Mobile Computing in Healthcare Needs, Applications, Issues and Future Trends Darshan Modani University of Houston Department of Computer Science Houston TX USA domodani@mail.uh.edu Abstract—Some of the key elements in revolution includes advancement in digital networks that expand the power of cellphones. These advancements in mobile computing has a potential impact to improve health care delivery, reduce health care costs, make health care services more convenient to patients and increase the overall efficiency and effectiveness of health care providers. Wireless technologies enable health care providers to monitor patients remotely, and give them timely health information, reminders and support. In this paper, we identify some key applications of wireless computing in healthcare environment, challenges and issues in bringing mobile computing to everyday practice and future trends. Seif Eldrasi University of Houston Department of Computer Science Houston TX USA smhamed@mail.uh.edu subscribers in US. This number has grown to nearly 303 million by 2011 and nearly 96% of US people have cell phones. Global cellphone penetration is continuing to grow rapidly. As the popularity of cell phones increased, so has their functionality. Keywords-component; healthcare; mobile; cellphone; ubiquitous; applications; health IT; I. INTRODUCTION With the recent outburst of smartphone technologies and worldwide deployment of mobile and wireless networks, it has become quite obvious that wireless infrastructure can support many current and emerging healthcare applications. For an example, consider a clinician who has just provided an inpatient service to a patient. The clinician could enter a description of the service on a paper record at the patient’s bedside. Alternatively, the clinician can simply enter specific parameters of the service in a mobile device. This data entered are automatically sent to the billing systems via wireless networks. How cool would be that? Another interesting application would be writing a prescription using a mobile device that transmits the order via the Internet to the appropriate pharmacist. Cell phones were first introduced in US in mid1980s. In 1984, there were just 340,00 cell phone Figure 1. Mobile Computing facts from MorganStanely. In the first year of its existence, 1981, the IBM PC sold 100,000 units. Most of those buyers were geeks or leading-edge business users. Apple’s iPad sold 1 million units in less than one month and 2 million units in just two months. IPad users still include geeks and business types but they are just as likely to include your six-yearold and your grandmother. The introduction of telecommunications technologies in healthcare environment has led to an increased accessibility to healthcare providers, more efficient processing, and a higher quality of healthcare services. While the current and emerging wireless technologies could improve the overall quality of service for patients in both cities and rural areas, it also reduces the stress and strain on healthcare providers while enhancing their productivity, retention and quality of life and reduces the long-term cost of healthcare services. Due to lack of accurate and comprehensive information at the location and time when it is needed, lots of medical errors occur which ultimately result in wrong diagnosis. The required information can be made available at any time any place using urbane devices and wireless networks. Although these errors cannot be completely eliminated, but some of the informational errors can certainly be removed by such technologies. Some of these technologies include location tracking, user interfaces, body sensors, and short-range wireless communications of health monitoring, universal wireless access to increase the accessibility of healthcare providers, and trustworthy communication between devices, patients, and healthcare providers. In this paper, we present the trends and applications of mobile computing in healthcare industry. We also present a vision of pervasive healthcare that includes requirements and applications of pervasive healthcare. II. SUITABILITY OF UBIQUITOUS DEVICES FOR HEALTHCARE Particularly cell phones have four attributes that make them well suited for delivering high quality health care applications. These attributes include: A. Personal As each cell phone is personal to a particular person, applications can be targeted to that particular individual. B. Ubiquitous Individuals take their cellphones wherever they go. Therefore, continuous physiological monitoring is possible everywhere and information and services can be delivered when and where they want. Because of their ubiquity with low cost, cell phones and other mobile computing devices are very well suited for supporting and treating many diseases. These technologies make it possible for healthcare providers to monitor patient’s health and to guide patient’s self-care beyond the limits of clinic, improving overall outcome and reducing cost. Mobile healthcare are primarily driven by five forces: • Providing medical and health related information to consumers via text messages or interactive applications is driven through large content becoming available through Internet. Because of cell-phone’s ubiquity and personal, they have ability to deliver content anytime anywhere. • As the awareness about health concerns and risk grows among individuals, they are more open to technologies that can quickly signal them or provide alerts about potential hazards. • As the size of sensors are reducing continuously, and becoming more reliable and less power hungry, they are likely to be incorporated into portable and ubiquitous devices like cellphones. • Wireless networks are becoming more stable day by day. This extends the opportunities to connect patients with physicians or healthcare providers. Remote monitoring of patients has become possible and can aid providers in rapidly identifying signs of abnormal functions and provide timely medication or treatment. The Bulletin Healthcare survey also found notable differences in mobile device adoption rates among different specialties: TABLE I. MOBILE DEVICE ADOPTION RATES AMONG DIFFERENT HEALTH SPECIALIZATIONS (HIRSCH, 2011) Specialty Mobile Adoption Physician Assistants 41% Emergency Room Physicians 40% C. Connected Cardiologists 33% Cell phones provide direct access to valuable resources and information. They also provide support to peer groups. Urologists 31% Nephrologists 31% Dermatologists 30% D. Increasingly intelligent Gastroenterologists 30% Smartphones are essentially as intelligent as small computers that can capture, store and process information. Psychiatrists 28% Optometrists 28% Radiologists 24% Rheumatologists 22% Endocrinologists 21% Oncologists 20% diagnoses. A device called Vitaphone which has sensors integrated into normal cellphone can collect electrocardiogram readings anytime and with its GPS capability, medical assistance to the patient can be provided if needed. Clinical Pathologists 16% B. Blood Glucose Monitoring Specialty III. Mobile Adoption APPLICATIONS OF MOBILE COMPUTING IN HEALTHCARE There are two major categories of mobile applications for healthcare: A. Applications that monitor physiological functions and send information to patients Monitoring applications such as examining blood glucose level, heart functions, vital signs rely on sensors that may be portable, or implantable. Communications of these types of applications are primarily from patient to providers. They offer more accurate diagnostics and rapid response to medical emergencies. B. Applications that deliver information and feedback to patients Patient appointment reminders and health education are examples of this kind of application. Communications in these applications are majorly from providers to patients. IV. PHYSIOLOGICAL MONITORING APPLICATIONS These applications enable remote continuous monitoring of various physiological functions as they go about their daily activities. This results in more up to date and accurate diagnoses, which ultimately improve patient’s health problems. They make continuous monitoring of patients possible as they go about their daily life activities. Some of these applications include: A. Cardiac monitoring It was introduced in 1947. This device enabled continuous recording of heart function outside clinical setting. The patients typically wear the monitor, which includes set of electrodes attached to patient’s chest and a recording device. The patient normally wears this device for a period of 24 hours and then returns it to their physician for analysis of readings. Newer devices have the capability of wirelessly communicating the readings. Researches have shown that extended cardiac monitoring can detect a larger range of problems than short-term Heart diseases, stroke, blindness, kidney failure, pregnancy complications, and limb amputations are all consequences of diabetes if not properly controlled. To avoid such complications, a diabetic patient must carefully monitor blood sugar level. Wireless and ubiquitous devices can be a useful tool to diabetics and physicians to help manage the disease better. With the use of GlucoPhone, users can send their monitoring data to online medical management database and also, at user’s discretion, can be forwarded to personal physician. This can help physicians recommend a change in medication by tracking patient’s health status. V. PATIENT COMMUNICATION AND SUPPORT APPLICATIONS Along with supporting remote monitoring, cell phones and wireless devices provide a wide horizon for communication between patient and healthcare providers. Such applications not only allow providers to communicate with the patients anytime anywhere, but they also deliver-health related information at a time and place where they have utmost influence. The outcome is lower-health related costs. Some of these kinds of applications include: A. Patient Records – EHRs and PHRs Many systems like eClinicWorks, LifeRecord, MacPracticeMD offer smartphone capabilities. With the implementation of American Recovery and Reinvestment Act of 2009, stimulus funding will be distributed to health providers who implement Electronic Health Records (EHRs). Mobile EHRs could allow physician to access the patient’s information that further allow physicians to communicate to the patients anywhere at anytime. Also, as consumers get more engaged to in tracking their health records, Public Health Records (PHRs) will gain acceptance. There are couples of PHR’s that are available for smart phones. For example, Polka works for iPhone. It stores and analyses the consumer’s personal health data, and offers health reminders. In addition to this app, there are several other emergency apps available. B. Health Education Health educators generally face difficulty in reaching out young people to educate regarding health. Cellphones can be used as a promising tool to reach out young people. Several health campaigns that deliver messages to cell phone can be an assuring alternative. For an example, in 2006, the San Francisco Department of Public Health introduced SexInfo. SexInfo is a free service that answers youth questions about sex through text messaging. It also gives contact numbers and location of local clinics. C. Appointment Reminders Giving out frequent reminders about patient’s appointments through text messages or through an interactive application can improve administrative efficiency and increase the effectiveness of physician’s time. This could ultimately result in healthcare savings. D. Public Health Alerts Text messaging can help in tracking disease outbreaks and also in providing timely alerts regarding health hazards or epidemics. Other potential applications could be to provide warnings of dangerous levels of pollution or notifying upcoming tsunami. E. Doctor-Patient Communication Communication between doctor and patient is very important to as in to convey important information to patient or to