Mobile Health System Selection

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Mobile Health System Selection Implementation
for Medical Professionals

• A / Prof Graeme K Hart
• Clinical Co-ordinator Electronic Health Record
  Project
• Deputy Director Department of Intensive Care
• November, 2003

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What Drives Me as a Clinician in 2004

• Improving Quality and Safety of Care for my
  Patients
• Breaking Down Artificial Silos of Care
• Making Life Simpler and Easier for me, Colleagues
  and Patients
• Improving Cost Effectiveness of my activities
  (Hopefully )

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What is Quality in Health?

• ..degree to which health services for individuals
  and populations increase the likelihood of
  desired health outcomes and are consistent with
  current professional knowledge
• Boyce et al 1997
• and reduces the probability of undesired
  outcomes
• US Office of Technology Assessment

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Assessment of New Technologies
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Dimensions of Quality

• EFFECTIVENESS
• What is the right thing to do ?
• Access to Current Guidelines / Protocols
• APPROPRIATENESS
• Was the right thing done to this person?
• Pathway and decision point audit
• PERFORMANCE
• Was the right thing done properly and well?
• Practitioner and Safety / technical quality audit
• OUTCOME
• Was entire process acceptable?
• Long term follow up clinical and satisfaction

Continuous Audit Feedback
Fletcher M, The Quality of Australian Healthcare
Current Issues and Future Directions.
Commonwealth Dept Health and Aged Care
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Any New IT System (mobile or fixed)

• MUST be able to fulfill the Clinical Quality
  Cycle criteria

• As well as fulfill
• Standards for Mobile Quality
• Wireless Security
• Communications (802.11b/g)
• Robustness
• Non interference with medical equipment
• Compatability with other communications devices
  nurse call / paging

• As well as fulfill
• Standards for IT Quality
• Interoperability
• Reliability
• Safety
• Fail Safe
• Security
• Robustness

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General Enabling Issues for Health IT

• Terminologies
• Reference databases
• Interoperability
• Governance of Decision Support Information
• Privacy
• Security
• Legislative eSignature, PKI,
• Cost / Benefit, support, evolution, system
  interfacing

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My Grounding Zone

• Why Health Care Information Systems Succeed of
  Fail.
• Heeks R, Mundy D, Salazar A.
• Information systems for public sector management
  working paper series 9. ISBN 1 9025 1825 X
• www.man.ac.uk/idpm

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Why Health Care Information Systems Succeed of
Fail Issues

• Understanding past experiences
• Dimensions of Change Reality Gaps
• Archetypes of HCIS Failure
• Gaps between FORMAL rationality and BEHAVIOURAL
  reality
• Gaps between context of DESIGN and IMPLEMENTATION
• Public Private Sector Gaps
• Country Gaps
• Gap Closure Techniques
• Heeks R, Mundy D, Salazar A
• Information systems for public sector management
  working paper series 9.
• ISBN 1 9025 1825 X
  www.man.ac.uk/idpm

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FORMAL rationality and BEHAVIOURAL reality

• Hard rational, Logical model vs Soft Human
  Behaviourist Model of Organisational Behaviour
• Technical rationality
• Managerial rationality
• Medical rationality
• Design and Implementation based on power base of
  controlling agency.
• IT or finance based conception and control may
  not relate to the vagaries of human interaction
  at patient / clinician interface or at health
  care provider / machine interface.

Heeks R, Mundy D, Salazar A Information systems
for public sector management working paper series
9. ISBN 1 9025 1825 X
www.man.ac.uk/idpm
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Whose Objectives are we addressing?

