Study examines use of wireless and handhelds at bedside

By Neil Zeidenberg

TORONTO – Bell University Laboratories (BUL) – a research partnership between Bell Canada and the University of Toronto – is investigating the use of wireless technology and handheld computers to bring quality evidence to physicians at the point of care.

According to Dr. Lawrence Spero, laboratory manager at Bell University Health Communication Labs, a 1999 study by Dr. Sharon Straus found that when physicians are given the opportunity to request information at the bedside, they used it extensively and it made a difference to the delivery of healthcare. “However, when it was removed from the bedside,” said Dr. Spero, “they reverted back to their old habits.”

The goals of the project, called “Bringing Evidence to the Point of Care” are:

• To assess the information needs at the point of care of hospital and community-based clinicians.

• To develop and evaluate formats for delivering the information on mobile computers.

• To determine if handheld devices can improve patient care and prescribing practices both in clinics and at the bedside.

It’s currently an academic research project, so no patients have actually been involved with the devices. If all goes well, however, they hope to move the study into a hospital setting within the year.

The plan is to use it in cancer care at the Princess Margaret Hospital, in Toronto. Depending on its success there, they could introduce it across the province.

But before testing moves into the hospital, there are a few details that need to be straightened out. For instance, biomedical engineers want to make sure that they aren’t bringing anything in that will be harmful to the environment, and researchers want to make sure they’re bringing in appropriate information.

They are also working with interface designs, since portable devices have small screens and limited memory. For these reasons, the preliminary studies are very important.

Researchers had initially assumed that physicians would not be interested in bedside evidence unless the information was delivered in less than 30 seconds. However, as it turns out, if the information is relevant and useful, physicians are prepared to wait a little longer. What they really want, though, is the best information as it applies to that patient.

The greatest additional demand is for evidence pertaining to drug interaction, since physicians want assurances they’re not using drugs that will interact with their patient’s current medication.

“The bottom line for us is, what gets delivered to the physician is not just information, but information that we have determined to be the best that’s possibly available,” said Dr. Spero.

Until now, most of the study has been done using RIM Blackberry handheld devices. However, simulations have also been tried using both the Palm Pilot and iPAQ computers. Testing will continue using other devices as well.

“This is still a study in progress, and Bell Canada has a fairly large wearable computer division on its side,” said Michael Milton, associate director, Bell University Laboratories, about the donation of three Xybernaut Mobile Assistants. “Recent testing has shown that the Xybernaut can boost a user’s productivity by almost an hour per day, just by having the computer with them.”

Another advantage of the wearable computer is that they operate at frequency levels that are less likely to interfere with hospital equipment.

Moreover, “wearables are a more intelligent device,” said Dr. Spero, “and much more readily programmed. The Xybernauts for instance, have a very bright screen that can be read under any circumstances.”

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From hospitals to home care, wireless improves data collection at point-of-care

By Andy Shaw

Nurses in Newfoundland have the future of wireless healthcare in their hands – quite literally – and they like the feel of it. The pilot project for a Palm Pilot-based home-care delivery system by a three-nurse team from the St. John’s Health and Community Service last year, zinged patient data invisibly over the city and sent up another burst of optimism about what wireless might do for long-term healthcare.

“We hit a home run there, and we didn’t quite expect it,” says Rob Parker, president of Adactus Care Technology, based in Halifax. “We told the nurses to call us when they had problems with the user interface. But they weren’t calling and we wondered why. So we called them and found out they weren’t having any problems.”

In the past, problems with remote wireless healthcare have been more numerous than wireless proponents care to admit. Among the troubles: transmission blind spots and concerns over security and synchronization, as well as the short battery life and questionable durability of some handhelds.

“For our project, the only trouble the care-givers had occasionally came from the fact that there’s a lot of granite buried in the hills around St. John’s,” admits Parker. “But they soon found spots around town that give them really good connections.”

Technologically speaking, the visiting nurses were connecting to a packet digital wireless network designed for encrypted data transmission. Their daily download included their appointments for the day, a description of the care to be provided at each visit, as well as demographic, medication, allergy and treatment history for each patient on their list. It also tallied up all the syringes, rubber gloves, and other medical supplies needed for that day.

