The Rise of Palmtop Technology in Medicine Part II


By: E-Healthcare Connections

E-Healthcare Connections ("EHC") is an information intermediary and publisher servicing a broad audience of high-level healthcare industry executives and physician leaders. EHC reviews, analyzes and reports on developments in the healthcare Internet in order to assist its readership and viewers to better comprehend the practical applications as well as the strategic implications of the burgeoning healthcare Internet community.

This article is republished with the kind permission of John D. Cochrane Editor & Publisher Health System Executive & E-Healthcare-Connections

John can be reached via email

As it stands, not quite 20% of physicians use PDAs today. But, as we discussed in Part I of our series on palmtop medicine, this percentage will change rapidly in the months ahead.

There is increasing competition and hard-charging technology innovations among the makers of palmtop devices. Just this month Handspring announced a combination cell phone and mobile computer. New devices that translate voice to text are already in the marketplace. More power. More storage. More connectivity. And, a convergence of technologies will fuel more rapid adoption by practitioners. In this issue we will profile some of the companies in this arena and continue with our review of the most recent case studies of enterprisewide mobile computer adoption.

Palmtops: State of the Industry

At least 50 companies, many of them start-ups, are hard at work on mobile computing hardware and software for physicians.Some start-up companies are getting help from established companies like Palm or Microsoft - which themselves are fiercely competing to provide the basic software operating systems for handheld computers. Other big companies with a piece of the action include IBM, Siemens and WebMD; drug makers like Johnson & Johnson, Eli
Lilly, Glaxo Wellcome and Bristol-Myers Squibb, and so- called pharmaceutical benefit managers - or P.B.M.’s - like Merck-Medco, AdvancePCS and Express Scripts.

Already, 90,000 doctors have downloaded a free early version of ePocrates, a drug- reference software program for handheld devices to check drug interactions, appropriate doses and side effects. Several companies are introducing advanced programs that, while a patient looks on, can let a doctor prepare a prescription to be printed, submitted by fax or, transmit it by wireless Internet links. Other companies are testing programs that provide patient charts, incorporate the doctor’s notes and keep track of the doctor’s time with patients for billing purposes. And, some handheld units even record and take voice dictation.

The new industry based on handheld devices may be more attuned to the way that doctors actually spend their workdays. Doctors are often festooned with beepers, cell phones and mini-tape recorders and handheld computers. These devices will ultimately be folded into one device. Younger physicians in postgraduate residency programs are also often forced to use the devices as part of their curriculum. One in four programs for family practice residents, in-cluding those at the Universities of Washington, Idaho, Montana and Alaska provide handheld units for family practice residents, according to the American A cademy of Family Physicians.

Also proliferating are web sites developed by individual "wired physicians" to enhance understanding of the latest and greatest downloadable software for a particular specialty. Add to that very active listservs where the conversations are fast paced and enthusiastic. Where do I find the best Palm OS medical applications? How can I program my own machine? My hospital is inally synching with our mobiles. What do we do now?

Mobile computing linked wirelessly with enterprise-wide electronic medical records just reeks of growth potential in the coming months. These companies that are just breaking even now will be the bellweathers in the not too distant future. But, the real action will be centered in hospitals, medical groups, and managed care organizations that plan on physician palmtops as an integral part of their IS strategy. Here are some emerging case studies, following on with our article from part I.

University of Missouri: Study of Palmtops in Residency Program

The Dept of Internal Medicine at the University of Missouri medical center in Kansas City conducted a study on the utility of palmtop computers in its residency program. Nine internal medicine residents and their program director participated in an 8-month cohort pilot study using palmtop computers with desktop synchronization and Internet access capabilities. After 2 months of use, the residents had found a variety of uses for palmtop computers, such as the calendar, downloading residency-provided medical information, taking lecture notes, using a spreadsheet for common formulas, Internet/MEDLINE searching with modem access, infrared file transfer, downloading call schedules, and patient tracking. At 8 months, the residents were comfortable using
palmtops on a daily basis.

The study concluded that palmtop computers are useful in the residency setting, and residents are capable of devising ways to use palmtops to suit their individual needs.