update patient’s health status to doctor so that doctor can act instantly. Live, two-way video conferencing app between doctor and patient would be a direct way of communication between doctor and patient. While these technologies can help physicians provide more timely diagnoses and treatment, it makes health care more convenient and pleasing for patients. VI. PROBLEMS AND ISSUES There are many challenges and issues in realizing the usage of mobile computing in healthcare. A broader view of such challenges includes lack of willingness to use alternative methods to get care, lack of comprehensive coverage of wireless and mobile networks, reliability of wireless infrastructure, limitations of handheld devices, lack of medical sensors in mobile devices and privacy and security. According to PriceWaterhouseCoopers Survey, one half of US health consumers are willing to take online care and consultation with clinicians over a phone. Figure 2 cites the overall results. Figure 2. Consumers willingness to Use Alternative Methods to get Care, 2009 A. Health System Not Configured to Use Wireless Applications To benefit from the wireless applications and mobile applications, the health care system has to adjust to the new technological advancements. The current system is not well configured to meet the health care needs. Wireless tools can help to overcome this shortcoming, but their usage will be limited because the tools are not linked to each other. There are several efforts being made towards this direction. For example, Alere Medical, one disease Management Company, remotely monitored patients using a device called DayLink monitor. This act ultimately got success. Results showed that diabetic patients who received support through the monitor reduced medical costs up to 40%. B. Privacy and security One of the primary concerns of mobile health computing is protecting the privacy and security of patient information. There are many issues of which providers or patients are unsure about. Some of these are: How can patient and providers be sure that only authorized persons will receive the date? What happens if wireless device that contains important data is misplaced or stolen? Has the information transmitted securely or not? According to Health Insurance Portability and Accountability Act of 1996, wireless technologies must meet privacy and security provisions. Some of the policies that govern wireless health care applications at Yale University are: • If protected health care data is stored on the handheld mobile device, it should be encrypted and also the access should be passwordprotected. • There should be a user id/password level security to protect the data if the device is stolen or lost. There should be user/device validation during synchronization and encryption of data stored on the device. • Before and data transmission, authentication should be enforced and the data should be encrypted during transmission. C. Lack of Standards Most of the applications and technologies available in mobile healthcare industry are stand-alone tools. These all applications lack technological standard. This means some applications may not be compatible with other or some applications will work only on specific type of cellphone. One of the most important issues is ensuring that the data generated for monitoring devices are encoded in standard format, which may allow the information to be stored and managed by different types of data stores. D. Lack of Total Network Coverage No cell phone networks offer complete network coverage across the entire United States. Many rural areas of the countries still lack network coverage, and even in major cities, the service is sometimes poor. These limitations may be problematic for wireless health care applications. Joseph Kvedar, M.D. director of the center for Connected Health in Boston mentioned: ”If one the text message out of hundred messages between friends goes amiss, it doesn’t matter. But if one heart reading of a cardiac patient is not delivered, someone could die.” At the minimum, the applications should be designed such that devices should be able to store the data or messages whenever they are offline and to deliver the data or messages when they become online. VII. HEALTHCARE SMARTPHONE APPS There are many smartphone applications being written for smartphones that are focused on professional health management or targeted at healthcare professionals. As of February 2010, there were 5805 health, medical and fitness applications within the Apple AppStore. The figure 3 depicts different categories of medical apps and their share. Figure 3. Medical Iphone Apps, 2010 Some of the apps are featured here: A. BMI Developer: DVMagic Studios Inc. This app simplifies many calculations necessary in determining various factors of your body health stats. This application helps to sort out the many factors (BMI, BMR, LBM, Body Fat%, Water Consumption, Body Shape, Body Measurements, weight, height, gender, activity level, etc.) into a quick and easy to understand summarized manner. This tool can be used in weight loss, gain, or maintenance for a healthier overall lifestyle. B. Epocrates Developer: Epocrates The company claims that more than 900,000 health care professionals regularly use Epocrates to make medical decisions and improve patient safety. This app provides access to things like clinical information on prescription medicines, effective treatments among overthe-counter products and drug interactions, information on things like alternative medicines, treatment guidelines and medical definitions. C. Medical Calculator Developer: MarketWall.com This application helps doctors and nurses compute useful formulas and equations. With more than 200,000 installs worldwide, this is the most popular Medical Calculator for the iPhone. This clinical calculator gives you quick access to calculations that are too hard to memorize or perform in your head. D. Calorie Track Developer: SkyWolf Tech This app helps you track your personal food intake. It allows easy entry of meal information on your iPhone or iPod where ever you go. It also keeps track of what you are eating and the nutritional values as you are eating. It graphs your food history to see trends. E. BP Tracker - Blood Pressure Tracker Developer: BHI Technologies, Inc. You can use this to easily log your BP, HR, medication and other useful information on your iPhone. It provides powerful graphing that shows weekly/monthly/quarterly trends and logging your medication data. This app shows tips to help you maintain a normal blood pressure level and supports to write notes for each BP entry. F. BKS Medical Encyclopedia Developer: BEIKS LLC The application enables anyone with an Android handheld to carry vast amounts of information in their pocket or purse. The encyclopedia includes medical terms, pertinent scientific items, abbreviations, acronyms, jargon, institutions, projects, symptoms, syndromes, eponyms, and medical history. G. Menstrual Calendar Developer: WITIZ This app allows every woman to track period, ovulation, temperature & more. You can have cycle Report and Basal Body Temperature Chart. Also use historical data to forecast menstruation and ovulation. VIII. FUTURE TRENDS There are several new healthcare applications that can evolve along with current applications such as mobile telemedicine. Some of these applications are: A. Intelligent Emergency Management System Intelligent Emergency Management System could be devised using the intelligence and information from mobile and wireless networks. This system would be able to manage a call received due to accident and effectively manage the emergency vehicles. B. Health-aware mobile devices Mobile devices could detect certain conditions by the touch of a user. Integration of handheld wireless devices with portable medical devices would allow detection of blood pressure, pulse rate and may be level of alcohol. C. Pervasive lifestyle incentive management Pervasive lifestyle incentive management involves giving a small mobile micro-payment to a user device every time a user exercises or eats health food. This incentive could then be used for donating to a charity, paying wireless monthly charges or paying healthcare expenses. Such a system can lead to healthier individuals and thus reducing the overall cost of healthcare services. D. Healthcare Information Access Pervasive access to healthcare information would allow a healthcare provider or patient to access the current and pass medical information. This will ultimately result in reduced number of medical errors by having access to current and complete information anytime anywhere by healthcare providers. Another application of this category can be “Mobile Healthcare Data Center” that can support a large amount of stored healthcare data to me made available to authorized decision makers for making healthcare decisions. Researchers maintaining patient anonymity can also use this data to carry out researches. E. Comprehensive healthcare monitoring services Comprehensive healthcare monitoring services would allow patients to be monitored anytime at any location. Using current conditions and his/her medical history, actions can be taken such as sending alert message to the nearest ambulance or a healthcare specialist. These services could reduce the time between the occurrence of an emergency and the arrival of needed help. IX. CONCLUSION What we believe is that mobile and wireless technologies can prove a boon to healthcare. It can have a substantial impact, in general, or they may become a vital tool for improving disease management, in particular. The role of mobile technologies in healthcare applications is expected to rise and become more prominent with an increase in mobile society and deployment of mobile and wireless technologies. But realizing the real potential of mobile and wireless technologies will require significant changes in the way the health care is structured and how the medical services are delivered. It is expected that researchers will address several challenges and issues cited in the paper and developers and we will reach a step closer to realizing a prospect of mobile healthcare. ACKNOWLEDGMENT We express our special thanks to the people who provided data and insights through their papers that are incorporated into this survey. We express our gratitude towards Dr. Rong Zheng who guided us throughout the course and with her continuous efforts assistance in timely manner aided in completion of this paper. REFERENCES [2] [3] [4] [5] [6] [7] [1] Richard Edler, “Health Care Unplugged: The evolving role of Wireless Technology”, California Healthcare Foundation, November 2007. Jane Sarasohn-Kahn, “How smartphones are changing Healthcare for Consumers and Providers”, California Healthcare Foundation, April 2010. Upkar Varshney, A Pervasive Healthcare and Wireless Health Monitoring, Springer Science and Business Media LLC, June 2007. Cory Allen Heidelberger, “Mobile Computing in Health Care Settings,” in INFS 892:Mobile Computing Tools in Healthcare, April 2011. Rodney H. Brown, “Health-care providers rely on mobile computing, April 2010 Usman Arshad, Cecilia Mascolo and Marcus Mellor “Exploiting Mobile Computing in Health-care”. Fran Turisco, “Mobile Computing Is Next Technology Frontier for Healthcare Providers”, Nov 2000. Exploiting Mobile Computing in Health-care * Usman Arshad*$, Cecilia Mascolo* and Marcus Mellor$ Dept. of Computer Science, University College London, Gower St, WC1E 6BT London UK $ Capula Elan, Palmerston Court, Palmerston Way, London, SW8 4AJ London UK Abstract—In this paper we report about our experience in using mobile computing middleware in context of health-care. The dynamicity and variability of context and conditions make this environment very suitable for the use of mobile and wearable computing techniques. The use of small and portable devices can be very beneficial in terms of efficiency and vital support to patients. However, the many challenges that this environment presents need to be addressed, possibly by a general mobile computing framework that could be used in different mobile settings. We will discuss these issues in the paper along with the description of the prototype we have developed. 