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Smart Phones Finding Voice in Health Care
Health Data Management Magazine, February 2006
"It's awesome to carry only one device," says Diamond, also a clinical assistant professor at the University of Washington School of Medicine, Seattle. "When I was using a cell phone and PDA, I sometimes wouldn't have both devices with me, so I either couldn't make calls or get the information I needed."
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Like many early smart phone adopters, however, Diamond isn't using his device to enter patient data or access complex clinical software or the Internet. "Data transmission speeds are slow and the memory capabilities are too limited," he says.
Smart phones, which have been on the market just over two years, are designed to be converged devices that provide the application functionality of PDAs with the voice capabilities of cell phones. They run on a variety of nationwide mobile phone networks, and some models are embedded with technology that enables them to be used over Wi-Fi networks.
Converged devices always generate a buzz when they hit the marketplace, and smart phones are no exception. However, like many first-generation technologies, the devices still have a ways to go before they match the hype.
"There are some kinks-including limited battery life-that need to be worked out before smart phones are widely adopted," says Lynne Bishop, an analyst at Forrester Research, Cambridge, Mass. "But they are still in their first generation, so users have some legitimate gripes about their limitations."
But there are encouraging signs for smart phones, Bishop believes. Adoption has been slow, but that can be expected because of the limited amount of health care applications for smart phones. However, clinicians have been more eager than general consumers to use the mobile devices because they are well suited for care delivery, Bishop says.
"There are many productivity and patient care benefits that can be gained by using smart phones in health care," she says. "We're still in the early phases of their use. But as more application vendors make their software available on smart phones and wireless infrastructures are upgraded and extended, this is the way medicine will go."
Early kinks
A plethora of clinical software vendors recently have designed applications that can be stored on smart phones.
The problem is that the devices have very limited memory compared with more established mobile hardware. For example, the Treo 650 has only 32 MB of memory, while Palm's LifeDrive PDA has 4 GB.
Diamond, who's using an earlier version of the Treo, quickly ran out of memory for his smart phone. He stores some reference applications on a flash card, which fits in the SD card slot on his smart phone. But limited memory is preventing him from purchasing more clinical reference applications for the device, he says.
Some smart phone applications don't require data to be stored on the devices. Many of these systems are designed to mobilize legacy software that runs on local area networks. But provider organizations often must make expensive upgrades to their infrastructures to ensure that they have the Wi-Fi signal strength or necessary connectivity to mobile phone networks to support these applications on smart phones, says Bishop, the consultant.
The price tag for such upgrades often is too high for small hospitals or group practices. As a result, smart phone adoption has been mostly limited to physicians who practice at large facilities that can afford such infrastructure, she adds.
Northeast Medical Center Hospital decided that smart phones could be worth the costs of infrastructure upgrades. The Humble, Texas-based hospital enhanced its mobile phone network coverage in part for a smart phone pilot study.
About 30 of the hospital's 300 physicians are using smart phones to access the organization's main clinical information system, from Reston, Va.-based QuadraMed Corp.
Northeast Medical Center is using software from Boston-based PatientKeeper Inc. to provide mobile access to the system. The I.T. department purchased the smart phones, but requires physicians to pay for data and voice services, which are provided by Sprint Corp., Overland Park, Kan.
Norman M. Sorgen, M.D., uses a Treo 650 smart phone to access patient data, including radiology reports, while making rounds in the hospital or doing everyday tasks-such as waiting in line at his bank-before heading to work. He also uses it to call colleagues if they have any treatment questions.
The hospital's I.T. staff had to talk Sorgen into switching to the Treo from his Palm PDA. But he now says his new device provides a lot more functionality.
"I can use my smart phone at the hospital, but it also enables me to access data while I'm not there," he says. "Now when I'm at a ballgame or at a friend's house, I can pull up patient data quickly and quietly."
Northeast Medical Center is playing to smart phone strengths-providing anytime, anywhere access to discrete bits of read-only data. Some industry observers question whether smart phones are suitable for more complex functions such as data entry.
"Smart phones are excellent devices for fairly singular applications, such as charge capture, or to look up lab data or other clinical information," says Bill Crounse, health care industry director for the health care and life sciences division at Microsoft Corp., Redmond, Wash.
