Inside the April 2002 print edition of
Canadian Healthcare Technology:
Feature Report: Wireless systems in healthcare
research point-of-care, wireless computing
In a project thats been organized by Bell University
Laboratories, an alliance between Bell Canada and the University of Toronto, researchers
are determining the types of clinical information and interfaces needed at the point of
care to make mobile computing effective.
From hospitals to home care, wireless improves data collection at point-of-care
Physicians and nurses testing hand held, wireless devices often find
them too useful to give up.
$150 million for e-Physicians
After conducting 13 pilot trials, Ontario announced plans to roll out
its e-Physician Project across the province. The program aims to introduce computerized
clinical systems into the practices of some 6,400 family doctors by 2004.
Voice in the machine
A new survey estimates that hospitals will triple their implementations
of voice-recognition systems over the next two years. Developers say that much of the
activity will take place in specialized departments.
Digital radiology education
Indiana University has teamed up with GE Medical to create a new
research and learning centre focused on educating healthcare professionals about digital,
filmless X-rays and other medical diagnostic images.
Baycrest Centre demonstrates how healthcare facilities can develop
professional quality, e-learning materials at relatively low-cost. The centre has produced
50 hours of content, and intends to have 75 hours available by June.
PLUS news stories, analysis, and features and more.
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
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.
Its 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 arent bringing anything in that will be harmful to the environment, and
researchers want to make sure theyre 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
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 theyre not using drugs that will
interact with their patients 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
thats 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 users
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. Johns
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 didnt 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 werent calling and we wondered why. So we called them and found out they
werent 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 theres a lot of granite buried in the hills
around St. Johns, 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. Johns. 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
When they get their download, it comes with a complete set of
protocols for each step of the care prescribed for that patient, explains
Collaboratives 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
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 havent been significant wireless care developments
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.
Its a very liberating technology, says Kelly
Kanellakis, the Toronto-based general manager of RoamAbout Wireless Business for Enterasys
Networks, and its mature to the point now that when we install the technology
even for pilot projects, people dont 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. Its bigger than a PDA at
about six by ten inches, with a built-in clamshell keyboard, noted Jay Wilson,
Concentras 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 theres 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 clinics 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
ChartSources note-taking functionality.
The physician is offered a decision-tree, explains Wilson.
The tree starts the record-keeping by asking the physician questions. If its a
laceration, for example, it will ask, how long is it? Then, how deep? and what colour? And
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
We havent encountered one yet who couldnt adapt to
the new system, says Wilson.
As for the return on their ChartSource investment, Wilson says:
Weve 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
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 Flemings 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. Josephs 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 were 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 cant 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 facilitys
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 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, affinitexs Manatee software presents
that physicians personalized views of all the data theyre authorized to
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
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
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. Well 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 provinces
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
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. Its 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
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.
Were sharing our story to help hospitals and long-term-care
facilities benefit from our experience and unlock the potential of 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
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
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
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. Weve 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.
Weve 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.