That data flowed in through the CDPD modems on their Palm Pilots to Mobile Home Care Platform (MHCP) software provided by Adactus Technology and implemented by Collaborative Network Technologies in St. John’s. MHCP, which will likely be known as Adactus Outreach when commercialized, was designed specifically for nursing and home support agencies. The platform not only schedules and informs the nurses’ day, it allows them to capture the details of their care and communicate them directly back to home base.

“When they get their download, it comes with a complete set of protocols for each step of the care prescribed for that patient,” explains Collaborative’s Keith Sheppard. “So when a bandage has to be checked, for example, it then steps the nurse through examining and describing the wound. Ticked off with the Palm Pilot stylus at each step, the nurse also notes any vital signs or other patient readings taken, as well as the supplies used.”

When the visit ends and the nurse re-connects with the CPCD network, the Adactus software instantly pushes all that new information back up to the central server. All done quickly and without having to run back to the office to finish the documentation.

“You automatically end up with a complete, time-stamped record of all the activities undertaken with the patient,” says Sheppard.

As far as Sheppard and Parker know, no other wireless system in the world has been tried that can so comprehensively and efficiently link the sharp end of home care to headquarters.

Not that there haven’t been significant wireless care developments elsewhere.

Throughout the United States in some 230 occupational health clinics, Enterasys Networks Inc. has been deploying its RoamAbout wireless technology and saving the clinic chain owner, Concentra Health Services, over $US 3 million dollars a year in medical transcription alone. Like the Newfoundland pilot, a handheld using customized software, in this case called ChartSource, is at the heart of the system.

Rolled out between spring and fall last year to all Concentra clinics, ChartSource enables physicians and physical therapists to roam about their clinics creating patient-care notes on the fly and without need of wires or transcription.

“It’s a very liberating technology,” says Kelly Kanellakis, the Toronto-based general manager of RoamAbout Wireless Business for Enterasys Networks, “and it’s mature to the point now that when we install the technology even for pilot projects, people don’t want to give it back.”

Especially the tablet-shaped Clio handhelds (from California-based Vadem Corp.) “The Clio is a thin client device for us. It’s bigger than a PDA at about six by ten inches, with a built-in clamshell keyboard,” noted Jay Wilson, Concentra’s vice president of information services and technology. “It was originally developed in Japan by Sharp, and is now made by Vadem Clio. Our physicians really like the larger real estate of a tablet device.”

The strong appeal has much to do with the fact that care-givers equipped with the wireless tablets do not have to turn away from their injury patients in order to enter data. Not only is treatment therefore a better experience for the patient, but there’s no need to run expensive cabling to the eight exam rooms in each Concentra clinic. Nor is there constant plugging in and unplugging. The two physicians at each clinic, for example, can move from room to room, tablet in hand and enjoying connectivity all the way.

“We developed ChartSource as a Web-based application using Visual Studio that is served up on Citrix from our Dallas headquarters here. Citrix is also running on the Clio handheld itself,” explains Wilson. “The ChartSource on the Clio is integrated in real-time into each clinic’s patient registration system.”

That means the mobile physicians can pick up details of previous visits by patients and their medical histories. Then during the examination, the physicians enter ChartSource’s note-taking functionality.

“The physician is offered a decision-tree,” explains Wilson. “The tree starts the record-keeping by asking the physician questions. If it’s a laceration, for example, it will ask, how long is it? Then, how deep? and what colour? And so on.

“As the physician answers the questions by clicking with a stylus, she can see ChartSource actually building sentences about the laceration on one side of the screen. So there is no need to type any entry, although the physician can also use the stylus to write additional notes.”

As for the learning curve involved, Wilson says after making about 100 notes on average, physicians are as proficient at recording their encounters in ChartSource as they had been at dictating their notes to a transcription service over the phone.

“We haven’t encountered one yet who couldn’t adapt to the new system,” says Wilson.