• Success of new delivery model may depend on
  whether the implementation is a Push or Pull
  Model
• Finance
• Administration
• Clinicians
• Patients
• Do the people (users / recipients) with the power
  to sabotage believe in the need?
• Do all participants share the benefits?
• Degree of Ownership and Empowerment of Users

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Solutions need well defined Questions

• Design of Mobile Solution dependent on
• Needs analysis
• Organisation, Health Care Provider, Patient /
  Client
• Scope of Solution depends on
• Problem to be Solved
• Financial Resources
• Technical Capabilities

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Identify Consumer Needs

• Who is the (Health IT) Consumers?
• What are their needs
• Clearly define the outcomes required
• Senior managers often dont understand work flow
  at different levels of organisation
• Software design facilitated by close
  observational work flow study
• Off the shelf software may need substantial
  local modification

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Organisational and Individual Culture

• Organisation and Individuals must see issues in
  same way
• Health IT becoming Fundamental
• BUSINESS CLINICAL processes
• Many issues beside the computer
• Organisational inertia large ships change
  direction slowly
• Fragmentation of culture
• Academic, Clerical, Clinical, Administrative, IT
• Mismatch of Goals Fragmentation Non
  sustainability

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Implementation

• Incremental vs Big Bang
• Integration with previous documentation
• Fail over strategies
• Training
• Go Live user support
• Post implementation assessment
• Publication of the experience.

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ITPOSMO case studies criteria
Match Solution to Need !

• Information delivered matches need
• Technology delivery vehicle matched to user
  and information
• Processes pre-existing behaviour not changed
• Objectives and Values information matches real
  needs
• Staffing and Skills training and delivery
  adequately supported
• Management and structures minimise
  organisational change
• Other Resources Money and Time affordable and
  available on demand

Heeks R, Mundy D, Salazar A Information systems
for public sector management working paper series
9. ISBN 1 9025 1825 X
www.man.ac.uk/idpm
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Whats so Special about Mobility?

• Reality of relevant clinical and decision support
  information at Point Of Care
• Hospital vs Home
• Matching technology to workflow
• vs
• Adapting workflow to leverage technology

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Is there a real benefit - Show me the data !

• Should we consider Informatics differently to
  other medical technology??
• Very little objective data in the medical
  literature
• Differentiate Electronic Health / CDS vs user
  interface-delivery method
• to support the most common medical treatment
  outcome criteria
• 28 day mortality, Hospital Length of Stay,
  Quality of Life
• What intermediate outcomes are available?
• Satisfaction, Cost, Quality of Care, Error
  reduction
• Almost no data published at Level 1 Evidence
• Much of it conflicting, poor methodology

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Literature Base

• Medicine slow to catch up with Industry
  extrapolate from S M!
• IT Publications with Vendor Valedictories
• Informatics Journals Rarely data driven reports
• Almost never randomised or multicentre trial of
  efficacy or patient outcome
• Domain specific general areas using mobile
  technology as part of overall system
• Anesthesia, medications management, community
• Journals often difficult to source because not
  mainstream holdings in many libraries

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Descriptive studies

• Locations
• Hospital, GP and Specialist Office,
• Nursing Community ,Home, Ambulance etc
• Functions
• Prescribing and Administration
• Pain service
• Access to laboratory data
• Decision support
• Clinical notes and Observations
• Work Lists
• Technology
• User interface laptop on wheels, Notebook, PDA,
  video, telemetry, composite
• Docking, Wireless LAN, Wireless WAN

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Taking the Technology to the Point of Care

• Technological Limitations
• Hardware
• Networks
• Applications
• User / Support limitations
• Consumer limitations

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What kind of a User Device should I buy?

• Important distinctions should be considered,
• Define the primary function of your future (eg)
  PDA
• appointment book vs. clinical reference vs.
  charting
• Search for applications
• based on needs of the user
• Define operating system that the application is
  compatible with - data / software cannot
  (necessarily) be transferred between systems
• Define a device
• colour screen versus monochrome
• memory (devices with add-on memory)
• communications capability
• add-on capacities
• bar code scanner
• Ruggedised
• Transportability, battery life

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One Size Fits All ? Convergence Confusion!
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Selection

• Software
• Hardware
• Network Architecture
• Support and Maintenance

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Work Flow and Location

• Hospital locations are not all equivalent.
• ICU bedside CIS vs Wards vs Operating Room vs
  Outpatients
• Reality of Old Building stock space, benches,
  wireless difficulty, asbestos
• Community Locations
• Fixed clinics, GP, community centres, psych
  support
• Domiciliary
• Ambulance and emergency support

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The New Mobile Environment
Ref www.airprism.com
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Security of WLAN

