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The grass roots origin of mobile computing in nursing November 2000
This article originally appeared in e.healthcare.news a paper based newsletter of the Medical Records Insitute. Some of the issues discussed appear in other parts or in other forms on this website. ED. "In the long history of humankind (and animalkind, too) those who learned to collaborate and improvise most effectively have prevailed." - Charles Darwin Abstract
Information Over Load According to Dr. Peter Lyman and Dr. Hal Varian, of the School for Information Systems and Management at the University of California, Berkeley. Humanity is generating in excess of two exabytes of new information annually. (An exabyte is roughly a billion times a billion bytes, or the equivalent of 500 billion copies of e.healthcare.news). A striking fact from their report "How Much Information": Printed material of all kinds makes up less than .003 percent of the total storage of information. This paper that you are currently reading (the medium not the message) is obsolete. (* EDITOR'S NOTE: This article was originaly published in "hard copy.") That is not to say that there is no place for printed material in the 21st century; there is still something highly pleasing in the tactile approach to retrieving information. And information will continue to be consumed in this fashion. But what it does say is that the bulk of the information being produced today will require a digital medium to access it. Magnetic (digital) storage is by far the largest and most rapidly growing medium for storing information. Digital storage is rapidly becoming the universal medium for information storage. Accessing all this digital content will require a device that is as portable and as convenient as the venerable newspaper, book or newsletter of the past.
Handheld computers, or PDAs (Personal Digital Assistants) offer the ideal solution to accessing and managing the cornucopia of information being produced in the healthcare industry each year. Gone are the days when newly graduated nurses were armed with most of the information they would need for a lifetime of practice. Good nursing practice requires tools to extend the human mind's limited capacity to recall and process large numbers of relevant variables. Handheld computers may provide the solution to data access needs and help support the nurse's clinical practice at the point-of-care. Nursing Informatics has a long and fruitful history (almost as long as the "information age" itself), but now it's time to move up an order of magnitude to Mobile Nursing Informatics. Adopting Information Technology in the Clinical Environment Technologies are often adopted because they make processes more efficient. Some technologies, such as writing and printing, have been so successfully embedded in society that we are hardly aware of them: these are the ubiquitous technologies that have formed the very foundations of our knowledge for centuries. Current technologies, such as the computer-based information systems being adopted, and are becoming embedded and ubiquitous in the healthcare systems. The earliest mainframes were huge behemoths with limited computing powers and were financially out of the reach for all but the most affluent of corporations and organizations. The mini computers that followed close on the heels of the mainframe made computing more accessible to smaller organizations, but they were still well out of the financial reach for the individual. With the advent of the Apple Macintosh, only a ¼ of a century ago, "personal" computing became a reality. By the end of the twentieth century desktop personal computers were ubiquitous in all organizations and could be found in most homes in the "developed" countries of the world. Certainly PCs could be found in most hospitals and at most nursing stations throughout the healthcare system of North America. Nurses have adopted these new technologies to help them deal with the growing tide of information, but the adoption of information technologies has not been painless. The literature is replete with failed attempts at wide spread implementation of information technologies in healthcare. Over-hyped and often disappointing results have led to a high level of skepticism amongst healthcare practitioners. Much of what has been presented as a solution to clinical problems has come from administration or the vendors of information systems with little or no consultation with the clinician. It is for this reason that most of the presented solutions have failed to achieve their stated goals of improved efficiencies and enhanced delivery of healthcare. Clinicians are best placed to identify the possibilities presented by the increasingly flexible and sophisticated technology available. Clinicians have long recognized the benefits of computers in clinical practice, but they are not widely used because of access difficulties. The current systems in place lack one critical feature; the ability to deliver data on demand. If you need to interrupt the delivery of healthcare to return to the nursing station to access data, you will forgo data access and focus on the more immediate requirement of delivery of care. Handheld or mobile computers, by definition overcome the limitation of stationary computer systems to deliver information on demand to those who must apply that knowledge. Mobile Technology Options and the Dominance of the Palm OS in Healthcare There are primarily two operating systems vying for market share in the handheld arena:
