Cell Phones, PDAs, and EHR Systems

Shepherdstown 22 June 2007Just as the information technology infrastructure of the past evolved to support outpatient care, now it must transform even more radically by becoming clinically driven inside of care facilities while also extending itself to go mobile and virtual with customer patients. The "smart" electronic health record (EHR) systems of the future will deliver needed information, services, and data via mobile, multi-purpose devices anywhere, anytime.

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Imagine a small mobile multipurpose (MMD) communication and coaching device that has a phone, embedded health-coach software, GPS, instant messaging, camera, music player, and e-money dispenser, all of which are interconnected to deliver health care to active, busy citizens.

Imagine a health care system in which digital and mobile technologies, medical knowledge at the point of need, enabling collaboration amongst providers so they can deliver better, safer, high-quality care for everyone.

Imagine a health care system where primary care physicians have access to your specialty medical information and specialists have access to your primary care information via inter-connected "smart" EHRs that are integrated with personalized eHealth service providers and delivered directly to a multi-purpose, intelligent, mobile digital device carried in one's pocket.

Cell phones linked to EHR systems have the potential to revolutionize health care in the coming decade. This article attempts to pull together relevant information about the development of integrated solutions in health care to date involving the use of cell phone technology in health care with an emphasis on their integration and use with electronic health record (EHR) systems. This article highlights selected issues of concern and offers a set of recommendations to health care organizations on possible next steps to begin taking. In the coming decade, the use of cell phone technology interfaced to EHR systems will dramatically change the daily clinical practices of many health care providers and the lives of their patients.

Cell Phone/Mobile Technologies

A cell phone is a long-range, portable electronic device used for mobile communication. In addition to the standard voice functions of a telephone, current mobile phones can support many additional services such as text messaging, e-mail, access to the Internet, and sending and receiving pictures. Today, most mobile phones connect to a cellular network, which is in turn interconnected to the public switched telephone network.

According to Wikipedia, the first fully automatic mobile phone system was developed by Ericsson and commercially released in Sweden in 1956. One of the first truly successful public commercial mobile phone networks was the Autoradiopuhelin (ARP) network in Finland, launched in 1971. ARP is sometimes viewed as a zeroth generation (0G) cellular network, being slightly above previous proprietary and limited coverage networks.

First generation (1G) - The first handheld mobile phone to become commercially available was the Motorola DynaTAC 8000X in 1983. Mobile phones began to proliferate through the 1980s with the introduction of "cellular" phones based on cellular networks, although analog transmission was in use in all systems.

Second generation (2G) - In the 1990s, second generation mobile phone systems began to be introduced. The first digital cellular phone call was made in the United States in 1990. In 1991, the first GSM network opened in Europe. Coinciding with the introduction of 2G systems was a trend away from the larger "brick" phones toward tiny 100-200g hand-held devices, which soon became the norm. This change was possible through technological improvements such as more advanced batteries and more energy-efficient electronics.

Third generation (3G) - At the beginning of the 21st century, third generation mobile phone systems began to be publicly available. These systems are continuing to evolve. Live streaming of radio and television to 3G handsets is one feature of this new generation of mobile cellular phone systems.

In fewer than twenty years, mobile phones have gone from being rare and expensive pieces of equipment used primarily by the business elite, to a pervasive low-cost personal item. In many countries, mobile phones now outnumber land-line telephones, with most adults and many children now owning mobile phones. The total number of mobile phone subscribers in the world was estimated at 2.14 billion in 2005.

Cell Phones In Health Care

Physicians today can acquire a mobile practice companion, using either a PDA or cell phone device, which offers immediate and secure access to critical clinical information when and where they need it to help them provide patient care. One of the biggest challenges for mobile computing vendors is to provide deeper and broader functionality. Expect mobile computing and/or cell phone companies to continue to expand the functional capability of their devices to perform such tasks as prescription lookup and renewal, viewing selected medical record information, charge capture, clinical messaging, and physician order entry over the coming years. The complexity of developing mobile and wireless medical applications, combined with a lack of standards, have hampered innovation in this area.