Palmtops in Military Medicine

Intelligent Systems Technology, Inc. (ISTI), a provider of business process management and e-learning solutions, won a research and development award from the Office of the Secretary of Defense to design a wireless, Web-based Medical Digital Assistant (MDA ) for physicians, nurses, pharmacists and combat medics.

The MDA will be a personal assistant for medical care providers that performs collection, retrieval and communication of relevant information for patients’ medical care. For the first phase of the effort, ISTI is focused on developing the overall system concept, performing key technology tradeoffs, and creating a concept prototype based on an open, standards-based architecture. A key goal is to improve the human interface to computerized patient records within military establishments in both hospital settings and in the field. (Visit for more information.)

University of Minnesota Physicians

About 30 doctors at the University of Minnesota have begun testing wireless handheld devices as a way to record patient notes for later transcription. They simply speak within earshot of their Compaq iPaq Pocket PCs and an audio file is created, and sent to medical transcribers through a radio frequency network. By April the university plans to have more than 450 physicians using handheld devices.

The University of Minnesota Physicians, the organization which manages the university’s doctors, has embarked upon an aggressive wireless technology program using an “electronic medical records” (EMRs) software program designed by AllScripts Healthcare Solutions Inc., Chicago, and operated on a Microsoft platform.

The physicians group plans to introduce the software’s functions over a period of time, said Todd Carlson, chief operating officer. After implementing medical transcription, the group will expand to electronic laboratory results, billing, scheduling, patient care and referring physician information.

The university is not the only Minnesota health care institution pursuing wireless technology applications. Allina, North Memorial Medical Center and Park Nicollet Health Services have begun installing wireless technology solutions or studying how they can incorporate them.

Several factors have slowed adoption of wireless technology in health care, among them concerns about privacy of patient files, unresolved legal issues over their use by visiting physicians at hospitals and clinics, whether handhelds can be used in all parts of a hospital and which wireless system works best. Security has been one concern of the University since its program began in December. “We are really afraid of hackers because we’re on a college campus and we’re afraid students will attempt to hack into our wireless system,” said Carlson. “We did a hacking audit with Ernst & Young at an additional cost because we wanted the system to be safe and secure.”

The University of Minnesota’s physicians work in more than 150 clinics around the state, but much of their work occurs in 38 clinics that are now equipped with radio-frequency transmitters to capture data and transfer it to traditional land-based networks for storage and retrieval. Users can then access the information through a Web site via computers or handhelds. The wireless network is set up so that when a doctor enters an area with a radio-frequency transmitter, the data in his or her iPaq handheld is transmitted automatically - the doctor doesn’t even have to push a button to make it happen.

Officials at the University expect the uses for handhelds to grow. They will be used to access patient information, keep calendars; and store information about referring physicians and pharmaceuticals. Doctors will enter patient information into a “structured note” form, allowing other physicians and researchers to more easily capture reports on patient and overall care. The handhelds will be able to tap into resources on treatment for common ailments. Doctors will be able to view an entire patient record without having to plow through a thick file.Data will be entered once and used by multiple users, throughout the system. For example, patient information entered into the initial file would automatically be captured for insurance-claim and billing forms.

The electronic medical records will also help patients in outstate Minnesota who have received care in the Twin Cities and then return home for continuing care from their own physicians. Those doctors will be able to access from their own computers the electronic records created at the University.

Wake Forest Medical School

A new curriculum launched by Wake Forest University School of Medicine in North Carolina teaches students to store and retrieve data on handhelds. The School of Medicine recently began to provide second-through fourth-year students with a portable device to carry with them on theirrounds. A s part of their technology-based curriculum, the medical school is using IBM WorkPad PC Companions which, linked to a synchronization data server, will deliver medical and reference information instantaneously.

Doctors will be able to look up critical reference information. They will also be able to store their colleagues’ pager numbers, including senior physicians, and download reference databases from the Internet to improve their diagnostic skills. They can even use the device to catalog the procedures they do on rotations rather than scribbling them on scraps of paper as in the past.