Microsoft's Windows Mobile operating system runs on smart phones from a variety of hardware vendors. "But smart phones are never going to be the device for physicians to use for data entry while rounding. They need a bigger screen for that. Smart phones are good for delivering specific data to the point of care."
For that reason, Microsoft executives are hedging their bets by designing software that can run on a variety of mobile devices. "There's no way providers will only use smart phones," Crounse adds. "So it's not about getting everything onto a single device."
Palm executives, however, are encouraged by the increasing number of clinical applications being designed to run on smart phones, says Gail Moody, director of business and health care marketing at Palm, the company that markets PDAs and smart phones that run the Palm OS, a rival to Windows Mobile operating system.
While smart phone use in health care is increasing, many organizations are only supporting the devices for very specific functions, such as e-prescribing or clinical reference access, she says.
Expanding the market
Palm and Microsoft are fierce competitors in the smart phone market, but recently have reached an agreement that some experts say could help expand the presence of the devices in health care.
Under the agreement, Palm will make a version of its popular Treo smart phone that runs the Windows Mobile operating system instead of the Palm OS, which is owned by ACCESS Co. Ltd., Tokyo. The new Treo 700w was released in January.
Palm executives say the company is not abandoning the Palm OS but wants to focus on marketing its hardware and offering users more software options. The company believes the agreement will enable it to convince organizations and users who are "married" to the Window operating system to use Palm hardware, Moody says.
As a result, physicians will be using a lot more Treo smart phones, regardless of the operating system they run, says Charles Golvin, principal analyst at Forrester Research.
"Palm can tap a much larger audience of users and software developers with a Windows Mobile smart phone," he says. "The company also will gain a significant sales opportunity directly into enterprises because those buyers will be confident that the devices will integrate well with their applications."
Diamond, at The Doctors Clinic, uses a Treo 600 running the Palm OS operating system, but says he's interested in testing a Windows Mobile Treo. Diamond previously used a PDA from Toshiba America Information Systems Inc., Irvine, Calif., which ran Windows Mobile, so he is familiar with the operating system. He switched to the Palm OS for the smart phone, however, because synching the Windows Mobile PDA took too long, he says.
Microsoft, for its part, believes the agreement will help Windows Mobile catch up to the Palm OS in terms of the number of clinical applications running on the platform, Crounse says.
The Palm OS has had greater physician adoption than other mobile platforms because it's been the preferred system for clinical reference applications for several years, says Eric Brown, vice president at Forrester.
Palm hardware also has been superior to devices running other operating systems, he adds.
"Palm devices have been simpler, cheaper and lighter, which makes them attractive to physicians," Brown says.
But as physicians adopt more interactive applications, such as those for entering patient data, they are going to need software that can rely on local storage and integration with other systems. This might make a Windows-based mobile architecture more attractive to I.T. executives, he adds.
But Microsoft stands to gain more benefits from the deal than just increased smart phone applications, Golvin says.
"Windows Mobile now will run on the most desired hand-held in the market," he says. Further, a Treo that runs Windows Mobile will provide clinicians with more integrated access to e-mail and documents in other Microsoft applications, such as PowerPoint and Word, adds Crounse from Microsoft.
Consumers getting smart
Physicians and I.T. executives, however, aren't the only ones driving the use of clinical applications for smart phones. Consumers also could benefit from such systems, says David Brooks, principal at BCC Consulting, a Durham, N.C.-based health care consulting firm.
Right now, clinicians are ahead of the consumer market. The roles typically are reversed: Technology typically makes a splash in the consumer market, clinicians buy it for personal use, and then they start asking CIOs and I.T. departments why they can't use it at the office.
But when it comes to smart phones and PDAs, the percentage of physicians using the devices to connect to the Internet is "far and away ahead" of the consumer population, says Bishop at Forrester Research.
Brooks, however, believes that as smart phones become more widely adopted, patients likely will be the ones pushing the envelope.
For example, many patients might want to use their smart phones to receive medication reminders or send weight and blood pressure readings taken at home to physicians without having to use a computer.