1 Introduction Small and portable devices, such as mobile phones, PDAs and the like, have recently been pushed on the marked and have allowed for complex cooperation and communication patterns that were not foreseeable some time ago. The ability to carry these devices, share the content using communication networks, possibly wireless, and synchronize their content with more standard devices have been seen as essential features. However, these technologies still come with some limitations and differences with respect to the standard computing platforms we have used for years. Resources (such as battery, bandwidth, memory) are by orders of magnitude smaller, and patterns of use change depending on the network availability and on the location of users. Applications have begun to be developed for these devices in order to allow data synchronization, Internet browsing, and cooperation. The most targeted domains have been Mobile Commerce and E-shopping, however it is becoming clear that the use of mobile technologies will become quite pervasive in our lives and that we need to support development of applications in different areas. In particular, we have recently been involved in the use of mobile computing in health care setting. The healthcare environment is quite unique in that it brings with it several constraints and requirements that any deployable application would have to adhere to. The most obvious issues are those of patient confidentiality and doctor- patient relationship. It is vital that medical data is kept confidential via the use of potentially several vertical layers of security. Healthcare data is mission critical and errors introduced by an application can have potentially fatal consequences. For example, in the case of a medical prescribing tool, a miscalculation or misprint in the dosage of any particular drug to be administered could have serious consequences for the patient. Hence, it is important that some kind of data integrity assurance is supported by the application. The clinical health-care working environment is ‘highly mobile’, with clinicians constantly moving around from patient to patient while performing their duties. This constrains the shape and performance of computing devices that can be used in such an environment. Many organizations have attempted to implement computing solutions to aid clinicians with their every day duties using a networked desktop environment. In practice, such solutions have failed to reach their target users, and instead simply served as administration systems. The reason behind this is the fact that in such a highly mobile environment, clinicians make decisions at the ‘point of care’ i.e., the patients bedside, and they do not have the time to leave and potentially queue up to refer to a desktop based application. Hence, the ideal platform for use in such an environment is the PDA or tablet PC platform, which the clinician can carry around and use wherever necessary. In this paper we will introduce the platform we have developed for use in health-care scenarios and show the general principles that have driven our design decisions. We will show how the platform is planned to be used, and how it can improve the efficiency of patient care. The paper is structured as follows: Section 2 describes the mobile computing environment and the challenges it presents. Section 3 introduces our case study, looks at the motivation and describes our adopted architecture. Section 4 describes the implementation in details. Section 5 discusses the interesting outcomes of our work and shares some of the experience gained from working in a mobile computing environment. Finally, Section 6 concludes the paper and outlines our planned future work. 2 Mobile Computing Point of care delivery is vital for the success of any application in the clinical healthcare environment. Hence, the use of a PDA platform utilizing wearable technology is ideal and is adopted by the work described in this paper. Wearable and mobile technologies introduce considerations and constraints that have to be dealt with when developing software. This section highlights some of these and explains how they impact upon development. 2.1 Network Model Mobile networks can be roughly classified into two types, ad-hoc or nomadic. An ad-hoc network is one that is formed by two or more mobile enabled devices that are in reach of each other and can form a compatible network. This model is suited to a peer-to-peer scenario there is no guarantee of any device remaining available or indeed being available at all. It provides no guarantee of resources or services, and has to deal with changing conditions such as disconnections, and resource availability. A nomadic network is one that includes a fixed network infrastructure of base stations. Mobile devices are able to rely on the resources made available on the fixed infrastructure as long as they remain within reach of network coverage. This model is suited to a client-server approach where client would be the mobile device and the server would be available via the fixed infrastructure. This model still has the problem of disconnections to the network when mobile devices go out or range. The work described in this paper is based on a nomadic model using a client server approach, although the application we are developing has extensions of use in emergency areas where base stations are not in reach: we will speak more about this extension in the future work section at the end of the paper. 2.2 Mobile communications Mobile communications are weak and prone to disconnections. This means that traditional applications that rely on network access will not work unless they use an always-on technology, and even then, they could encounter pockets of no coverage. In our view it is important for applications to take temporary disconnections into account, and adapt accordingly. This involves the use of reflection to detect network availability and the ability of an offline mode of operation when disconnected. This marks a move towards thick client devices with embedded intelligence. The situation is complicated further when potentially many concurrent users have access to the same piece of data. In such a situation if some people are working offline on locally cached copies the data while others are working online, inconsistencies can quickly develop. Hence, there is a clear need to be able to identify such inconsistencies and deal with them accordingly. With weak communications, data transfer rates have to be taken into account. Application developers need to consider the time it takes to download data to a device or to upload from it and whether this time delay makes the application unusable. Of course, data rates depend on the type of mobile technology that is to be used, but is even more significant in cases where a user is charged for connection to network on a time basis. 2.3 Resources Mobile devices such as PDA’s are extremely resourceconstrained in terms of memory, processing power, battery lifetime and screen size. Applications for such devices need to be resource conserving and lightweight enough to achieve a level performance deemed usable. The application developer also needs to take into account the strain put on these resources during runtime, and there are often tradeoffs to be made as to where to execute processes and store information, whether it be locally on the mobile device or remotely on a more powerful device. More details on these issues can be found in [6] and [7]. The way we address these issues is discussed in Section 4. The fact that PDAs have a very small screen and a different means of navigation than traditional systems means that careful consideration needs to go into the development of a usable user interface. In the next section we will describe our approach to the use of mobile computing in health-care. 3 Our approach 3.1 Scenario The motivation behind the work described in this paper is to aid the clinician by empowering him/her with mission critical information at the point of care. This is achieved by developing a PDA based application that uses mobile technology in a Client-Server Nomadic setting. The application being developed combines an Electronic Patient Record (EPR) system with an e-prescribing application. The purpose of an EPR system, is to replace traditional paper based methods of documenting patient records with electronic records that are available to multiple users concurrently. The records are dynamic in that they change on a regular basis, and global consistency is important. One example of the dynamic nature of patient records is current medication that is prescribed to a patient. The e-prescribing application provides the clinician with a database of drug information including the complexities of drug interactions and contra-indications. The clinician is able to prescribe drugs to his patients and the application flags up potential problems caused by drug interactions. 3.2 Architecture Figure 1 shows the architecture we have adopted: a clientserver architecture separated by a mobile network. The server connects to a central data-store, which contains data shared by the client PDA devices. The communication between the client and the server is via a packet based communication protocol. A session is initiated by a clinician logging in to the system via the client User Display. This initiates the Downloader component to contact the server and retrieve patient record data from the database. Once downloaded the clinician is able to navigate the data via the application. If data are modified by the clinician, the Updater component ensures that the changes are reported to the server and that the datastore is updated accordingly. It also makes sure that the change is communicated to all other clients logged onto the system. One of the key aspects of our approach is ability of the client to work offline, i.e., if the client PDA is out of reach of the network any changes made by the clinician are cached locally until such a time at which the network is once again available. To enable this the client needs to be network aware. This is achieved by the server Presence Broadcaster regularly broadcasting one-way messages on the network, which are picked up by the Presence Receiver on the client. As long as the client receives these messages, it assumes it is still connected to the network. This information is fed into the updater, which makes the decision as to whether to cache the changes or send them to the server. User Display PDA based Client Application Packet based communicator Presence Reciever Updater Downloader Mobile Network Presence Broadcaster Updater Downloader Packet based communicator Server Application Logging component Conflict detector and resolver Central Datastore Datastore Connectivity Component Figure 1. Architecture While offline, a client may miss updates made by other clients. A process to receive these missed updates once the client is again online is put in place. Further to this, while offline, the clinician may make updates that conflict with updates made by other clients. The Conflict Dectector and Resolver component and the Logging component take care of this. Further details are provided in Section 4.5. 