An early adopter, Dr. Wesley Davis of the Medical Center’s Department of Obstetrics-Gynecology, says, “I store in my IBM WorkPad information on drug dosing, procedures and patients - basically, all the things you can’t remember, but need to. Its a huge improvement over paper, plus the ‘search’ capability gives me control over the information I need, when I need it.” So far, the school has acquired more than 375 IBM WorkPad devices.

“The Palm computing platform has the potential to revolutionize the way our medical center departments run and com-municate,” said Dr. Johannes Boehme II, associate dean for academic computing. “We see an unlimited potential with this platform that could lead to the development of customized departmental applications and the eventual deployment of several thousand WorkPads.”

The medical school is currently assessing a solution combining the Palm computing platform with Riverbed Technology’s Scout server and Puma Technology’s Satellite Forms development environment to make e-mail, scheduling, and medical reference material available to students and instructors alike.

Allscripts Announces New Installations in February

Allscripts Healthcare Solutions just announced that they will be installing their TouchWorks suite of mobile clinical applications at the Diagnostic Clinic in
Tampa, FL. This 120-physician multi-specialty group, with eight locations in the Tampa area, will replace their existing electronic medical record with a
program that includes order entry, charge capture, result viewing, pre-scribing, as well as, document creation and patient management.

“Several years ago, we developed our own in-house EMR because of enhanced quality and the need to facilitate various managed care and business
activities,” stated Jim Rivenbark, M.D., Medical Director of Diagnostic Clinic. “However, our legacy system was limited because it was a character based,
“green screen” technology and we were forced to maintain paper charts. After an exhaustive search, we chose the TouchWorks suite of applications because they would streamline physician workflow, improve documentation, allow order and charge entry at the point of care, and improve the quality of patient services.”

The Diagnostic Clinic expects to reduce maintenance costs and recognize a significant return on investment by replacing their current system. All physicians can access the EMR with handheld wireless devices or desktop workstations. TouchWorks will also integrate with the clinic’s IDX practice management

The Facey Medical Foundation, a 110- physician practice in Southern California, is also going with Allscripts. According to Bill Gil, the CEO of Facey, “We chose the TouchWorks suite of solutions because it streamlines clinical and administrative tasks for our physicians and enables our team to spend more of their time with patients than with paperwork.” Instead of requiring the implementation of a full electronic medical record all at once, TouchWorks provides a modular approach. This strategy allows physicians to start with the applications that address the most pressing needs first, and then progress at their own pace to a complete mobile electronic medical record, or mEMR

Facey physicians will be using a digital application to capture clinical information. Multiple physicians practicing at different offices will be able to access the record. In addition to the dictation module, Facey was attracted to using a single handheld device for writing electronic prescriptions, capturing charges, ordering labs and viewing results, and accessing clinical reference information.

A third medical group also selected Allscripts this month. The Central Utah Medical Clinic will install a combination of Allscripts programs and the IDX Group Practice Management System, or IDX GPMS . The clinic will complete the first phase in April. It will include the full GPMS application as well as the TouchWorks dictation, document management, and clinical result modules. They selected these three modules to quickly streamline their transcription
process. This summer, the clinic will add modules for e-prescribing, capturing charges, and automated order entry.

“The simplicity of the IDX practice management system combined with the Allscripts modular approach enables our physicians to gain maximum benefit with minimal disruption,” stated Scott Barlow, Chief Executive Officer of Central Utah Medical Clinic. “Since we’ve decided to implement GPMS simultaneously with the TouchWorks suite of clinical solutions, the ability to choose which modules to implement and when to implement them was an
important factor for us.”

By implementing both A llscripts programs and the IDX system, the clinic expects to link clinical and financial activities. For example, using a handheld device, doctors and nurses can enter patient encounter related information at the point of care using TouchWorks Charge and then submit this data wirelessly to the GPMS software - a more efficient process that ensures accuracy and speeds reimbursement.

The IDX GPMS system will include scheduling, billing and accounts receivable, referral management, and relational reporting. CUMC expects to improve claims collection, ease compliance with proposed government coding regulations, and create a seamless, patient-centric environment for its network of primary and specialty care physicians.