As for the return on their ChartSource investment, Wilson says: “We’ve noticed almost immediate productivity gains in our back office. That note the physician creates is immediately available in our patient registration system – not 24 hours later after being transcribed. So, if we are referring patients to a specialist, we can print up the notes instantly and give them to patients to take with them.”

Soon, Concentra intends to hand out Clios and a modified version of ChartSource to all its therapists, and to others in their clinics who now generate paper as a result of encounters with patients.

Such south-of-the-border wireless developments are being watched closely by Peter Spasov, at Fleming College, in Peterborough, Ont. In his capacity as head of projects for Fleming’s Applied Computing and Engineering Sciences, a Spasov-led project is developing a wireless system for the 198-bed long-term care facility being built on the Fleming campus in conjunction with the St. Joseph’s Health Care Group.

With Alzheimer sufferers and other long-term care residents who may have lost some of their mental faculties, it will be important for caregivers to know where they may have wandered off to.
“So we’re particularly interested in developing a personal locating system (PLS),” says Spasov, who adds that one of his regular challenges is explaining to potential backers and partners why he can’t just come up with some simple adaptation of the Global Positioning System (GPS). “I have to point out to them that GPS only works outdoors,” says Spasov.

Indoors, Spasov says off-the-shelf wireless components and technologies are sufficiently proven now to build an open standards PLS prototype, one that can be fully integrated with care-givers’ PDAs and other elements of the new facility’s IT network.

“I think the system can even be made intelligent, meaning that patients or anyone else can use it as a navigational aid,” says Spasov. So if users get lost in the building, they can find their way to where they want to and are authorized to go.

To that end, Spasov and his researchers might want to check out another off-the-shelf wireless device and related software developed by a Canadian company that has proven its worth in recent U.S. trials. Ottawa-based affinitex, the healthcare division of AiT, recently unveiled its latest version of VeriMe, a wireless personal authenticator. Weighing about the same as a fountain pen, the VeriMe unit communicates wirelessly with a network. Instantly the device authenticates and logs the user on to the network whenever he or she comes within close range of a network access point.

So physicians making rounds, for example, can authenticate themselves with a fingerprint made on the VeriMe and move in and out of network access. Whenever the physician steps up to a networked computer, affinitex’s Manatee software presents that physician’s personalized views of all the data they’re authorized to access.

When the physician walks away, VeriMe and Manatee combine to save the changes the physician has made and log the user out – without so much as a keystroke from the physician.

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Ontario hopes to expand its e-Physician Project across the province

By Jerry Zeidenberg

TORONTO – After experimenting with the computerization of doctors’ offices in 13 pilot projects, Ontario now intends to start rolling out its $150 million e-Physician Project across the province.

According to Glen Holder, PhD, executive lead for the e-Physician Project (ePP), requests for proposals to vendors will be issued this spring on the Merx on-line bidding system (www.merx.com).

The ePP intends to conduct a “competitive procurement process to select multiple qualified vendors of hardware and software,” from which various family doctor networks across the province will be able to pick and choose their own particular solutions.

Components of the system will include clinical management software systems, portal services, a core-data set/emergency health record, along with IT infrastructure support and integration services.

ASP solutions will also figure prominently as systems are created province-wide, to reduce the amount of maintenance, tweaking and system upgrading that must be performed when doctors run their own local servers. Indeed, a pilot project in Chatham, Ont., is currently using an ASP solution, remotely connecting to secure servers in Toronto.

Essentially, the ePP will establish the standards for technology solutions, while physicians will be free to choose their preferred solutions from vendors, integrators and developers that obtain the stamp of approval. “We’ll provide the conformance testing, so the family doctor networks can buy their own solutions,” commented Dr. Holder at a February information session held in Toronto.

The e-Physician Project is run by Ontario Family Health Network (www.ontariofamilyhealthnetwork.gov.on.ca), which was established last year to help restructure the delivery of primary care across the province. The OFHN is seeking to shift family physicians from independent, fee-for-service practitioners into teams of doctors working with a set group of patients.