4 Implementation We now describe the details of the platform we have developed. The server is a Java application that provides access to an Oracle database. The client device is also a Java application. The server retrieves data via an API that returns the data in the form of an XML document. Similarly changes to the data are committed to the database by passing the API an XML document representing the changed data. The reasons for choosing XML are discussed in Section 4.4. The Server exists as part of a fixed network infrastructure that is extended to the mobile clients using an 802.11b wireless LAN. 4.1 Presence Information In order to be network aware, the platform needs a mechanism to gain presence information. The clients use two approaches to gain this information 1) Active approach – The clients are responsible for checking if the network is accessible to them. The client would send something similar to a ping command to the server expecting a response to indicate accessibility. This approach is efficient, as minimal messages have to be sent over the network. However the client has to do more work. 2) Passive approach – In this approach the Server is the active component and continually broadcast a message over the network attempting to reach clients. The clients simply listen for this message continually and as long as it is received on a regular basis, they assume the network is available. This approach has the disadvantage of putting extra load on the network We use the passive approach in our scenario at the expense of the increased network load. This method is preferred as it requires minimal work on the part of the client, and given the scarce resources available on the client it is preferable to push work onto the server end. Further to this, it is expected that the client is likely to require a lot of access to the network, hence increasing the number of times the ping-like message would have to be sent. 4.2 Working offline Applications for mobile devices can fall into three main categories, when dealing with disconnections. 1) Always-on Applications – These are dependent on network availability and require constant interaction with other networked machines, for example web based applications. These applications would fail completely if the network was unavailable, and hence are only deployed with always on communications such as GSM, or are limited to the afforded boundary of coverage. 2) Hot Sync Applications – These are commonplace on PDA platforms. In hot sync, it is not critical that the network is constantly available, and the user can continue to use the application when disconnected. When the user reconnects to the network, a synchronisation process takes place to filter across relevant information generated as a result of being disconnected to the network. The synchronisation process often occurs as a result of the user taking affirmative action to execute the process. A typical sync application could be a synchronization of an email inbox between a laptop and a PDA. 3) Auto update applications – These applications fall in between the other two approaches. Being connected to the network is important in such applications, however the user is able to work offline when the network is not available. Once back in reach of the network an automatic synchronisation process can take place. These applications appear similar to hot sync applications, but there are distinct differences. As mentioned, Sync applications often perform synchronisation as a result of an affirmative action on the part of the user, whereas in auto update applications, synchronisation remains transparent to the user. Further to this auto update applications often involve data that is shared by multiple users, hence synchronisation on a regular basis is important so modifications made to the shared data is filtered throughout the system, whereas hot sync applications usually involve synchronisation between a small number of devices (usually two) often belonging to a single user. Our application follows the auto update model, which exploits transparency as far as possible, including the implementation of an automatic conflict resolution component (see Section 4.7). Transparency makes the application more usable, as the target users will not want to worry about whether they are working online or offline. At the time of writing, many applications particularly those that depend on network availability, have tended to treat PDAs as thin clients, i.e., where the PDA is nothing more than a basic IO device. However our approach employs the PDA as a thick client with the embedded intelligence to store information locally when it is disconnected from the network. As explained in Section 4.1 the server continually multicasts a presence message to the clients. In normal (online) operation any modifications made to the data by clients are immediately communicated back to the server, which makes the appropriate modifications in the central data store, logs the modification, and then multicasts the modifications to filter them throughout the system. The offline mode of operation is triggered when a presence message is not received in a given period of time. Once working offline, the middleware still accepts modifications made to the data, but caches them locally. As soon as the presence messages are again being received, the client knows that it can once again enter into online mode, however it is vitally important that the following three process are carried out first: • The client needs regain missed updates from the server to maintain data consistency in the system. • The client needs to commit the changes it has made locally to the server • A conflict check needs to be carried out to ensure that the modifications made by the client while it was offline do not conflict with modifications made by other clients. These processes are achieved by the conflict resolution and logging components (see Section 4.5). 4.3 Development on PDAs One of the first things that became clear while prototyping on the PDA platform was the limitation of memory, which severely hinders the amount of data that can be downloaded to a device. PDA applications have to work around this limitation. In order to cope with it we decided to adopt a ‘session based download’ approach. For example, in the case of the EPR application we decided that a doctor would log into the system, and only the records of the patients assigned to that doctor would be downloaded to the device, the session being the use of the application by that doctor. We used this approach as opposed to downloading all the patients on a ward for example. It is also important to consider memory usage at runtime, as the size of data to be stored is not the only consideration. Some runtime processes can also be memory intensive, for example, depending on which parser is used, parsing XML can consume a lot of memory. Further to this, XML parsing itself can be a processor intensive process. Since our application is centered on delivering data in XML, our choice of parser would have to give us maximum performance. Another important consideration for PDA like devices is the extent of multithreading that is used. In our experience, the use of too many concurrent threads on such a device can soon make an application unusable. In fact, at time of writing, Palm have only just added support for multitasking and multithreading with the release of version 5 of their PDA operating system PalmOS. Microsoft’s PocketPC operating system has supported multithreading and multitasking since release, however as the number of threads increases, memory consumption is also increased and the application becomes increasingly unusable. Another constraining factor on the PDA platform is the small screen size. This has considerable effect on the kind of applications that can be deployed on such a device. The biggest change is using a stylus as opposed to a keyboard or a mouse. This change impacts the UI as many traditional UI widgets or components are not usable via such an input mechanism, hence the developer is restricted to simple components such as buttons and dropdown lists. One of the terms that is emerging to describe the desired features of a PDA based user interface is ‘high poke ability’. This includes using only simple widgets, but also encompasses usability models such as ensuring that the user does not have to frequently tap the screen to use the application to the extent that it requires too much effort to get even a small amount of work done. There is a shift from traditional desktop applications, which strive to provide a complete and comprehensive application that offers maximum functionality and, to a system that is centred on the critical workflow of the user and includes only the core and most important functionality. In fact such restrictive and simple UIs make PDAs intuitively easier to use and easier to learn than desktop systems for non computer literate personnel. Battery lifetime is another concern on PDA platforms, and indeed battery technology is one area, which has not seen any significant advancement and is not expected to in the near future. Hence application developers will have to accept that the workflow of their applications will have to conform to use for short stints of time followed by a period of recharging the device. Application sessions cannot be long lived such that they exceed the battery lifetime. This problem is significantly magnified with the introduction of wireless communication, which can have significant drain on battery power. Our application is being developed using the Java programming language. Java is emerging as an important language in the mobile device arena, and much of this is due to its platform independent nature. With the market still growing, a whole host of mobile devices have emerged including mobile phones, PDAs, tablet PCs and laptop computers each being ideal for use in some scenarios but not others. Further to this many more such devices are likely to emerge which are specifically designed for a certain environment. Some companies such as Intermec already offer specialised PDAs, which could for example be ruggedized for use in an industrial setting. Another interesting trend at time of writing is the way mobile phones are striving to become more like PDAs, offering more complex applications, whereas PDAs, are trying to become more like phones trying to offer voice call capability. Such heterogeneity between different hardware and operating systems means that platform independence is highly desirable. With the realisation of this, Sun Microsystems have already put considerable effort into developing small lightweight java virtual machines and standards such as Personal Java and J2ME to aid this. In our application, the use of several of these devices as opposed to just one may well be desirable. Hence we have made a point of decoupling the UI from the core functionality in order to make the application portable between these different devices by accommodating an appropriate interface given the form factor of the device. 