Finally this month (Feb 2002), Allscripts announced that Albert Einstein Healthcare Network (Einstein) has signed a multi-year agreement. Einstein will implement Rx+, FirstFill, and Charge for a number of their primary care and specialty physicians at Albert Einstein Medical Center in Philadelphia, PA . After several modules have been implemented with a core group, Einstein will expand the TouchWorks solutions to other physicians in their organization.
Einstein plans to complete implementation of the first of these solutions by the end of the first quarter of 2002.

Albert Einstein Healthcare Network has more than 350 primary care doctors and specialists on staff, with an additional 700 affiliated physicians. Einstein

Medical Center offers residency and fellowship training programs in many specialty and subspecialty areas. “We have seen many exciting advances in healthcare through the years and, from our perspective, providing access to real-time information is one of the next great advances. It can fundamentally improve the way physicians care for their patients,” commented Laurence M. Russell, MD, Medical Director, Einstein Community Health Associates.

Other groups that use Allscripts applications include the Dana-Farber Cancer In-stitute, Dartmouth-Hitchcock Medical Cen-ter, George Washington University Medical Faculty Associates, Temple University Health System, the University of Minnesota Physicians group, the University of Southern California Care Medical Group, and the University of South Florida Physicians Group.

“We have seen many exciting advances in healthcare through the years and, from our perspective, providing access to real-time information is one of the next great advances. It can fundamentally improve the way physicians care for their patients,”

PatientKeeper Announces New Clients

PatientKeeper, Inc, a palmtop software company, announced that Childrens Hospital Los Angeles, Emory Healthcare, Memorial Hermann Health System,
and University of Maryland Medical System have awarded PatientKeeper with multi-year contracts. The aggregate value of these contracts is nearly $4 million over the term of the contracts. The decision to select PatientKeeper was the result of Mobilizer Platform’s open architecture, interoperability, context
management, security, and enterprise management. It will also link with a variety of handheld devices (Palm OS and Pocket PC) and wireless and non-wireless transports (802.11, Bluetooth, WWA N, network cradles, infrared, etc.). According to the company, over 45,000 clinicians are currently using PatientKeeper.

“The Mobilizer Platform represents innovative technology that addresses both the realities of today and possibilities of tomorrow,” says Dr. Sajjad Yacoob, Medical Director of Clinical Informatics, Childrens Hospital Los A ngeles. “PatientKeeper helps us address the organic growth of mobile applications with features like: single signon, centralized administration, and a common patient list. Meanwhile, the open architecture and software development kits (SDKs)
will allow us to integrate best-of-breed application from chosen vendors going forward.”

Emory Healthcare selected PatientKeeper’s Mobilizer Platform because of its ability to integrate with legacy systems, and host third-party applications. The program works on both Pocket PC and Palm OS devices, and it also provides for enterprise security controls,” says Dedra Cantrell, Interim CIO at Emory Healthcare. “Physician ease of use and adoption were also key selection criteria.”

“PatientKeeper provides lists, labs, meds, and radiology reports on PDA s to our physicians without forcing us to invent and maintain the integration software to tie these solutions together,” says David Bradshaw, Memorial Hermann Health System’s CIO.

Military Palm Applications

The U.S. military has been using Palm devices to support field forces in the Gulf of Arabia and in Kosovo, including using them for medical evacuations. A unit of the Nevada National Guard that is currently in Kosovo gives Palms to medics aboard UH-60 Black Hawk helicopters to track patient information. The handhelds run Med-Media software, tracking vital signs, treatment or medication received on board the helicopter, and initial diagnoses of patients.
Once patients are moved to a hospital, information on the Palm handheld can be synchronized with hospital databases, giving doctors and nurses information on each patient.

“The system saves us precious minutes during patient transport, and provides us with a 60% faster method of communicating with doctors and nurses at hospitals,” said Sgt. Mark Stevens of the Nevada National Guard. eResidency Partners With eMedicine on Palm Application, Inc., producer of the 24/7, online World Medical Library, will expand its partnership with, Inc. with the development and marketing of SkillStat 1.0, a new Palm OS application. SkillStat provides physicians and other health professionals with instant access to information on procedures commonly performed in the hospital. The application currently includes fifty procedure chapters organized into organ-based categories. Each SkillStat chapter includes information on the indications for the procedure, essential equipment required, detailed descriptions of specific steps to successfully perform the procedure, tips on positioning and anesthesia, and a section on potential complications and strategies for effectively dealing with them.

