CAS Quarterly Meeting Financials

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Open Platform Standards and Collaborative eHealth
Development for Saving Time, Saving Money, and
Saving LivesDr. Jeff Sutherland, Chief
Technology OfficereHealth Developers Summit
2001 November 15-16,
2001, Aptos, CA
Turning the Promise of Mobile Computing into a
Reality
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The Problem

• The average large healthcare delivery system does
  not bill for gt10 of procedures rendered. As a
  result, many are losing money, losing staff, and
  losing quality of care.
• Medical error is the third leading cause of death
  in the U.S. after heart disease and cancer.
  50-100 of the largest group of lives lost,
  caused by medication error, can be saved by
  having the right information at the point of
  care.
• Mobilization of medical data is the fastest (and
  perhaps only) path to physician adoption of
  critical clinical automation.
• Right data on the right patient, at the right
  time and right place, for the right person is key
  to efficient operations and patient safety.
• The burden of harm conveyed by the collective
  impact of our healthcare quality problems is
  staggering Our present efforts resemble a team
  of engineers trying to break the sound barrier by
  tinkering with a Model T Ford. National Institute
  of Medicine, 2001

3
The Environment

• Neurosurgeon Hopf and a dozen other physicians
  eliminated one hour of paperwork at the end of
  every day.
• Realtime access/update of patient records.
• Low RF radiation and days of battery life on easy
  to use Palm device.
• Faster claims processing.

4
Growth of Mobile Subscribers
CSH study demonstrates strong reason for mobile
device growth
Mobile Devices
PCs
Source Morgan Stanley Dean Witter Equity
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Device of the month
Source Wireless and Mobile Computing. First
Consulting Group, Oct 2001.
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Clinical Use of PDAs
Source Wireless and Mobile Computing. First
Consulting Group, Oct 2001.
Bluetooth
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Everything is going mobile

• Biohazard Detector - researchers develop toxin
  detector that can plug into a PDA to sniff out
  harmful agents in seconds.
• A 1997 study in The Journal of Infection Control
  and Hospital Epidemiology found that 42 percent
  of hospital personnel who touched only the
  surfaces of the rooms of contaminated patients
  ended up with drug-resistant microbes on their
  gloves.
• ActiveECG is an inexpensive, handheld cardiac
  monitor that works with your existing Palm OS
  handheld computer.

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Mobile Platform is Required

• A common mobile platform is required for
  enterprise deployment and automated management of
  handheld computer applications.
• Open standards will be required to allow
  interoperable, independently authored third party
  applications to be deployed on a single handheld
  device chosen by a clinician.
• Business models need to be developed to allow a
  single physician, a three person development team
  in a garage, a healthcare application
  provider, or a large HIS enterprise vendor to
  simultaneously deliver well integrated software
  on a common mobile platform.

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Why a Platform Strategy?

• Key issues
• Physicians using personally owned PDAs and
  freeware applications in their workflow.
• A comprehensive, long-term strategy for
  centralized control of deployment, management,
  and update of handheld applications throughout
  the enterprise is essential.
• Clinicians want all future applications on a
  single PDA.
• Clinicians want multiple applications to
  interoperate seamlessly on a single PDA (like
  Outlook, which makes multiple applications
  function as one).
• Nurses and other allied health professionals, as
  well as physicians, must be supported.

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Devices, Applications, Scalability

• Multiple device types and interfaces are demanded
  by different clinicians. Each new device of the
  month requires expansion of platform
  capabilities.
• Independently authored, third party applications
  that seamlessly integrate with other applications
  on a single PDA must be supported.
• A mobility platform must scale to support a
  rapidly increasing number of applications for
  different specialties and clinics.
• Large amounts of information that must stored and
  managed for expanding mobile applications.

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Integration, Reliability, Performance

• Expanding mobile applications require integration
  with many backend systems.
• Open adapters for XML component integration
• Standard interface libraries
• Many EMPI and CDR integration issues must be
  supported.
• A platform must support always ready operation,
  multiple types of synchronization, and more than
  a dozen modes of wireless transport.
• Remote monitoring of the mobile infrastructure is
  critical. Internet brownout, wireless dead spots,
  router and firewall breakdown must be addressed
  by hardware redundancy and automated failover.

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PDA Platform Requirements

• Patient-centric workflow
• Patient context management
• Messaging and alerting
• Palm OS and Win CE framework support
• Intra-application messaging between independently
  authored applications
• Automated application installation and update
• Server monitoring of mobile hardware, software,
  and transactions

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Server Platform Requirements
N Applications
MultipleDevice Types
SDK
MobileDevice
SingleSign on
ApplicationInteroperability
Patient ContextManagement
Security
Application Framework
Handheld Data Store
MobileCommunications
MobilePatient Index
Mobile Services
TransportWireless orEthernet
HIPAAAudit Trail
Web Reports
CentralAdministration
Messaging Alerting
Personalization
Transactions
Servers Staging Integration Interfaces
JAVA
XML
HTML
Business Logic
PK Objects
Adapter Components/Open API
Mobile Legacy Integration
Mobile ClinicalRepository
MobilePatient Index
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Web Reporting Requirements