In addition, physicians could receive patient monitoring data on their smart phones from medical devices at the hospital or in a patient's home. Then they could use the same device to call a patient while they are reviewing the data.
One such monitoring application for smart phones has already been developed. Telzuit Medical Technologies Inc. offers a cardiac monitoring patch that transmits data to a Treo smart phone. The Orlando, Fla.-based vendor's patch, which attaches to a patient's chest, uses Bluetooth technology to send the data.
The software copies the heart monitoring data, which is then transmitted via a smart phone to the vendor's servers. Physicians can access the data by logging into the vendor's Web site. Treos embedded with the application are rotated among patients. So far, a few health care organizations are testing the system, Telzuit executives say.
These and other types of monitoring applications are perfect for smart phones, Brooks says, because they don't require users to enter or analyze vast amounts of data simultaneously-tasks that often require large screens.
"Smart phones will never be a great place to do a lot of work, but instead are good for accessing information," he says. "The big applications will grab and select patient data."
Some patients already use smart phones to enter and receive small bits of information. A few clinical trials companies, including PHT Corp., Charlestown, Mass., have begun offering Treo smart phones to trial participants.
The devices have been used in a variety of PHT trials, including one where asthma patients entered their symptoms, medication use and impact of their asthma on their daily life into a smart phone.
They then sent the data to PHT's servers via a mobile network from Cingular Wireless, Atlanta. Trial sponsors were able to access the data via a secure Web application hosted by PHT.
The vendor has purchased more than 1,500 smart phones to use in clinical trials. While PHT still uses PDAs for many of its trials-it has purchased more than 18,000 of the devices-it cites the ability of smart phones to capture small bits of alphanumeric data and transmit the information via mobile phone networks as reasons for using the devices.
Overseas movement
Health care smart phone applications also are gaining some momentum overseas, according to Crounse at Microsoft.
In some countries-such as South Korea and China-that are experimenting with health care applications, smart phones have been more widely adopted by consumers compared with the United States, he says.
Some smart phone vendors also are testing applications for the mobile hardware overseas before releasing it in the United States. For example, select Samsung smart phones can receive patient monitoring data from Switzerland-based Card Guard AG's monitors. The user's blood pressure, blood glucose, pulse and heart monitor information can be sent over mobile phone networks to the devices, and then uploaded to the vendor's software.
Patients use the smart phones to view, store and send data from the devices to physicians via a secure Web page within the system.
Sidebar
Choosing the right smart phone, network servicePhysicians and provider organizations wanting to use smart phones previously were limited to the specific devices or operating systems that could support their software. Now that many clinical systems can run on various smart phones and mobile operating systems, choosing a device has become more complicated.
Though some smart phones run the Linux, Symbian OS, or other operating systems, most clinical applications are designed for the Palm OS or Windows Mobile operating systems. Palm Inc., Sunnyvale, Calif., manufacturers the Treo, the most widely used smart phone running the Palm OS.
Several vendors, however, including Palm, Audiovox, Hitachi, Symbol Technologies, Motorola, BenQ and Samsung, offer several models of Windows Mobile-based smart phones. Some of these vendors' devices have features, such as scanners, that are marketed for specific applications, such as asset tracking and inventory control. Other smart phones boast oversized screens or slide-out keyboards.
But the best smart phones are the ones that are equally good at offering PDA and mobile phone functions, contends David Brooks, principal at BCC Consulting, a Durham, N.C.-based health care consulting firm.
Until recently, the only mobile hardware that offered such convergence was the BlackBerry wireless communications device from Ontario-based Research In Motion Ltd., he says. But now other devices, such as the Treo smart phone from Palm, and some devices from BenQ, are coming close to offering a truly homogenous device, Brooks adds.
"What hybrid smart phones do is help break down barriers at the enterprise by offering applications that run well outside a facility," he says. "Their capabilities are driving the notion that eventually there will be just one device for PDA and phone functions."
Brooks recommends that users who want to use a smart phone for mostly data functions choose one that has better PDA capabilities. Users that need more calling features should choose a device that's more phone centric, he says.