4.4 Use of XML The last section discussed how platform independence is desirable. XML gives us a mechanism to generically represent data, which is instantly transferable between heterogeneous platforms. Our application takes this one step further with the use of XSLT to cater for different platforms. For example, consider the difference between a PDA and a tablet PC. Clearly the tablet PC is much more feature rich and has a much larger screen hence can present a lot more information visually. One way to achieve this would be to pass all the information available from the server to the mobile device whether it be a PDA or tablet. On receiving the information the different user interfaces on the two devices could decide to display all the information, or in the case of the PDA, just a small portion of it. However this clearly violates the concept of trying to conserve memory and keep processing to a minimum. Hence our application uses XSLT at the point of data retrieval to filter out the information that is not required for the device to which the data is to be sent. This is facilitated by simply specifying a different XSL style sheet to the transformer. XML also separates our application into a middleware layer and an application layer. This is achieved as the middleware only deals with XML data. The data is retrieved by the middleware at the server end from the enterprise database system via an API that returns the data as XML document. This document is then sent to the client device, and the middleware hands off to the application layer by passing it the XML document. Following this, any subsequent changes made by the client are communicated to the middleware as XML. Again the middleware sends the XML to the server, at which point it hands off to the application layer by passing it the XML, and so on. The point is that the middleware handles all data as a CLOB of XML only, and does not care about the semantics of the XML. 4.5 Conflicts and conflict resolution Allowing users to work offline in a system in which data is concurrently shared between multiple users, introduces several complexities into an application. For example, changes have to be cached locally until the user is back online at which point they need to be filtered throughout the system. Also while the user is offline he/she may well miss data updates made by other users who were online. As a result the offline client then has an inconsistent view of the data, and may well make updates that conflict with updates that have already been made. Our middleware deals with the complexities of working offline by using a server administered logging process and a user configurable conflict resolution process. The server maintains a global version number, which is incremented with each update to the data. The update, along with the version number, is logged by the server. Each of the clients maintains a local version number, which corresponds to the last update they received from the server. Comparison of the version numbers between the server and client reveals whether any updates have been missed, and hence resent. The sequence diagram in Figure 2 and description below depicts how this works. PDA A Server PDA B Version 1 Download Version 1 online online Download Version 1 Update Version 2 offline log unreachable Version 2 Update Version 3 log unreachable Online Version 1 Version 3 online Examine log Version 3 Figure 2. Missed updates As the diagram shows, both client A and B are online to begin with, and individually download data from the server. At the point of download the server sends the global version number, which is recorded by the client. Client A then goes offline, and Client B then makes two successive updates. The server updates its global version number accordingly and multicasts the update along with the new version number to all the clients. Since client A was offline, it does not receive the updates, and hence its version number remains at 1. Client A then goes online once more, and on doing so sends a message to the server which includes its version number. The server is able to compare this to its global number and thus knows that client A missed two updates. The server is able to consult its log and resend the updates to client A. The conflict resolution process is carried out on a per update basis, so each time an update is sent back to the server, it is compared against entries in the log for potential conflicts. If a conflict does occur the resolution process can then be started. The definition of a conflict depends on application logic, and hence the middleware needs to provide a way for the application to specify rules to resolve conflicts. Our middleware achieves this through the use of XML. When the server receives an update, it takes the XML for that update along with the XML for previous updates from the log and passes them to the conflict resolution module. This module then compares the two pieces of XML for conflicts according to rules defined by the application. If a conflict occurs the middleware first tries to automatically resolve them, otherwise the user can be notified accordingly. 5 Discussion Performance is an important consideration for applications on resource-constrained devices. Given the fact that XML is text based, and the application will deal with transferring reasonable amounts of the data over the mobile network, means that there may well be a considerable delay while the transfer is being downloaded. Hence, it was decided to employ compression before sending the data over the network. The disadvantage to this is that we are now imposing on the processing power of the mobile device during the decompression process. However, the advantage gained was far more significant. Using simple zip format, a compression advantage in transmission time of the order of ten was seen. This varies according to the content of the XML, however given the data is similar to that of the English language other compression techniques that exploit the entropy of this type of data could show even more improvement. The other potential overhead with using XML is the parsing of the data. Many of the fully featured parsers in existence would simply put too much drain on the memory and processing power. However there are several ‘small footprint’ parsers that are available that offer basic parsing functionality. We opted for NanoXML [3], but other similar parsers exist such as TinyXML[4] and MinML[5]. One of the notable consequences of working in the mobile environment is the different tradeoffs that have to be made. For example consider the location where data should be stored. It could be stored locally on the client device giving the advantage of fast access. However, clearly this is going to impact on the limited memory available on mobile devices. Alternatively the data could be store remotely at the server and downloaded as required, however this would incur a time overhead as the data is downloaded to the device. Thus there is a trade-off here between memory consumption and communication overhead, and the decision depends on the semantics of the data in relation to the application. For example data that requires frequent accesses would be better stored on the client then the server. Another trade-off comes as a result of the weak processing power on the mobile device. It would often be advantageous to migrate processes to a more powerful machine such as the server in our application. This would save time in executing the process, although it would introduce a communication overhead. It would also ease the processing load on the client device. So again we have a trade-off between the communication overhead and the load on the device. The healthcare community is showing a strong trend in the adoption of mobile technology, particularly in the use of mobile device such as PDAs [1,2]. Hence there are a vast amount of applications being developed for such devices. Most of the established applications are stand alone with the mobile devices such as drug databases and patient monitoring tools. However there is currently a lot of work being done into looking at systems that utilize mobile technology especially in the area of EPR. These include the systems described by [8], [9] and [10]. However current systems depend on the availability of the wireless network and do not address the issue of disconnections. Other work includes location aware ad-hoc applications such as connecting a PDA to a remote monitor at a patient’s bedside to explain diagnosis. 6 Conclusions and Future Work In this paper we have identified the complexities introduced when working in a mobile environment. In particular we have looked at resource constrained mobile devices such as PDAs, and shared our experience with developing on this platform. Our case study has shown one example of how small portable devices can be employed to bring significant benefits over traditional workstation based systems. Introducing mobile communications to the devices opens the door to a whole range of novel application. We found that in a PDA based development environment the application programmer has to be more aware of the implications of mobile computing and often adapt the usage model of the application to accommodate these. Our case study has presented a generic architecture that for data sharing client server applications that could be employed in many scenarios. In particular we have emphasized the ability of our application to work in an offline mode of operation, and having a mechanism to detect and resolve conflicting changes to data using application specific rules. The future direction of our work is looking to extend the principals learned, into an ad-hoc peer to peer setting. This is a more dynamic environment in which the mobile devices cannot rely on resource availability at all. Further to this in an ad-hoc setting, all devices may be potentially resource constrained. The natural extension of our case study into an ad-hoc environment is in the use of ambulatory care. For example data may be recorded in an ambulance on the way to the hospital and on reaching the destination transferred to a clinicians PDA or automatically integrated into the hospital system. References [1] M. Ancona, E. Coscia, G. Dodero, M. Earney, V. Gianuzzi, F. Minuto, and S. Virtuoso, “Ward-In-Hand: Wireless access to clinical records for mobile healthcare professionals.” TEHRE 2001 m-Health Conference, First Annual Conference on Mobile & Wireless Healthcare Applications, November 2001 [2] G. Dodero, V. Gianuzzi, E. Coscia, S. Virtuoso, Wireless networking with a PDA: the Ward-In-Hand project, Proc. Workshop on "CORBA and XML: towards a bioinformatics integrated network environment", Genova, 17-18 May 2001. 115-118. [3] NanoXML http://web.wanadoo.be/cyberelf/nanoxml/ [4] TinyXML http://www.gibaradunn.srac.org/tiny/ [5] MinML http://www.wilson.co.uk/xml/minml.htm [6] C. Mascolo, L. Capra, W. Emmerich. Mobile Computing Middleware. In Tutorial Notes of Int. Conf. Networking 2002. LNCS 2497. Springer. [7] C. Mascolo, L. Capra, S. Zachariadis, W. Emmerich, XMIDDLE: A data-sharing middleware for Mobile Computing. Wireless Personal Communications 21:77-103. Kluwer 2002. [8] O. Portale, Healthcare: the mobile opportunity, 08 November 2002 http://www.sun.com/mobility/enterprise/feature_story.html [9] D. K. Vawdrey, E. S. Hall, C. D. Knutson, A self-adapting, transportaware mobile patient healthcare insfrastructure. http://www.poketdoktor.com/PoketDoktorArchitecture.pdf [10] Sybase, Mobile computing in healtcare, http://was.sybase.com/mec/2959healthcare.pdf Telematics and Informatics 20 (2003) 99–106 www.elsevier.com/locate/tele The application of mobile computing and technology to health care services Khawar Hameed School of Computing, Staffordshire University, Stafford, Beaconside ST18 0DG, UK Abstract Mobile computing and technology is becoming prevalent in many aspects of private life and public services. This paper presents a discussion of the technology and its application in context of the UKs health care service, and outlines some potential benefits that may result from its integration into existing information systems and architectures. The additional component of ÔmobilityÕ is believed to provide value to health care services, information systems and ultimately the patientÕs experience. Ó 2003 Elsevier Science Ltd. All rights reserved. 1. Introduction In the opening statement by the United KingdomÕs Secretary of State on implementing the National Health Service Plan (NHS, 2001) it is said that implementing the plan will ‘‘make the NHS a modern public service meeting modern public expectations’’. In addition to expectations of medical service provision, based upon modern healthcare practice, the issue of expectations for information provision and management is key. Modern expectations of this go far beyond the type of information provision and management associated with conventional information systems and technology. It is also stated that the creation of more effective processes relies on quality information, modern information, and communication technology, and that building the information core is vital. The information core can be seen as the heart of any organisation or system. The fundamental building blocks that support the information infrastructure are, therefore, of great importance and relevance. E-mail address: k.hameed@staffs.ac.uk (K. Hameed). 