of Palmtop Technology in Medicine Part II
By: E-Healthcare Connections www.e-healthcare-connections.com
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
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 doctors notes and keep track of the doctors
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
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 http://www.intelsystech.com
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
The University of Minnesota Physicians, the organization
which manages the universitys 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
The physicians group plans to introduce the softwares
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
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 were on a college
campus and were 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 Minnesotas 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 doesnt 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
An early adopter, Dr. Wesley Davis of the Medical
Centers Department of Obstetrics-Gynecology, says, I
store in my IBM WorkPad information on drug dosing, procedures and
patients - basically, all the things you cant 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
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 Technologys
Scout server and Puma Technologys 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 clinics 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
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 weve 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
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
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
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
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
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 Platforms
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 PatientKeepers 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
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 Systems
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 eMedicine.com, Inc., producer of the 24/7, online
World Medical Library, will expand its partnership with eResidency.com,
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
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 physicians 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
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 www.epocrates.com.
ePocrates has signed partnerships with 7 of the 10
leading pharmaceutical companies, as well as leading PBMs and managed
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 patients 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 patients
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 agents
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
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
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
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 Andersons 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 didnt 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 practices EMR program, OmniChart from Medical Manager
Health Systems, which runs on the offices 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
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 http://www.palm.com/enterprise/studies.