In an article entitled "Better Health Well in Hand" by Peter Boland, Ph.D., recently published in Healthcare Informatics, he states, "Since chronic conditions require day-to-day monitoring and management for years on end, patients need daily feedback and social support to stay on top of their condition and avoid costly life-threatening situations that can flare up. Likewise, care management teams need to efficiently monitor a range of patient symptoms - as they are occurring - in order to adjust medical regimens, actions plans, medications and office visits as needed. Medically relevant information, such as patient-generated data on symptoms and provider feedback on changes in medical regimen, is very time sensitive and must be exchanged quickly and securely. This strongly suggests that cell phones will be the primary vehicles for patient-provider communication in the future."

In the examples below, you will see a variety of ways that cell phones and PDAs are already beginning to be used in health care to monitor vital signs and respiration rates, analyze EKG patterns and send the information to a call center or EHR systems, store emergency medical information, maintain personal health records, locate wandering patients, connect providers to patients, put accurate information immediately at the clinician's fingertips when needed, and so much more.

Selected Examples of Cell Phone Technology Used in Health Care

SkyScape's MedAlert is a new service that delivers comprehensive medical reference alerts by specialty to your cell phone. Now, it's easier than ever to stay updated on your specialty without having to read voluminous articles and news releases. You simply choose Journal summaries and breaking medical news resources that interest you and have them sent directly to your cell phone. MedAlert allows you to instantly improve your efficiency and productivity while greatly enhancing patient satisfaction at point of care. See http://www.skyscape.com/estore/productdetail_medalert.aspx

CellularMD is the first mobility suite available that health care enables the device providers already carry: their cell phone. CellularMD isn't a cell phone, but a suite of health care applications that can be loaded on many of today's cell phones and PDAs. The suite mobilizes the health care tasks of dictation, document signature, prescription, billing and more. To complete the picture, remember all of the functionality of today's organizer applications: calendar, scheduler, address book, e-mail, instant messaging and more. See http://www.softsource.net/products-CellularMD.htm

MedicTouch Pulse Meter - MedicTouch LLC, developer of the first cellular wearable health and wellness devices, and Sun Microsystems Inc., launched the Pulse Meter mobile health solution for Java technology-enabled mobile phone in 2004. MedicTouch Pulse Meter is the first mobile health and wellness monitor that allows users to monitor their pulse, view the results in a high-resolution screen on a Java technology-enabled mobile phone, and transmit the data to a Java compliant server. The Pulse Meter and Java mobile phone combination creates an ideal health monitoring solution for sport enthusiasts, the elderly, rehabilitation outpatients and health care providers; providing health monitoring anytime, anyplace, anywhere. See http://www.hoise.com/vmw/04/articles/vmw/LV-VM-05-04-25.html

Wherifone - Wherify Wireless Inc. is a developer of patented wireless location solutions and services for family safety and communications. In 2006 it was reported that their Wherifone was the world's first GSM/GPS locator cell phone designed specifically for children and seniors. The two-way cell phone has built-in Aided-GPS location and "managed dial" features that allow family and care providers to quickly locate and communicate with their elderly patients and relatives.

NTT Docomo has deviced a mobile phone based medical records database for nurses and doctors on the move. On Nikkei.net it was recently reported that the password-protected system is being used by the Kameda Medical Center who visit around 200 patients in the region. The data is viewed using the Docomo Foma 3G handset and the system lets the doctors and nurses access the patients' hospital records.