0736-5853/03/$ - see front matter Ó 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 7 3 6 - 5 8 5 3 ( 0 2 ) 0 0 0 1 8 - 7 100 K. Hameed / Telematics and Informatics 20 (2003) 99–106 Technology provision to support a modern society with demanding expectations has resulted in rapidly evolving information systems that attempt to satisfy those demands. The creation of such systems is based upon a kind of symbiotic relationship where technology facilitates new means, and opens up new horizons. In return, and in context of adopted technology, the expectations, requirements and demands of society further fuel the development. As such, the fundamental building blocks of information systems are constantly being enhanced, or new ones identified, to enable this development. As we enter the new millennium, technology support is such that we are on the brink of entering a true information age, where technology integration will be key in all aspects of social, economic and political systems. In building an information core to satisfy the modern needs of a given application domain, such as primary health care, it is essential that the correct components or building blocks are used to satisfy those modern expectations. In doing so, potential benefits to be realised include gaining a competitive edge and the provision of an enhanced service––both in terms of scope and quality. Technological developments have resulted in an additional fundamental component, or building block––mobility. Mobility, in this sense, refers to the application of mobile computing and technology to support mobile working practices. In other words, enabling a style of work and information access that one would normally associate with a fixed location, or enhancing existing mobile working practices. 2. An overview of mobile computing Before outlining the application of mobile computing and technology to aspects of health care, the following section outlines some key characteristics and directions of mobile computing. The purpose is not to provide specific details of technology, but to provide a holistic appreciation of the existence and implication of mobile computing. Mobile computing can be broadly described as computing technology, comprising software, hardware and communications specifically associated with mobility (Zaslavsky and Tari, 1988). In other words, a form of technology that is not fixed and is capable of being portable. Typical and popular materialisations of the hardware include palmtop computers, laptops and mobile telephones, with more sophisticated devices integrating and combining functionality. The communications infrastructure comprises technology that enables mobile devices to connect and communicate over a network or directly with each other using wired or wireless technology, or a combination of both. Mobile applications are specifically written for use on mobile devices and these may be general applications or domain specific. The combination of mobile technology allows access to networks and resources in a manner previously associated with fixed location computing, and this has led to the flexibility of exploring and adopting new ways of working to achieve corporate goals and objectives. As a supporting technology, computer systems provide a range of benefits associated with an application domain. As computer systems become mobile, opportunities for transforming working practices associated with an application K. Hameed / Telematics and Informatics 20 (2003) 99–106 101 domain into mobile working practices are created, thereby retaining and expanding the benefits associated with technology application. There is a recognition that access to technology resources from a range of locations or whilst in transit is necessary (Kleinrock, 1996; Kleinrock, 2000) and becoming increasingly important. Accordingly, the demand for mobile computing and networking solutions has increased (Agrawal and Famolari, 1999). Given these factors, mobile computer systems are becoming an accepted part of the technology and information systems infrastructure within organisations. The adoption of mobile technology for personal use through to corporate application is evident and increasing. For example, the late 1990s saw a boom in the mobile telecommunications market as the cost of owning and running a digital mobile telephone became far less than ever before. This wireless digital telecommunications technology has become commonplace and is being fuelled further by decreasing ownership costs, greater technical capability (Agrawal and Famolari, 1999; Weinberger, 2000), and wireless mobile applications such as on-line mobile banking. Personal digital assistants (PDAs) are almost as commonplace now as were Filofaxes in the eighties. The reach of mobile technology is touching and embracing the entertainment industry as MP3 and DVD formats and players have rapidly become commonplace, allowing individuals to experience mobile multi-media entertainment. Vehicle manufacturers are specifying global positioning system (GPS) technology as standard, bringing real time navigation to private vehicle owners as well as to public transport. From a commercial perspective, the adoption and use of mobile technology for service and applications provision has obvious benefits in terms of gaining competitive advantage––mobile telephony and the Internet are the fastest growing businesses in the telecommunications market (Guardini et al., 2000). Tables 1 and 2 (Ovum, 2001) show predicted adoption of technology and information access by location and method by 2006. In this prediction the existence of mobile computing is significant. Table 1 Information access by location Access location Number of users (million) Home users Work users School users Mobile or wireless users 732 198 143 543 Table 2 Information access by method Access methods Number of users (million) Internet PCs Internet enabled TVs Mobile phones and PDAs (microbrowsers) Other internet devices 549 134 705 161 102 K. Hameed / Telematics and Informatics 20 (2003) 99–106 The mobile technology artefact base has developed significantly in recent years due to increases in the range of software and hardware platforms. The range of hardware, software and operating systems available or under development illustrates this. The type of hardware devices to support mobile computing is wider than ever before. This includes notebook computers, palmtop/handheld computers, PDA systems, GPS, digital mobile phones, portable DVD players and MP3 players. This is evidence that the IT industry is investing seriously in mobile computing technology. Estimations regarding technology prevalence indicate a 50% increase in the proliferation of wireless Internet access and related technologies over the next two years and the availability of wearable mobile computers and embedded mobile computers in 2007 (Gartner, 2001). The development of mobile computing can be seen as one of evolution as well as a revolution. An examination of the industry and its products shows the movement towards mobile computer systems through the development and transition from one platform environment to another. Specifically from mainframe to mini, from mini to micro, from micro to notebook, and from notebook to palmtop, and there is evidence that the industry itself is shifting position in preparation for the mobile revolution. Within the last five years the digital wireless communications infrastructure around the globe has improved dramatically in anticipation of supporting mobile technology and communications. Not only is mobile technology part of a technological revolution, it will revolutionise the way in which technology is applied in all aspects of life. This will result in a mobile generation where nothing less than fully integrated mobile technology and systems will be expected as the norm. 3. Mobile computing and health care There is great emphasis and acknowledgement of modern information and communication technology, with a vision for the future in which this technology plays an essential role in the delivery of the NHS plan. It is forecast in the plan that implementation will, ‘‘give people a health service fit for the 21st Century’’ (NHS, 2001). As the secretary of state has outlined, patients can expect to see differences in the delivery of healthcare information delivered through a range of channels. As mobile computing proliferates at a rapid pace, it is likely that this technology will be a key channel in the delivery of that information. The application of mobile computing to healthcare has typically not been as extensive that of other technologies, such as medical imaging. However, developments in mobile computing and communication have now enabled this technology to be applied in ways previously unseen (Istepanian, 1999; Shimuzu, 1999). This has enabled platform independent distribution of medical applications and information, particularly in the areas of paramedical and other frontline support (Murakami, 1994; Bukhres, 1998; Menier, 1999). Developments in wireless communications technologies and the move to hand-held mobile devices is also forcing a re-evaluation of existing technology infrastructures within healthcare (Moore, 2001). Moreover, as society becomes increasingly mobile in almost all aspects of life, the expectation and requirement for a supporting healthcare service will, K. Hameed / Telematics and Informatics 20 (2003) 99–106 103 no doubt, increase in parallel. This will be within context of normal social distribution (such as terrestrial communities) through to extensions of those communities in nonterrestrial environments such as water and air (Anogianakis and Maglavera, 1997). Table 3 extracted from (NHS, 2001) shows a subset of commitment, achievements and benefits relating to the development of IT in the NHS. Whilst reference to the application of mobile computing and technology may be inferred or implicit in these, a fourth column outlining the specific benefits of mobile computing has been added. As the global infrastructure for communication has evolved, so has the demand for information, both in terms of information provision and information consumption. To be disconnected in a connected world creates a divide between the information rich and the information poor. The NHS, as an information provider, has used typical technologies for the distribution and presentation of information. For example, the Internet as an underlying transport technology, and web-browsing software for the visualisation of information. The benefits to the NHS as an information provider are associated with the rapid sharing of information, ranging from the provision of faster communication between parties through to the provision of access for specific healthcare information, e.g. evidence-based and clinical guidelines. The power and associated benefits of information provision are widely acknowledged, as are the demands for such a provision. As the underlying technology changes from fixed location to mobile, the mechanisms for mobile information dissemination become pertinent. As the NHS plan requires information, applications and services to be delivered in new ways and through new systems (NHS, 2001) mobile computing and technology can, and will, provide an effective vehicle for the realisation of this goal. Table 3 The role and benefits of information systems and mobile technology in the NHS Commitment Achievement Benefit Additional benefits To support patient care through electronic records Four heath communities are piloting electronic health records to share patient information across health and social care. A further 13 NHS sites are focusing on the delivery of patient care in a range of settings, from NHS Direct to mental health or cancer care From October 2000 the terms of service for GPs have been amended to allow them to maintain all or part of their patient records on a computer system A personÕs health record will be available at the time they