard setting for each EMR function.

Using iPhone speech recognition technology, physicians could dictate directly into an EMR to create notes, draft narrative reports or generate custom patient instructions. Mac design programs could be repurposed to make a really slick tablet drawing tool for anatomical diagrams that illustrate procedures and diagnoses.

There is no question that I think tablets are underutilized in healthcare. I have pushed them into the hands of pharmacists at my facility and have tried various different things to encourage their use. While I would love to see tablet computers adopted in mass among healthcare systems, I just don't think it's in the cards for the iSlate for several reasons.

Like many pharmacists I read a lot of journal articles. This is especially true because of the dual role I play at my hospital. It’s not uncommon for me to read a couple of articles a day through the week and a few more thrown in on the weekend. The articles come from various medical and technology journals that I regularly visit plus the occasional article recommended by a friend or colleague. I still receive some journals in hard copy, but many now arrive electronically. Because I look into a computer screen 12-14 hours a day, I’m not particularly fond of reading articles on my laptop or tablet pc; it gives me a headache. As I’ve said many times, looking at a normal LCD monitor is like looking into a flashlight. Instead of reading PDFs on my computer I print them out and take them with me wherever I go (I can hear the collective moan from the conservationists in the crowd; sorry). This kind of defeats the purpose of having electronic documentation and certainly isn't very "green". With that said, advances in e-ink technology and e-reading devices may change my approach.

I’ve been waiting for an e-reader that will allow me to read PDF files without having to zoom in and out or dance around the screen. I've tried reading on my Droid and my iPod Touch, and while possible, I wouldn't want to do it for an extended period of time. It's just not convenient.

The Kindle DX was the first e-reader to hit the market with a screen big enough to accommodate my needs, and it was my front runner for quite a while. However, before dropping $500 on the DX I wanted to see some of the new devices that have been “on their way” since early 2009. Some of these devices are listed below.

The Impact of Mobile Handheld Technology on Hospital Physicians' Work Practices and Patient Care: A Systematic Review¹

The Journal of the American Medical Informatics Association
Mirela Prgomet, Andrew Georgiou, Johanna I Westbrook

Abstract

The substantial growth in mobile handheld technologies has heralded the opportunity to provide physicians with access to information, resources, and people at the right time and place. But is this technology delivering the benefits to workflow and patient care promised by increased mobility? The authors conducted a systematic review to examine evidence regarding the impact of mobile handheld technology on hospital physicians' work practices and patient care, focusing on quantification of the espoused virtues of mobile technologies. The authors identified thirteen studies that demonstrated the ability of personal digital assistants (PDAs) to positively impact on areas of rapid response, error prevention, and data management and accessibility. The use of PDAs demonstrates the greatest benefits in contexts where time is a critical factor and a rapid response crucial. However, the extent to which these devices improved outcomes and workflow efficiencies because of their mobility was largely absent from the literature. The paucity of evidence calls for much needed future research that asks explicit questions about the impact the mobility of devices has on work practices and outcomes.

This weeks cool technology comes by way of a comment left at RxInformatics.com in response to a recent post I wrote on smartphones and pharmacy practice.

The author of the comment, @pillguy, is an iPhone fanboy and pharmacy technology guru.

@pillguy: “The iPhone certainly has some promising applications related to EHRs. Airstrip is one of the coolest I have seen.

The smartphone takes PDAs to the next level with access to realtime information. I can see a TheraDoc, Pharmacy OneSource, or Zynx type clinical monitoring/alerting app fit in with the Airstrip suite nicely.”

It’s no secret that I’m a big fan of tablet PCs. In fact, I can’t imagine life without one. The reason why acute care pharmacists haven't adopted the tablet PC platform escapes me. My complete opinion on the matter can be found here.

With the growing need for real-time access to patient data it no longer makes sense to be anchored to a desktop PC at the point-of-care. Couple this with the rapid growth of portable technology and you have a rare opportunity to develop a mobile pharmacy practice in the acute care setting. Whether that model will utilize tablet PCs, UMPCs, WebStations, netbooks or other mobile device remains to be seen.

Recently I was fortunate enough to be a beta tester for the new Android version of Lexi-Comp's suite of medical information software. I was very excited for the opportunity as I've been using what I would consider inferior drug information resources since purchasing my Droid about a month ago. The installation was a problem initially as the databases wouldn't install directly to the microSD card on the Droid. As you can imagine, the databases are large and immediately filled up the physical memory on the device. Within a couple of weeks of reporting the problem to Lexi-Comp they had corrected the issue and sent me a new build that installed seamlessly.

RTT News: “3M Health Information Systems has released 3M(TM) Mobile Dictation Software, a powerful new application that extends 3M's dictation, transcription, and speech recognition solutions. Available on the BlackBerry(R) or Windows Mobile(R) platforms, the software offers physicians the freedom of using a single device for phone, email, and dictation, and provides "anytime, anywhere" access via Wi-Fi or 3G wireless service. 3M Mobile Dictation is enhanced with a full range of security features that fulfill HIPAA and hospital-specific guidelines for encryption and authentication.” – Developments such as mobile dictation could decrease the turnaround time between the physician's spoken word and a readable document, which is one of the biggest issues with dictated notes. With the popularity of smartphones most physicians will have easy access to timely dictation. In theory that is.

Visit the 3M site for more information.

Installing and using Citrix Receiver on your iPhone/iPod Touch

While at ASHP Midyear a colleague and friend of mine, @pillguy, was able to pull up the pharmacy system at his hospital using Citrix on his iPhone. At that moment I was attacked by a green monster and nearly consumed with envy. I can not yet match this feat of superiority with my Droid, but I'm hopeful.

Citrix Receiver is a free download from Citrix Systems, Inc. available at the iTunes store. To use Citrix Receiver simply go to the iTunes store, download it and follow the onscreen instructions. Below are some screen shots using Citrix Receiver to access applications at my facility.