Centocor Signs Agreement with ePocrates

ePocrates announced in late February that it had entered into an agreement with Centocor, Inc., a Johnson & Johnson company. Effective December 13, 2001, ePocrates will distribute handheld devices to physicians nationwide. These physicians will be able to download the ePocrates Rx drug reference guide, along with articles from leading medical journals and clinical content providers. Physicians participating in the program will also receive regular medical updates relevant to their practices.

“We have a large network of physician users who rely on ePocrates for drug reference information, news of product launches, announcements about new indications, and product safety alerts,” says Jeff Tangney, co-founder and vice president of business development at ePocrates. “Because our users are so responsive, we are able to provide pharmaceutical clients with measurable results concerning the impact of their messaging at the point of care.”

The ePocrates Rx drug reference, which contains definitive data on crucial safety topics such as indication-specific dosing, adverse reactions and multiple drug interactions, was developed to address the daily challenges faced by physicians by providing accurate, up-to-date information on 99% of the most commonly-prescribed drugs. In addition, ePocrates Rx includes the AutoUpdate feature which automatically updates data on the physician’s Palm OS handheld device each time the doctor synchronizes his handheld device.

ePocrates Inc. claims to have grown to over 500,000 users since its launch in November 1999. They purport to have one fourth of all physicians. In addition to the ePocrates Rx clinical drug database, ePocrates also offers ePocrates ID, ePocrates Rx Formulary, DocAlert messaging and ePocrates Honors, a physician recruitment tool.

Headquartered in San Carlos, CA , ePocrates is a privately held company led by president and CEO John Voris, former COO of PCS and veteran of Eli Lilly. The company was founded in 1998 by Richard Fiedotin, MD and Jeff Tangney and is funded by Sprout Group, Bay City Capital, Draper Fisher Jurvetson, InterWest and Three Arch Partners. For more information on ePocrates, visit

ePocrates has signed partnerships with 7 of the 10 leading pharmaceutical companies, as well as leading PBMs and managed care organizations.

Handheld System Tested for Diabetes Control

Emory University endocrinologists at Grady Memorial Hospital in Atlanta have applied an FDA approved computerized decision support protocol, the "Intelligent Dosing System," to the treatment and management of diabetes. Building on historic dose-and-response data from 190 patients in the Grady Diabetes Clinic, the Intelligent Dosing System individualizes medications prescribed for diabetic patients, according to the manufacturer, The RxFiles Corporation of Nokomis, Florida. IDS was originally developed to adjust doses of medications used to prevent transplant rejection, and to manage the treatment of patients who need to take blood thinners. It was approved by the FDA in A ugust 2001.

The study at Grady is the first attempt to see if the IDS can be applied in the management of diabetes, particularly insulin adjustment. “Diabetes is a leading cause of illness, disability, and death in the United States,” said Curtiss Cook, M.D., associate professor of medicine at the Emory University School of Medicine, and one of the first physicians to use the Intelligent Dosing System. “By lowering blood sugar, blood pressure and cholesterol levels, however, many of the complications of diabetes can be prevented, and patients can lead a healthier life.” This technology, Dr. Cook explained, “should help us take much of the guesswork out of how to adjust diabetes medications, thus allowing us to treat patients more effectively.”

The system is based on a handheld Palm OS devoce, and can also be accessed with Windows systems. A “next” dose calculator is used in conjunction with a comprehensive database to determine the patient’s last dose, current dose and the desired concentration of medication. This can be determined and changed as necessary by the healthcare provider, based upon the unique combination of circumstances presented bythe patient’s condition, disease progression, co-morbidities, compliance and therapeutic response. By using brief patient information, and selecting any surrogate marker (such as blood sugar) that is clearly affected by the drug, this system has proven to be very accurate.

The goal is to use the system to evaluate 200 to 300 patients by May 2003. Expectations and early indications are that the system will prove to be an effective way to reduce medical complications and improve patient care. Nurses are already using the system, and others are waiting to be trained.