The physicians would receive a pre-arranged rate of compensation for their work, based on the number of patients in the roster, with adjustments for patient gender, age and special needs.

The physician-team would take care of patients 24 hours a day, seven days a week – removing a good deal of pressure from hospitals during non-business hours when patients tend to crowd emergency rooms for medical attention.

The OFHN is seeking to organize 80 percent of the province’s family doctors into networks – some 6,400 practitioners – by the year 2004.

Computerized solutions are seen as key enablers of the networks, as they will allow doctors to share the records of patients, any time of night or day, from any location. They can also enhance the delivery of care by improving the accuracy of medical charts, and by offering automated applications such as drug-interaction checking and access to hospital information systems.

Access to hospital computer systems would enable family doctors to quickly obtain lab and radiological results, and to check on the status of hospitalized patients.

As an incentive for family doctors to computerize – and to join a network – the OFHN is using its $150 million technology fund to pay two-thirds of the costs of I.T. when a physician joins a network and computerizes his or her office.

However, both the process of creating family networks, and implementing computerized solutions, has been slow.

Indeed, many physicians in Ontario have been loath to join formal networks with rosters of patients. A recent member survey by the Coalition of Ontario Family Physicians (COFP) found that 98 percent of respondents opposed primary care reform.

Even in the 13 pilot projects that have been run, getting the I.T. component up and running has been slow going. Physicians have had trouble with software capabilities and configurations. Some felt ill-prepared to use computers, and lacked time for selecting, implementing and using I.T.

Indeed, few of the physicians working on computers at the pilot projects actually used the key application of electronic patient records.

For the ePP, there are further complications. It’s working in conjunction with the Ontario Smart Systems for Health (SSH) project, which, for its own part, has discovered that delivering services such as secure e-mail are more complicated than first believed.

These technical difficulties have slowed the creation of a province-wide SSH infrastructure for the healthcare sector, upon which the ePP is hoping to piggyback many services to doctors.

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Unlocking the power of e-learning – a Baycrest Centre case history

By Stephen Tucker

One of the problems hospitals and long-term care facilities face today is how to provide staff with cost-effective continuing education. Tight budgets, shrinking resources, and staff with limited free-time add up to quite a challenge. For the past 18 months, Baycrest Centre has developed the potential of e-learning to help solve this problem.

Baycrest now has more than 50 hours of Web-based training available for continuing education. The out-of-pocket expense to develop the initial 50 hours of content was $10,000. We did the work ourselves with paid and volunteer help. If we had hired the services of outside suppliers, we estimate the project would have cost Baycrest $200,000.

Our per-person cost of viewing an hour of on-line training is $3, versus an industry average of $10 to $25. By June, we hope to have 75 hours of training available. We plan to team up with other Toronto-area healthcare facilities to jointly produce high-quality, e-learning content at low-cost.

We’re sharing our story to help hospitals and long-term-care facilities benefit from our experience and unlock the potential of e-learning.

E-learning

E-learning uses the Internet or an intranet to deliver training content. E-learning comes in many different forms. Sessions can be broadcast live on a set date and time.

Simulated-live broadcasts consist of content prepared beforehand with an instructor on-line to answer questions via a chat room or telephone conference line. Content from live and simulated-live sessions can be archived and accessed at any later time. Content can consist of any combination of video, audio, text, photo, or graphic element. Interactive tests can be offered on-line.

Traditional learning revolves around an instructor, a time, and a place. E-learning gives the choice of time and place to the learner. It also allows the learner to pick and chose the topic they want to study, when they need to know it.

Many educators now believe that a blended approach to training – some combination of classroom work or seminar and e-learning – offers the highest return on investment. Classroom lectures and seminars provide interaction with instructors, peers, and procedures. E-learning provides flexibility and a custom approach.

Because the trend today in the medical community is toward accredited continuing education, we began to explore what e-learning could do to meet this need for Baycrest personnel.