are seen and will hold a complete and up to date summary of their clinical history or current condition. This work is essential to developing national standards for electronic records A personÕs health record will be available at the time of consultation, irrespective of the location of that consultation. Quality of off-site service and information will be enhanced GPs can now provide the full benefit of running a paperless practice The benefits of a paperless office can be extended and adapted for a diverse range of working practices in terms of location and time To remove the contractual requirement for GPs to maintain paper records 104 K. Hameed / Telematics and Informatics 20 (2003) 99–106 In order for services within the NHS to function effectively, information needs to be captured, ingested and integrated. There are many points of data capture, normally associated with fixed location services e.g. patient registration or consultation at a general practice, with some points of data capture being of a more mobile nature, e.g. visiting care workers in the community, or capture of patientsÕ conditions by doctors ‘‘on call’’. As society becomes increasingly mobile, there will be a need for the points of data collection to diversify to cater for this mobility. The mechanisms for information collection in a mobile society, therefore, also become pertinent. Currently, 90% of patient contacts with the NHS are through primary health care (NHS, 2001). Given the volume of this type of contact, the supporting infrastructure to support primary health care is, therefore, of significance––particularly the infrastructure that enables workers to provide a direct and effective patient-centred service. The evolution of flexible primary care services, such as Care Trusts, Personal Medical Services and ‘‘walk-in’’ centres can be extended by the adoption of mobile computing which can facilitate new methods of service delivery within, and outside of, these platforms. As an extreme example, the concept of a walk-in centre can be entirely reversed to a ‘‘walk-out’’ system where workers are equipped to provide a set of health care services away from the normal base of provision. Table 4 Example applications of mobile computing to primary health care Mobile technology usage Benefits The use of mobile terminals by primary health care workers at points of service provision (on or off-site) The effective portability and usage of electronic patient records and history improving the quality of contact Data can be captured using standard formats and templates, with a local electronic knowledge base to guide data entry, enhancing the quality and accuracy of the captured data Access to common and consistent decision support systems to enable the best diagnosis, thereby enabling consistently high standards Enhancing support for distributed and remote electronic learning across a range of personnel using multi-media resources The effective dissemination of information pertaining to good practice Immediate transfer and integration of patient information into the information system thereby ensuring the integrity of complete patient information and improving co-ordination between PHC teams Patient access to NHS information services for self-care, irrespective of time or location Facilitation of telecare and telemedicine allowing the remote capture of data (e.g. periodic remote monitoring of blood pressure) Remote mobile access to information services for primary health care workers Transmission of data from remote locations to a central system using mobile communications technology Mobile portals for information access The use of mobile devices by patients K. Hameed / Telematics and Informatics 20 (2003) 99–106 105 Whilst it would be unrealistic to discuss the complete and extreme mobilisation of health care services and personnel, it is realistic and feasible to discuss the adoption of mobile computing and technology to a sub-set of services and personnel. Table 4 outlines some examples of mobile computing and its application to primary health care. In context of on-going development of electronic patient records (EPRs) and electronic health records (EHRs), with the full and complete implementation of EPRs targeted for 2005, the re-evaluation of the concept and implementation of EPRs in context of patient, practitioner and process mobility also becomes relevant. It can be seen from the above that the use of mobile and wireless technology can result in new opportunities, both technical and non-technical, for enhancing many aspects of the fundamental processes that govern the successful operation of a system such as the health service. Whilst use of the technology can result in significant benefits, its adoption is liable to encounter constraints based upon philosophical changes to working practices, and practical constraints of systems integration and economic justification. This would be anticipated from any supporting technology but more so from mobile and wireless technology because of the manner in which it can radically alter the way in which a system functions. 4. Summary This paper has presented a holistic view of mobile and wireless technology, and examples of its application in the health service. There is no doubt that that mobile and wireless technology is permeating into many aspects of life, including the health service, and will continue to do so both through choice and requirement. It is also recognised that the wireless Internet and the new generation of wireless devices will play a key role as health care technology. The power and potential of mobile and wireless computing is now being realised in many sectors of private and public sector services. In the case of health care, the adoption of the technology can be seen as adding value to key process and information systems supporting the delivery services where ultimately it is the patients that benefit. The demands of a modern health care service and expectations of patients will, no doubt, continue to fuel its adoption. References Agrawal, P., Famolari, D., 1999. Mobile Computing in Next Generation Wireless Networks. Paper presented at the 3rd International Workshop on Discrete Algorithms and Methods for Mobile Computing and Communications, Seattle, WA, USA, 20 August 1999. Anogianakis, G., Maglavera, S., 1997. The MERMAID Project Intranet: Mixing Satellite and Terrestrial Communications for Achieving ‘‘Healthcare for All’’. Paper presented at the IEE Colloqium on EUÕs Initiatives in Satellite Communications, 8 May 1997. 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A Virtual Machine for a Functional Mobile Agent Architecture Supporting Distributed Medical Information. Paper presented at the Proceedings of the IEEE Symposium on Computer Based Medical Systems, 18–20 June 1999. Moore, S.K., 2001. Unhooking medicine (wireless networking). IEEE Spectrum 38 (1), 107, 108, 110. Murakami, H., Shimizu, K., Yamamoto, K., Mikami, T., Hoshimiya, N., Kondo, K., 1994. Telemedicine using mobile satellite communication. IEEE Transactions on Biomedical Engineering 41 (5), 488–497. NHS, 2001. Building the Information Core––Implementing the NHS Plan: Department of Health, UK Government. Ovum, 2001. Where/how will we access the Internet in 2006? Computing, Jan/Feb 2001. Shimuzu, K., 1999. Telemedicine by mobile communication. IEEE Engineering in Medicine and Biology 18 (4), 32–44. Weinberger, G., 2000. The New Millenium: Wireless Technologies for a Truly Mobile Society. Paper presented at the IEEE International Solid-State Circuits Conference––Digest of Papers, 7–9 Feb 2000. Zaslavsky, A., Tari, Z., 1988. Mobile computing: overview and status. The Australian Computer Journal 30 (2), 42–52. Wireless and Mobile Computing Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: Fran Turisco and Joanna Case First Consulting Group October 2001 Acknowledgments This report was written by Fran Turisco and Joanna Case of First Consulting Group’s applied research department, Emerging Practices. They would like to acknowledge the assistance of Hal Gilreath of ArcStream Inc., who contributed through an interview and review of the draft manuscript; Bill Marshall and Ralph Clements from First Consulting Group’s Doghouse Technology Services; and Jane Metzger and Erica Drazen from First Consulting Group’s Emerging Practices for thoughtful review comments incorporated into the final document. The California HealthCare Foundation, a private philanthropy based in Oakland, California, focuses on critical issues confronting a changing health care marketplace by supporting innovative research, developing model programs, and initiating meaningful policy recommendations. The iHealth Reports series focuses on emerging technology trends and applications and related policy and regulatory developments. Additional copies of this report and other publications in the iHealth Report series can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-2423 or visiting us online at www.chcf.org. ISBN 1-929008-72-4 Copyright © 2001 California HealthCare Foundation Contents 5 Overview 7 Purpose 8 I. What Is Mobile Computing? Three Data Transfer Options Mobile Computing Devices Current Technology Issues and Limitations Technology Selection Considerations Future Directions for Wireless Technology 19 II. Applications: What Mobile Computing Does Seven Applications of Mobile Computing Inpatient Care Solutions Outpatient Care Solutions 26 III. Implementation Considerations: Benefits, Issues, Risks, and Tactics The Benefits of Wireless The Problem of Electromagnetic Interference (EMI) HIPAA and Other Regulatory Considerations Risks with Implementing Mobile Computing Tactics For Success 32 Appendices Appendix A: Wireless Landscape Diagram Appendix B: Mobile Device Operating System Summary Appendix C: Performance Shortcomings of Wireless LAN, Wireless Internet, and Data Synchronization Technologies Appendix D: Representative Mobile Computing Vendors and Products Appendix E: Reference Web Sites Appendix F: Glossary 41 Endnotes Overview MOBILE COMPUTING IS BECOMING AN IMPORTANT part of health care’s information technology (IT) toolbox. Technology advances and the proliferating health care applications indicate that mobile computing will find a secure place in both inpatient and outpatient care. It is not too early for organizations to investigate the benefits it can offer and how it would fit in with current information systems, workflow, and care practices. Mobile computing is not a single technology, but a combination of three components (handheld computing device, connecting technology, and a centralized information system), each with different performance considerations, costs, and risks. Successful implementation of mobile computing requires employing all of these components in the way that best suits the work and environment of the end users. The major benefit of mobile computing—connecting caregivers to clinical data and applications anywhere and anytime—is increasingly attractive in a health care environment where physicians work longer hours and see more patients. They are looking for a more efficient means to enter and retrieve data; they cannot afford the time required to locate an available desktop, log in, and then enter information into a system. On the nursing side, with a severe shortage of personnel, technology at the point of care can increase nurses’ efficiency. Furthermore, new regulatory pressures for comprehensive clinical documentation point to the value of data recording and retrieval that is portable, accurate, easy to use, and reasonably priced. Newer mobile computing applications not only provide clinicians with access to medical reference tools but also handle patient care and administrative tasks such as basic charge capture, prescription writing, clinical documentation, alert messaging, and general communications. Additionally, vendors of hospital information systems (HIS) are using wireless technology and teaming up with mobile computing vendors to provide