• Rogue Wireless Deployments
• Malicious Hackers
• Meeting Security Requirements
• Performance Management and Troubleshooting
• Manage the Airwaves
• Stateless (semi-automated) and stateful
  (automated system monitoring)
• (Theft / loss of devices containing confidential
  information)

Deploying Secure, Reliable Wireless LANs in the
Healthcare Environment Bill Sims
www.rsleads.com/304ht-208
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Acute pain management service visit cycle
baseline mode
Paper Based record system Electronic data only
for registration and laboratory data access
David H. Goldstein MB BCH MSC FRCPC, Elizabeth G.
VanDenKerkhof RN DRPH, Michael J. Rimmer A Model
for Real Time Information at the Patients Side
Using Portable Computers on an Acute Pain
Service CAN J ANESTH 2002 49 7 pp 749754
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Acute pain management service visit cycle
radio frequency mode.
Electronic record system Electronic data from
registration and laboratory data
access Integrated with treatment, OR safety and
procedure check, medications and allergies
David H. Goldstein MB BCH MSC FRCPC, Elizabeth G.
VanDenKerkhof RN DRPH, Michael J. Rimmer A Model
for Real Time Information at the Patients Side
Using Portable Computers on an Acute Pain
Service CAN J ANESTH 2002 49 7 pp 749754
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Technical concerns - PDA

• Constrained OS functionality
• Screen size and display capability
• Battery life no onboard storage device
• Recovery of lost data
• Numerous operating system standards
• Palm OS, Windows ,Windows CE,
• Personal vs corporate use
• Security
• Loss
• Network security
• Physical Network connection
• Cradle, Wire, IR, RF Wireless

Ref 5 hurdles to Successful Mobile and Wireless
Deployments www.airprism.com
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Decision Support Information

• Major current use (may be platform specific)
• Locally Developed
• Protocols, pathways, advice, local formulary
• Information vendors / standards /
  interoperability
• Commercial
• Australia and New Zealand
• US European may have significant differences in
  formulary and usage information
• Integration into Workflow depends on planning,
  software implementation and device / information
  format matching

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Specific Applications currently Live

• Physicians Consultations and Procedure Log Books
• Medications Management
• Pain services
• Pathology Vital and specimen collection
• Observations entry
• Positive patient ID
• Inventory/supply management
• Nursing order and Worklists
• Tracking of records, X-rays
• Ambulatory, Ambulance and Community

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Mobile Emergency Services
Sweden (IS SWEDE ) Hand held computer radio
linked to hospital base. EmergencyDemographics
and vital signs transmission Routine daily
call schedules and job notifications GPS, Bar
code scanning, vital signs, voice
UK London ambulance Voice and Data 802.11b
WLAN, GPRS, GSM
Photo www.symbol.com
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Physician Consult example
Check DRUG for ADE profile
Prescribe Therapy
Locate Patients pharmacy
Kiel JM, Goldblum OM Using personal digital
assistants to enhance outcomes. J Healthc Inf
Manag 2001 15237-50.
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Physician Consult example (2)
Transmit prescription to Pharmacy
Record Follow up information
Collect Billing Information
Kiel JM, Goldblum OM Using personal digital
assistants to enhance outcomes. J Healthc Inf
Manag 2001 15237-50.
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Bar Code identification of patient, staff and
specimen
www.bd.com
www.symbol.com
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Reduced error in specimen handling

• Valley Hospital reported
• 77 reduction in critical specimen errors
• 13 average reduction in staff time per
  collection
• 55 average reduction in specimen receipt time in
  the laboratory
• South Georgia Medical Center reported
• 72 reduction in specimen and patient
  misidentification errors

Bologna L., Hardy G., Mutter M. Reducing specimen
and medication error with handheld technology.
Presented at 2001 Annual Conference and
Exhibition. Healthcare Information and Management
Society February 4-8, 2001 Chicago, Il.
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Electronic Medications Management
University of Wisconsin Hospital Clinics
. Integrated medications management reduced
administration errors by 77
Drug information at point of care
Chelsea Westminster Case Study Patient
information at point of care multiple users
Information sources mims.com.au, symbol.com
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The Future is Bright

• Remember the Fundamentals of Good System Design
• Let the work define the application and
  technology
• Close the Quality Cycle Loop !