The primary battle for market share is between Palm and Microsoft. There are other players in the market place, however their market penetration is currently insignificant and for our purposes we can safely ignore the other contenders for now. The Palm OS currently enjoys a substantial lead in market share. Estimates vary from 70% - 80% with the Microsoft CE (a scaled down version of the Windows OS) controlling the lion's share of the remaining 20% - 30%. Palm's success in market dominance can be largely attributed to the simple elegance of the Operating System. The simplicity of the Palm OS confers the compelling benefit of an abbreviated learning curve for both new users and software developers. This abbreviated learning curve has facilitated the development of large numbers of clinical software applications designed to run on the Palm OS, (an order of magnitude greater than that of the competing Microsoft OS) which has understandably resulted in a high level of adoption by healthcare practitioners. Once one has selected the operating system the choice of hardware is largely done on personal preferences. However the TRGpro (http://www.trgpro.com) model is developing a large following in healthcare primarily because it is the only Palm OS device utilizing industry standard Compact Flash (CF) cards. A CF card is non-volatile mass storage about the size of a matchbook and is capable of storing up to a Gigabyte of information. A Grass Roots Solution to Knowledge Management Clinicians have taken it upon themselves to adopt mobile computing; it's a grass roots movement that was initiated by physicians when they realized that the Palm OS platform is particularly well suited for the tasks of data collection, drug reference access, and various medical calculations at the point of care. The inherent simplicity of the Palm OS is what makes it so attractive to clinicians. The Palm platform lends itself to the creation of small, task specific applications, that in many cases can be developed by non-technical users with a minimal learning curve. Physicians, to assist themselves in their personal practice, have created most of the medical Palm OS applications currently available. It is only after the individual physician has used the application, and then perhaps shared it with colleagues, that it is then available for download to the medical community. As of November 23rd 2000 there were: 257 Healthcare documents and reference materials available for download from MemoWare (http://www.memoware.com). And 548 Palm OS medical software applications available for download from Healthy Palm Pilot (http://www.healthypalmpilot.com) covering a wide selection of solutions:
The above list is by no means an exhaustive listing of Palm OS software solutions available to the clinician. It is meant to be illustrative of the 'grass roots movement' occurring within the healthcare community. Recall that most of these programs have been developed by independent clinicians to address specific needs in their practice. This may well be the first time in the history of healthcare informatics where the practitioners on the front lines are developing their own solutions to IT. Rate of Adoption The rate of adoption of mobile technology by clinicians is non trivial. Estimates of adoption of PDAs in the general population range from 2% - 3%. A recent Harris poll estimates that 10% - 15% of physicians have already embraced mobile technology. Benefits of Mobile Computing in Healthcare Clearly physicians have found compelling reasons to use mobile technology. This is borne out by the recent study "Survey of Physicians' Experience Using a Handheld Drug Reference Guide" presented at the AMIA (American Medical Informatics Association) symposium in Los Angeles on November 4-6 2000. The paper presented by investigators at Brigham and Women's Hospital, a teaching affiliate of Harvard Medical School, reports:
Handheld databases are emerging as significant tools to assist the clinician at the point-of -care. They support the clinician like a colleague or textbook that enhances their training, intuition and common sense. Issues and Status of Nursing Use of Mobile Technology At a recent Weekend Immersion in Nursing Informatics (WINI) workshop in the summer of 2000 when the 55 attendees were polled by a "show of hands" on the question; how many had a handheld computer, only 5 responded positively. This admittedly unscientific poll would appear to indicate a 10% adoption rate within nursing, but one must realize the attendees of such workshops are the leaders in nursing informatics and have a disproportionately high percentage of "early adopters". There are no statistics currently available on the penetration of mobile computing within the general nursing population. However informal estimates resulting from equally informal queries by RNpalm of nurses would seem to indicate less than 1% of all nurses own a handheld computer. This is a level of penetration that is lower than the current penetration within the general population of the developed nations. As recently as March 2000 if one was to conduct an Internet search with the search criteria: "Nurse + Palm", the search engine would return the results: nurse, Jane Doe, who lives in Palm Springs - when the search criteria entered was: "Nurse + Handheld + Computer" returned results were equally useless. Why is it then, that so few nurses utilize handheld devices? It has everything to do with the culture of the healthcare industry. Physicians drive healthcare, and until the device had gained wide acceptance by the physicians, no nursing initiatives were possible. Now that the Palm Platform has been widely adopted by physicians, nursing initiatives are beginning to take root. RNpalm initialized the movement when it released the first nursing specific Palm OS software and simultaneously launched the worlds first website dedicated to discussing the use of PDAs in nursing on September 1, 2000. RNpalm is an association of independent nurses who's stated goals are: "To provide a resource for nurses who are desirous of keeping abreast of the advancement in Mobile Information Technology and it's impact on Nursing." The movement to adopt PDAs in nursing practice closely parallels the adoption of PDAs by physicians in so far as it is a "grass roots movement." Since the introduction of the RNpalm, Website articles on PDAs in nursing are starting to appear in the online press, and research on the use of mobile computing in nursing is beginning to be published. As mentioned earlier the benefits of mobile computing for physicians are being realized and are being published in the literature. However to realize the full potential of this powerful clinical support system, the entire healthcare team must adopt mobile computing. Also, maintaining dual (computerized and paper based) systems to accommodate those who refuse to use the new technology can increase costs by 130% to 240%. An even more compelling reason is the opportunity presented by handheld computing to enhance patient safety and care. When the entire healthcare team adopts handheld technology, the elusive improved efficiencies and patient record keeping promised by a standardized knowledge management system might be realized. After all even Florence Nightingale was known as a "systems person," compiling and analyzing statistics about patient care so effectively that she helped to reduce the mortality rate for hospitalized soldiers from 38% to 2% during the Crimean War. Nursing Advances in Mobile Computing The following examples illustrate nursing innovations in mobile computing at the point-of-care. 1) Mobile Computing System for Nurses. At the same AMIA symposium in Los Angeles where the ePocrates paper was presented, a group of Korean investigators presented a paper entitled "Implementation of Mobile Computing System in Clinical Environment: MobileNurse" These investigators developed MobileNurse a prototype of a mobile nursing information system using a PDA. It was used for retrieving patient information such as, physicians' orders and test results anywhere at anytime. It was tested in a clinical setting. The system enabled nurses to provide point-of care data processing that reduced time-consuming and redundant paperwork. The investigators concluded that the system would ultimately improve the quality of care, by delivering clinically relevant data to the point-of-care. 2) PDAs in Home Healthcare The Royal District Nursing Service in Victoria Australia recently conducted a trial of the use of PDAs. Following are some examples of how fictional Nurse Heavensent used the PDA in one day to send and receive emails, check databases, enter data and keep notes. Each of the activities described below was achieved during the trial.
The fictional case study is a composite of actual events during the trials. The case study demonstrates how a combination of information and telecommunication technologies can improve the efficiency of the nurse's daily work processes and bring immediate benefits to patients. 3) Nurses Manage Diabetic Care with PDAs The Charles H. Best Centre for Children and Youth, in Whitby, Ontario, launched a pilot project that makes use of handheld computers and software to log patients blood sugar levels, insulin doses, exercise, meal plans plus high and low blood sugar episodes and illness management. To begin, 20 patients are participating in this project. "Every 20 minutes someone in Ontario is diagnosed with diabetes and resources for support are being stretched thin," says Marlene Grass, Founder and Executive Director of the Charles H. Best Diabetes Centre. "But a course of management exists. A recent 10-year study (the Diabetes Control and Complications Trials) showed that people with Type 1 diabetes have fewer complications when they work closely with their health care team, reviewing the data on a regular basis." "This program allows us to dramatically increase the amount of patient data available to the team as well as decrease the amount of administration time involved in collecting the data. With more information, we can work to decrease long term complications which in turn, dramatically lowers health care costs for the province." "We've taken the traditional method of pen-to-paper and created a digital format" said Nick Zamora, principal at Optium Digital Solutions (the supplier of the software). "The information is accurate and leads to better communication with clinical staff. Instead of spending 20 minutes each day on the phone, young patients can transmit their information in seconds." The information management system is composed of:
4) Adoption of Nursing Specific Palm OS Software RNpalm has introduced 3 nursing specific Palm OS software applications since September 1st 2000. Downloads of all 3 applications exceeded 5,000 as of November 23rd 2000. These are strong indicators that nursing is ready to move quickly to adopt this new technology and utilize it to its full potential at the point-of-care. We anticipate the rate of adoption for mobile information systems within nursing to be rapid, and it will ultimately equal and perhaps exceed that of physicians. Mobile Nursing Informatics will be at the core of nursing in the 21st century. Ready access to data and analytical tools will fundamentally change the way practitioners of the health sciences conduct research, and approach and solve problems. Conclusions Many previous attempts to introduce information technologies into a clinical environment failed to win the widespread support of clinicians. Recent history has delivered one unassailable lesson. Any attempt to use information technology in a clinical environment will fail dramatically when the motivation is the application of technology for its own sake rather than the solution of clinical problems. The fact that clinicians are picking up handheld devices and using them to solve clinical problems bodes well for the future of PDAs in healthcare. The "grass roots" origin of the movement towards handheld computing in healthcare holds great promise for the future of mobile computing at the point-of-care.
Sylvia Suszka-Hildebrandt, MN, ARNP editor PDA cortex
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