As an institution with a large training component, Baycrest has a wealth of geriatric-care learning opportunities available in the form of accredited grand rounds, core curriculum, in-service training, and seminars. We can capture these sessions on video and transform them into e-learning content – content available 24 hours a day seven days a week.

Three lessons learned about developing e-learning

Lesson 1: Focus internally. Initially, we thought that we could market content to other institutions in order to defray costs and perhaps make a small profit. We soon discovered that although hospitals, long-term care facilities, doctors, and nurses were very interested in our content, they were reluctant to pay for it. We soon recognized that the real success was to be had within our own facility. Marketing to those beyond our walls would not be a “build it and they will come” scenario. We do offer content externally, but it is not so much a marketing focus as it is an effort to support our mission of enhancing the care of the elderly.

Lesson 2: Produce high-quality e-learning content at low cost. The cost to build and deliver an effective solution is pennies, not the thousands of dollars as we originally thought.

Additionally, we learned that live broadcasts are not only too expensive for what you get, but also difficult to manage and prone to technical problems. Costs can be kept down by using simulated live broadcasts or simply archiving a filmed and edited session.

E-learning does not require expensive hardware and software. We are using standard PCs and servers, enhanced with additional memory, for editing, rendering, and content storage. We are also using commercially available graphics cards. Our video cameras cost about $1,200 each. Several core software packages are free from Microsoft including Producer and Media Server. Other software is readily available at nominal cost. Hewlett-Packard, Microsoft, and local macromedia company, Northern Objects, donated consulting time to help us get started, which has helped us keep costs down.

Lesson 3: Develop content in-house. One of the true delights of this first phase of implementation was working in a professional capacity with my daughter Allisan, a 16-year-old high school student. Allisan, who will be going to film school this fall, and I talked about the Baycrest project. She volunteered to help film and edit our content. She posted messages on the Web and found four other students interested in this technology. She was soon the team leader of our Rich Media project.

It would be wonderful to detail everything Allisan and the other students have done for us, but the point is outside suppliers do not have a monopoly on this knowledge. If committed high-school students can record, edit, and produce professional quality content, then you know that you can do this in-house too. Start small, as we did, and learn as you go.

As a rule of thumb, it takes about 20 hours to produce one hour of content. This breaks down to be about five hours for editing and 15 computer hours for rendering. We estimate that it will now cost Baycrest about $500 to produce one hour of content. Transmission will cost about $3 per viewer per hour.

Geriatric Nursing Exam Workshop

Recently, Baycrest Centre hosted a two-day preparation workshop, “Canadian Nurses Association Certification in Gerontological Nursing.” The workshop consisted of more than a dozen presentations, each lasting about 45 minutes. Nurses from all over Canada who paid tuition but who could not attend the workshop at Baycrest will have on-line access to each of those presentations, including video of the presenters, text slides, and other workshop information, as they study for the exam. It will be the next best thing to being there. We believe this is the first time a nursing certification exam workshop has been transformed into e-learning content in Canada.

Another example of how we are using e-learning is the filming of accredited grand rounds. We’ve found that staff members who were unable to attend a grand round are accessing the e-learning version at various times, day and night. Some consult the information when they have a question on the best practices for a specific treatment or problem.

We’ve found that many of our users simply listen while they are at their desks. The video portion is not as important to them as the spoken word. This is one of the most important things to remember in preparing e-learning content – make sure the audio portion is very high quality.

We give users the ability to search the archive by spoken word. This puts the information right at their fingertips. To make the information even more accessible, we are providing sub-titles in several different languages. We use a software program called Authorware to create interactive tests – answer a question incorrectly and the software will replay the appropriate segment of the training video.

Results, recommendations, and conclusions

Based on our experience, we recommend that you look in-house for a solution that meets your needs using your own content. Seek out free and inexpensive tools. You may be surprised to find these are readily available. With a little help from suppliers and like-minded institutions, you can set up a high-quality e-learning solution now, one that will save you training costs, build your reputation, and help support your unique healthcare mission.

Stephen Tucker is Director, Information Technology at the Baycrest Centre for Geriatric Care,Toronto, Ontario. He welcomes your comments and questions.

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