The IDS dosing system is actually a suite of three software applications designed for use on a handheld personal digital assistant or computer. The three applications include DoseRx, a “next” dose calculator; InterchangeRx, a calculator that safely switches patients between drugs, from brands to generics, or between drug classes while maintaining the original agent’s established therapeutic effect; and Practice PrescribeRx, a graded prescriber training simulator to introduce new drugs, refresh experience with seldom used drugs, and document proficiency among medical professionals.

Study on Use of PDAs in U.S. Family Practice Residency Programs

A variety of handheld computers have entered the market over the last 10 years, with a growing number of applications to help people organize information or keep their schedules. Criswell & Parchman, writing in the J. of the American Medical Informatics Assn Jan/Feb 2002, were interestedn in evaluating the uses of PDA s in family practice residency programs.

In November 2000, the researchers mailed a questionnaire to the program directors of all American Academy of Family Physicians and American College of Osteo-pathic Family Practice residency programs in the United States. Approximately 306 of 610 programs, or about 50% of the programs, responded to the survey.

Two thirds of the programs reported that handheld computers were used by either individuals or groups in their residencies, and an additional 14% had plans for implementation of handheld computers in some form within 24 months.

Both the Palm and the Windows operating systems were used. The Palm operating system was the most commonly used system. Military programs had the highest rate of use (8 of 10 programs [80%]), and osteopathic programs had the lowest (23 of 55 programs [42%]). Of programs that reported handheld computer use, 45% had handheld computer applications that are used uniformly by all users.

Funding for handheld computers and related software applications was nonbudgeted in 76% of the programs in which handheld computers were used and
so residents had to pick up expenses themselves. In programs providing a budget for handheld computers, the average annual budget per user was $461.58.

In 72% of the programs, all the upkeep and maintenance for these new computer devices were provided by interested faculty or residents who had some experience with computers, rather than computer personnel.

In addition to the applications that came already installed, such as calendar, memo pad, and address book, the most common clinical uses of handheld computers in the programs were as medication reference tools, electronic textbooks, and clinical computational or calculator-type programs.

Peoria Surgical Group

The introduction of handhelds to Anderson’s seven-physician Peoria, IL Surgical Group last year illustrates how these increasingly popular devices could jump-start the EMR movement. When the Peoria surgeons considered going paperless, they nixed working on stationary desktop computers in exam rooms. They simply didn’t want their backs turned to patients while they typed. Instead, they chose two portable devices - the iPaq handheld, made by
Compaq, and the Fujitsu 3400 pen tablet computer, a step up from the PDA and about as big as a file folder.

Peoria doctors can use either device. Both allow them to call up or enter data with a stylus. The iPaqs and Fujitsus wirelessly access the practice’s EMR program, OmniChart from Medical Manager Health Systems, which runs on the office’s server. With OmniChart, doctors can write prescriptions as well as review patient records. The practice anticipates adding a sister program soon that will allow physicians to document patient visits - replacing dictation - and
capture charges.

RehabCare Group Physical therapists

Physical therapists with the RehabCare Group, St. Louis, Mo., use Palm handhelds to obtain information on patients, as well as to record information on sessions with their patients. Previously, the organization received patient information via fax, a time-consuming method that also created massive amounts of paperwork and data entry. Today, therapists synchronize their handheld computers with the corporate database via a modem located at their treatment
facility, allowing them to obtain pa-tient information in about three to four minutes.

Therapists also use the handhelds throughout the day to record the amount and type of therapy given to patients. At the end of the day, therapists again sync their handhelds with the database, providing the corporate office with not just clinical out-come information, but with billing and payroll information. The Palm handheld solution, developed by St. Louis-based Quilogy, has enabled the RehabCare Group to cut data-entry costs and fax volume by 80%.



Palmtop medicine is capturing the interest and enthusiasm of physicians, even when conventional wisdom says that physicians in general have little interest in computer applications for their practices. That in itself should be reason enough for hospitals and health systems to step up to the plate

More information on case studies and the use of Palm handheld computers in the enterprise is available at

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