Information Technology at the Point-Of-Care
The grass roots origin of mobile computing in nursing
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
Healthcare is the most information-intensive
of industries, and it is evolving rapidly as new information
supplants old. Mobile computers are increasingly being used
to extend the human mind's limited capacity to recall and
process large numbers of relevant variables and to support
information management, general administration, and clinical
Integrating mobile information systems into
the practice of healthcare will add value by helping to decrease
costs, increase efficiency and enhance patient satisfaction.
These mobile computing devices will transform data into valuable
information at the point-of-care. Mobile computing devices
will dramatically affect how healthcare is practiced in the
future. Mobile information technology in direct patient care
will take center stage in nursing informatics in the 21st
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
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that you are currently reading (the medium not the message) is obsolete.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
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
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
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:
83 Diagnostic Tools (identification and classification of
40 Health and Fitness (lifestyle modification and alternative
103 Interventions (procedural and treatment protocols)
58 Investigations (lab tests and other diagnostic tools)
62 Record Tracking (databases for tracking healthcare)
169 References (grab-bag of medical knowledge base)
33 Research Tools (critical appraisal tools)
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:
50% of physicians using ePocrates qRx handheld drug reference
guide avoided one or more serious adverse drug events per
week (ePocrates qRx is a handheld drug reference guide and
free to download from http://www.epocrates.com)
Over 90% of clinicians surveyed reported that it took them
20 seconds or less to find information · 80% said that ePocrates
qRx improved their drug knowledge
83% said that their patients were better informed as a result
54% reported higher levels of satisfaction with their medical
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
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%
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
Commencing her workday from home, Nurse Heavensent logs into
the handheld computer and checks today's schedule of visits.
Using a mobile phone with Global System for Mobile Communication
(GSM) data connection she connects to the organization's mainframe
client information system. This allows her to check for emails
and adjust visits, allocate a health aide to pick up one of
her clients for today and check what equipment she needs to
take to a particular patient.
Setting off to see her first client Nurse Heavensent activates
the handheld computer to measure the amount of travel time.
At the client's home, she uses the PDA to automatically measure
'visit time'; and enter data describing the visit activities.
Returning to her car, she reads an email, which informs her
that a colleague is ill and that she will need to visit another
client. A 'Client Information Inquiry' message downloads the
information about the new client. In response to another email,
she also enters the discharge details into the PDA for a client
who is about to enter hospital. Nurse Heavensent also sends
an email to the liaison nurse working in the hospital, requesting
follow up of this client.
At a new client's home, the nurse enters Registration and
Financial details into the PDA and arranges when the next
visit will occur, entering this information into the scheduling
Returning to the Centre at the end of the day, the nurse
exchanges information with the mainframe client information
system via a wireless Local Area Network (LAN) connection.
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
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
"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:
Hand held computers with a customized program for patients
to enter daily glucose levels, insulin doses, details of acute
episodes and how they dealt with the episode
A modem that attaches to the handheld computer to automatically
dial into a web site and download patient information to a
secure database for collation, analysis and report generation
Real time access to original results and consolidated reports
for patients, diabetes educators and other designated health
Two-way messaging so the patient can receive care management
recommendations from the diabetes educators at The Charles
H. Best Diabetes Centre.
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.
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
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.
MN, ARNP editor PDA cortex