Wireless Obstetrics Monitoring Device - In October 2006, Virtual Medical Worlds reported that Fairview Hospital was the first hospital in the United States to use a new wireless technology to monitor the progress of high-risk pregnancies and other obstetrics patients remotely. The wireless technology allows obstetricians to use their personal digital assistants (PDAs) or Smart Phones to remotely access fetal heart tracings, maternal contraction patterns, up-to-date nursing notes, and other critical, virtual real-time data transmitted from the hospital's labor and delivery unit. See http://www.hoise.com/vmw/06/articles/vmw/LV-VM-11-06-35.html

Ring Sensor is an ambulatory, telemetric, continuous health monitoring device developed by d'Arbeloff Laboratory for Information Systems and Technology at MIT. It combines basic photo plethysmographic techniques with low-power telemetry. Worn by the patient as a finger ring, it is capable of monitoring vital signs related to cardiovascular health. Remote monitoring is possible via a wireless link transmitting patient's vital signs to a cellular phone or computer. According to an April 2004 article in Technology Review, clinical trials have been done in conjunction with Massachusetts General Hospital's emergency room, and researchers are now working on commercialization of the ring-sized device. See http://darbelofflab.mit.edu/ring_sensor/ring_sensor.htm

LifeComm - San Diego wireless technology giant Qualcomm is planning to launch a mobile network that would allow people to use their cell phones to manage myriad health issues including diabetes and dieting. Called LifeComm, the service would offer cell phones that could double as glucose meters to monitor blood sugar levels in diabetics, track aerobic activity in dieters or otherwise function as a medical device. The new wireless phone service is expected to launch in 2008 in the United States. See http://www.signonsandiego.com/news/business/20070518-9999-1b18mvno.html

Clinical Imaging - Use of cell phones to send images via e-mail to consulting physicians at remote locations appears to be a feasible approach for visualization of chronic leg ulcerations, according to an article in the February 2005 issue of the Archives of Dermatology, one of the JAMA/Archives journals. See http://www.hoise.com/vmw/05/articles/vmw/LV-VM-03-05-16.html

As of July 2007, Life Record was pleased to be the first and only EMR to run perfectly on the Apple iPhone. Life Record EMR is an Electronic Medical Record application for use in medical practices of all types. Given the recent buzz about the iPhone, we had to include this in the article. See http://emr.liferecord.com/

Finally, in an article from ScienceDaily.com, it was reported that a Michigan hospital has cut in half the time it takes to begin life-saving treatment of heart attack patients by using cell phones to transmit electrocardiograms (ECG) from the field, according to a study published in the November 2005 issue of Catheterization and Cardiovascular Interventions: Journal of the Society for Cardiovascular Angiography and Interventions. According to the article, "An emergency room physician reviews the ECG and, if the patient is having a heart attack, calls in the cardiac catheterization team even before the ambulance arrives at the hospital. The result - The patient is immediately whisked to the cardiovascular cath lab, where an interventional cardiologist opens the blocked coronary artery, restoring blood flow to the heart." See http://www.sciencedaily.com/releases/2005/10/051015092957.htm

Cell Phones, PDAs, and EHR Systems

In addition to the above, there are a growing number of other examples clearly showing that the use of cell phones or PDAs to view or interact with a patient's electronic health record (EHR) continue to grow and evolve rapidly. As hospitals and clinics acquire EHR systems over this next decade, cell phones and PDAs will be an integral part of the architecture that is deployed. The following are just a few examples that illustrate what is happening in this arena.

When handheld personal digital assistants hit the market in the late 1990s, the Army's Telemedicine and Advanced Technology Research Center (TATRC) immediately started exploring how clinicians could use them, both on the battlefield and in military treatment facilities. Medical PDAs - called MDAs at TATRC - can improve medical record keeping, give providers instant access to medical information and patient histories, alert providers to lab results, speed up the flow of patient information among providers and commanders, and may shorten the time first responders spend on the battlefield filling out forms. For more information about this and other innovations visit www.tatrc.org