They also should evaluate how mobile phone networks charge for data and voice functions on their devices before choosing one, Brooks adds.
Nurses at the Visiting Nurse Association of Florida Inc. use smart phones that are marketed as PDAs that have phone capabilities. Though he's happy with the devices, Bill Miller, executive vice president at the association, already is looking at replacing them.
The Stewart, Fla.-based organization last year purchased about 500 smart phones from Audiovox Corp., Hauppauge, N.Y., that run the Windows Mobile operating system. Nurses are using them to collect and send information from patient homes to the provider organization (see story, page 70).
One problem he has with the VNA's current smart phones is that the connection on their recharging cord is very fragile. The organization spends $30 a piece to replace a small clip that fits in the cord each time one breaks.
VNA of Florida is planning to replace all its smart phones within a year, though not solely because of the charging glitch.
It purchased the devices in the middle of their life cycle, a move that ensured the devices had many usability issues resolved and were cheaper than the newest models, Miller says. However, the smart phones have limited battery life compared with more recent models, another reason the organization is shopping around, he adds.
Miller has several other recommendations for provider organizations that plan to purchase smart phones in bulk:
* Test your software on the devices before making a large purchase. Tell your mobile phone network provider the uses of the smart phones and see if they'll let you test them for a month.
* Start purchasing early. Identify which device you want before you need it and begin buying 10% of the total amount at a time.
* If your device is being discontinued, see if you can buy a vendor's remaining stock.
* Evaluate mobile phone network providers. Ensure that their network coverage is strong in the areas that your clinicians will be working. Also, ensure that your provider can offer itemized bills so you have an easier time tracking clinician phone use.
Sidebar
VNA vocalizes support for smart phones
"Smart phones are a great device for applications where workers are truly mobile," he says. "They could enable users to document and access patient information remotely. But how many people actually need that level of access?"
Bill Miller, executive vice president at the Visiting Nurse Association of Florida Inc., believes his clinicians do. Most of their time is spent on the road at patients' homes, which means the organization puts a premium on enabling nurses to collect and share patient data.
A few years ago, VNA of Florida nurses were using notebook PCs at patient homes to enter and retrieve their information from an integrated clinical and administrative information system from Dallas-based Homecare Homebase. But the devices were heavy and bulky for nurses to carry, Miller says.
The organization then switched to PDAs-from Palo Alto, Calif.-based Hewlett-Packard Co.-to connect to the system. But nurses had to connect the PDA to a mobile phone when they wanted to retrieve or upload data. The devices were connected by cables that often broke, Miller says. So did the devices' charging cords.
"We wanted to use an all-in-one device," Miller says. "But there weren't a lot of smart phones on the market at the time so we were limited to devices that could support our software."
About a year ago, Miller purchased 500 smart phones from Audiovox Corp., Hauppauge, N.Y. The devices, which run the Windows Mobile operating system, enable nurses to access the main information system via a mobile phone network. VNA of Florida manages the hardware, as well as phone and data network service contracts for all the smart phones.
"We thought we'd have a difficult time training nurses on the new devices because they have a smaller screen than the PDAs they had been using," Miller says. "But they love them. Now they need one device to access the system as well as text message and call people in our office."
The devices, which have a 3.5-inch screen, are marketed as PDAs with phone capabilities. Other smart phones are marketed as phones that can run PDA operating systems. Some of these devices have 2 to 3-inch screens, which can render them difficult for reading and entering vast amounts of data.
The Audiovox devices feature both a stylus and a virtual keyboard, which nurses use for data entry. Further, the Homecare Homebase application enables nurses to enter data via drop-down boxes, so there's not a lot of typing required, Miller says. Nurses enter both patient and administrative data, such as the exact time they arrived at and left a patient's home. "But all the data boxes have a free-text option," Miller adds. "You can't depend on patients to always fit inside the box."
Nurses then synch the devices over a mobile phone network from Verizon Wireless, Bedminster, N.J., by pressing a button. The synch, which sends the data to the vendor's servers, erases all patient data from the smart phone. The software then analyzes the newly uploaded data to generate billing, payroll and supply reports. VNA of Florida administrative staff can access the data from the vendor's servers.
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