• Real-time utilization reports online, supports
  zero latency operations
• Administrators can review reports by department
• Clinicians can obtain an overview of patient
  administrative and clinical data
• Lab can quickly summarize which tests are most
  often requested or how many stat lab requests are
  made
• Most current, complete, accurate, and available
  data in the enterprise

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Managing Application Portfolios

• TaskKeeper
• NoteKeeper
• PlanKeeper
• RxKeeper
• Procedure-Keeper
• 3rd Party Apps

• ChargeKeeper
• LabKeeper
• DxKeeper
• InfoKeeper
• MemoKeeper
• 3rd Party Apps

Personal Applications
Enterprise Applications
mPI
One Mobile Device
One User Interface
Any Device

• Any Transport
• Ethernet cradles
• 802.11
• Bluetooth
• Cellular

Single Signon Context sharing Hard encryption
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Lots of lives to save

• Medical error is the 3rd largest cause of death
  in the U.S. exceeded only by heart disease and
  cancer. (JAMA, July 26, 2000, p 483)
• 12,000 deaths/year from unnecessary surgery
• 7,000 deaths/year from medication errors in
  hospitals
• 20,000 deaths/year from other errors in hospitals
• 80,000 deaths/year from nosocomial infections in
  hospitals
• 106,000 deaths/year from adverse effects of
  medications (4th leading cause of death)
• 50-90 of medication errors can be eliminated at
  time of installation of automation at the point
  of care.
• There is a growing conviction in all hospitals,
  even in those which are best conducted, there is
  a great and unnecessary waste of life.
  Florence Nightingale, 1859

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Point of Care Automation Results
Malcolm, B. Carlson, R.A. Tucker, C.L.
Willette, C. Veterans Affairs Eliminating
Medication Errors Through Point of Care Devices.
Proceedings of HIMSS 2000, Session 73, Dallas.
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PDA Medical Record

• All essential medical data on a Palm Pilot or
  PocketPC.
• Designed to integrate with global medical data
  system.
• Personal care, home care, and military care
• Former Surgeon General of the Navy evaluated this
  application as the best portable medical record
  available for soldiers or government employees
  and far superior to current smart cards.

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Generalized eXtensible Medical Record NCVHS 1999
Primary Data MGH Boston
Seattle Clinic Visit
My URL
First pass could be visualization of accessible
data by the physician and patient. This requires
a minimal level of standardization. It would be
of great use and help to focus attention on what
needs standardization and in what
priority. Mobilization of medical data essential
to reach the physician at point of care.
HL7 Methods
History Dallas
NCVHS XML tag definitions

• GXMR Requirements
• Patient identification capability
• XML everywhere
• Government facilitates efforts of standards
  bodies and assures a single security model
• HISB organizations standardize data descriptors,
  tranformations, object/component models
• Infrastructure based on W3C Internet protocols

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RF/Bluetooth Sensing

• Keeps track of movement of patients, people,
  instruments, supplies.
• PDA senses what is in the room and what state
  each device in the area is in.
• PDA automatically calles up patient in room and
  checks current state of patients, meds,
  condition, etc.
• Doc opens PDA for the first time and all this is
  displayed.
• Doc walks to large format terminal and beams PDA
  state to terminal which automatically logs him in
  and brings up multiple applications with current
  patient information on screen as s/he sits down.

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Standards Focus

• Open SDK on PDAs
• Universal mobile user interface with
  interoperability framework
• Open Adapters to Frontend and Backend Systems
• Standard database technology RDBMS independent
• TCP/IP/HTTP interactions for global
  interoperability
• W3C standards, particularly XML set of standards
• Device and wireless protocol agnostic
• Standard Interface Libraries
• Healthcare standards HL7, CCOW, HIPAA,
• Component technologies allow faster, better,
  cheaper integration
• Java server technologies for cross platform
  portability
• .NET support for Microsoft portable and desktop
  clients

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Clinician Value Proposition

• Value to clinician users
• Applications-based (efficiency, error-reduction,
  lost revenue, etc.)
• Common UI and patient-centricity(Increase
  adoption and reduce training)
• Access to greater functionality sooner
• Not painted in a corner integrate best of
  breed mobile applications
• Flexibility to create own applications(e.g.,
  protocols to influence physician behavior)

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Hospital Value Proposition

• Value to hospital decision makers
• Centralized administration
• Enterprise-wide controls to help manage the
  organic growth of PDAs (e.g., HIPAA)
• Not painted in a corner
• integrate best of breed mobile applications
• develop own applications
• force another vendor to port their application to
  a common framework
• Often PatientKeeper Personal is already in use

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Developer Value Proposition

• Value to the developer community
• Lowered barrier to entry for application creation
• Shorten time to market
• Create portfolio effect Crossing the Chasm
• A installed base to sell into distribution
  channel
• Leverage with component technology vendors (e.g.,
  encryption, Infrared printing, barcode scanning,
  wireless networks, etc.)