According to a recent article in Information Week, starting at the end of March 2007, Blue Cross of Northeastern Pennsylvania plans to provide 100,000 of its members - and later all 600,000 - electronic access to their and their dependents' personal health records. The information, which includes recent diagnoses, prescribed medications, and immunizations, will be culled from the insurer's claims data and information that members provide. "It's not a complete record, but it will have relevant diagnoses and drug information, which members can share with doctors or others", said Dr. Drew Palin, Chief Development Officer at Blue Cross of Northeastern Pennsylvania. Members will be able to access their information from cell phones, as well as PDAs and PCs. See http://www.informationweek.com/industries/showArticle.jhtml?articleID=197001014

PocketMD - is in wide use throughout the nation's system of Veterans hospitals. Pocket MD uses Windows Mobile and Pocket PCs. With it, doctors have wireless access to complete patient records stored in the Veterans Health Administration VistA database. Pocket MD, based in Fargo, N.D., is working on extensions for its product that would enable doctors to update patient records on the fly, order medications, and record vital signs. While originally designed around the VA's highly acclaimed VistA Computerized Patient Record System (CPRS), PocketMD now supports a full array of commercial legacy EHR systems from McKesson to Cerner, Siemens, and MEDITECH. See http://www.pocketmd.com/

Other Selected Issues - Privacy, Security, and Patient Safety

One concern about the future of the wireless enterprise network has to do with the privacy and security of patient data. Use of available access control, encryption, VPN, and other technologies, coupled with effective policy and procedures, should resolve these types of concerns. In the end, it is not whether it is here to stay, but rather the extent to which we have the foresight to fully exploit cell phone technology while preserving the privacy and security of the individual's health information.

With regards to patient safety, in a recent study researchers presented figures and observations saying cell phones bring more timely communication to hospital care, and no longer present a significant danger of electronic magnetic interference with hospital equipment. The study, published in February in Anesthesia & Analgesia, is believed to be the first to investigate whether use of cell phones by medical personnel has a beneficial impact on patient safety. See http://www.ergoweb.com/news/detail.cfm?id=1265

Recommended Next Steps

Cell phone and/or mobile technologies, will revolutionize health care in the coming decade and will change the daily business practices of health care organizations and enhance how they provide patient care. The following set of recommendations is presented on possible next steps for large health care provider organizations to take:
  • Consider establishing a multi-disciplinary Mobile Technology working group.
  • Monitor and obtain lessons learned from existing cell phone or mobile medical technology projects around the world.
  • Consider becoming actively involved in selected mobile technology research and development (R&D) efforts that relate to the delivery of patient-centric health care and health information systems.
  • Identify cell phone or mobile medical technology pilot projects involving product development and implementation that may specifically benefit your patients in the future.
  • Conduct Cost-Benefit Analysis and Return On Investment (ROI) studies for these type of initiatives before making any major commitment by your organization.
  • Investigate changes in clinical practices and business processes that your organization may need to make in anticipation of implementing mobile technology applications/devices in the future.
  • Recognize that applications utilizing this technology will begin to mature very rapidly over the next 5-10 years.

The authors delve deeper into this area of cell phones, mobile technologies, and their use in health care of the future in their book entitled "Medical Informatics 2020", published in January 2007 by Jones & Bartlett. See http://www.jbpub.com/catalog/0763739251. Also, consider visiting the Virtual Center for Collaboration, Open Solutions, and Innovation (COSI) in Healthcare at www.shepherd.edu/surc/cosi

Authors:

Peter J. Groen is on the faculty of the Computer & Information Science Department at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation - see www.shepherd.edu/surc

Marc Wine is a coordinator for Intergovermental Health IT within the Office of Intergovernmental Solutions at the U.S. General Services Administration (GSA). He also is a guest lecturer on Medical Informatics at the George Washington University in Washington, D.C.

Douglas Goldstein is an "eFuturist", author, guest speaker, and CEO of Medical Alliances, Inc. See www.medicalalliance.com


Peter Groen, Marc Wine, Douglas Goldstein

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