portable solutions for their systems. Wireless and Mobile Computing | 5 Further advancement of the technology is needed to address connectivity, performance, security, integration, and cost issues for more integrated applications. However, the rapid rate of development and maturity for wireless technology, combined with the appearance and promise of more powerful handheld devices, is expected to spur application development to create solutions that support the work of health care professionals in both inpatient and outpatient settings. There are risks of implementing emerging technologies: Vendors and products are immature, with a limited record of success; mobile computing functionality does not currently compare with traditional systems; and integrating mobile computing applications with current systems is risky and expensive. Like any technology, mobile computing implementation requires careful planning, user involvement, executive sponsorship, and commitment from the organization. Pioneering organizations are providing valuable lessons on how to successfully introduce mobile computing into the work setting to improve care delivery and workflow efficiency. Common themes from these organizations include: ■ Start with the business problem. What can mobile computing do that traditional applications cannot? ■ Set realistic expectations by understanding technology capabilities and limitations, costs, and risks. Because the applications are immature and many vendors are new to the market, factor additional time and resources into the decision-making and implementation phases. ■ Learn from the experiences of others; review case studies and take lessons from their successes and failures. Be aware that the technology changes may be easier to integrate than the work process and role changes. 6 | CALIFORNIA HEALTHCARE FOUNDATION ■ Pilot the application. Mobile computing lends itself to pilot projects because there are low front-end expenditures for the devices and applications, and many can be piloted with simple interfacing requirements. Start small and build on successes. Mobile computing and wireless technology solutions have entered the health care industry and are beginning to prove their worth to providers and hospitals, as well as patients. Understanding the technology and how it is used in health care are the subjects of a series of timely reports written by First Consulting Group and published by the California HealthCare Foundation. In addition to this primer, the upcoming series includes: ■ E-encounters ■ E-disease Management ■ E-prescribing ■ Diffusion These reports, as well as other reports in the iHealth Report series, can be obtained by calling the publications line at 1-888-430-2423 or visiting our Web site at www.chcf.org. Purpose THIS REPORT IS INTENDED TO SERVE AS A GUIDE for health care clinicians and administrators who want to understand mobile computing and wireless technology concepts in health care. Geared toward non-technical readers, it provides a snapshot of the current marketplace with a view toward future developments. More technical information on capabilities, issues, connectivity, and coming developments are included in the appendices and referenced in the text for those interested in more detail. A vendor list and a basic glossary are also included. The following is an outline of the major areas of this report. I. What Is Mobile Computing? This chapter begins with a description of the basic components of mobile computing and how they work together to provide the portability that caregivers need. Following the description is a high level overview of the three ways data is transferred from the handheld to the patient care information system— data synchronization, wireless LANs, and the Internet. Information on the mobile devices, technology issues, best-fit scenarios, and future trends is included to give a full understanding of the components of mobile computing. 2. Applications: What Mobile Computing Does Building on the understanding of the technology, this next chapter provides an overview of the major application products for both inpatient and outpatient settings. Characteristics of the current marketplace, including acceptance, barriers, trends, and future directions are addressed. 3. Implementation Considerations: Benefits, Issues, Risks, and Tactics The third section provides some insights into how to address decisions on selecting and implementing mobile computing in health care. Understanding the problem, expected benefits, technology considerations, HIPAA compliance, and the impact on internal processes are factors that organizations weigh when considering mobile computing. Finally, lessons learned from early mobile computing implementations will help today’s adopters set realistic expectations and glean value from this new technology. Wireless and Mobile Computing | 7 I. What Is Mobile Computing? Most mobile computing applications today in health care do not interact at all with the Internet. RECENTLY THE TRADE AND POPULAR PRESS HAS been full of cover stories touting mobile computing and wireless technology as the linkage solution for personal communication and business transactions. Given all of the excitement about mobile computing and the frequent association with the Internet, it is not surprising that there are a number of misconceptions about what wireless is and does. Recent items in the press indicating widespread adoption of wireless include: ■ The number of wireless Internet users will reach 83 million by the end of 2005, or 39 percent of total Internet users.1 ■ By the end of 2004 there will be 95 million browser-enabled cellular phones and more than 13 million Web-enabled personal digital assistants (PDAs).2 ■ The wireless LAN market is expected to reach $1 billion in 2001; this figure will double by 2004.3 In fact, these items refer to different technologies. The first refers to the wireless Internet; the second is about Internetready devices, and the last refers to wireless LAN. All of these technologies will be discussed in this report. Probably the most common misconception is that wireless means the Internet. Actually, wireless refers to the underlying technology that supports the transport of data between the mobile handheld computing device and the main computer system without a wired connection between them. The Internet is a global network that provides access to information and applications using a browser or Web navigating application. Most mobile computing applications today in health care do not interact at all with the Internet. To unravel these misconceptions and understand what mobile computing can offer, it is important to recognize that mobile computing is not one technology. It is a range of solutions that enable user mobility by providing access to data anytime, from any location. For health care managers and caregivers, a high level understanding of wireless technology and mobile computing options is fundamental to sound decision-making on whether and in what ways to use them. 8 | CALIFORNIA HEALTHCARE FOUNDATION Figure 1. Mobile Computing Components Data Communication Technology Component Wireless Connection Wired Connection Handheld Computing Device Component Information System Component As shown in Figure 1, mobile computing has three components: 1. Handheld, mobile computing device 2. Connecting technology that allows information to pass back and forth between the site’s centralized information system and the handheld device and back 3. Centralized information system Here is how mobile computing works: ■ The user enters or accesses data (such as vital signs, charge information, clinical notes, or medication orders) using the application on the handheld computing device. ■ Using one of several connecting technologies, the new data are transmitted from the handheld to the site’s information system where system files are updated and the new data are accessible to other system users, such as the billing department. The process works the same way starting from the other direction. For example, a physician may want to have access to all new laboratory results for today’s clinic patients. This information is stored in the site’s information system and now needs to be transmitted to the handheld device. Again, the connecting technology delivers the data to the handheld and the physician can roam around, accessing the appropriate information from the handheld device. The process is similar to the way a worker’s desktop PC accesses the organization’s applications, except that the user’s device is not physically connected to the organization’s systems. The communication between the user’s device and the site’s information systems uses different methods for transferring and synchronizing data, some involving the use of radio frequency (RF) technology. ■ Now both systems (the handheld and the site’s computer) have the same information and are in sync. Wireless and Mobile Computing | 9 Three Data Transfer Options In today’s market, the three most commonly used wireless data transfer methods are: 1. Wireless local area network (Wireless LAN) 2. Wireless Internet or wireless Web 3. Data syncing or “hot syncing.” This is not a wireless data transfer method, although it is often referenced as “wireless.” Data syncing uses docking cradles or docking stations that are connected to a LAN to transfer data from the device to the organization’s information system. (For a complete picture of the mobile computing landscape, refer to the diagram in Appendix A.) Wireless LAN Wireless LAN is a flexible data and communications system used in addition to, or instead of, a wired LAN. Using radio frequency (RF) technology, wireless LANs transmit and receive data over the air, minimizing the need for wired connections and enabling user mobility. Unlike some technologies such as infrared, wireless LAN is not a “line-of-sight” technology. Therefore the handheld device can operate anywhere within the coverage area. In a wireless LAN, as shown in Figure 2, the caregiver enters data into a handheld device such as a personal digital assistant (PDA), laptop, or tablet (see Table 1 and Figure 5 for descriptions) that has a special wireless LAN card. This card has an antenna that transmits the data in real time using radio frequency technology to an access terminal, usually connected to a ceiling or wall. The access terminal is connected to the local area network and sends the data received— or requests for data—from the handheld to the patient care information system. Conversely, data from the site’s information system can be sent to the handheld using the same technology. Figure 2. Wireless LAN Diagram Local Area Network Sends/Receives Data Information is sent real time to the access terminal. The access terminal sends the data to the HIS via the LAN. Access Terminal Wired LAN Wireless Wired LAN Clinician Uses PDA, Laptop or Tablet to Access/Record/Send Patient Information 10 | CALIFORNIA HEALTHCARE FOUNDATION Information System Currently wireless LANs work best in health care settings where (1) the area of mobility is confined to a campus or building; and (2) the need for up-to-date patient information is immediate. If the caregiver is using a small handheld device like a PDA, the small screen size is suited to only limited data viewing and data collection functions such as lab order entry, single results display, and clinical notes entry. Laptops and tablets provide more processing capabilities, more data storage, and larger displays so users can access entire patient records and view results in a number of graphical formats. Ambulatory and inpatient medical record applications work very well in a wireless LAN environment with larger user devices. (See Table 1 and Figure 5 for more specifics about devices.) Case in Point: The Children’s Health Fund Mobile Clinics Medical staff working from The Children’s Health Fund mobile health van now have access to the organization’s electronic medical record (EMR) system while traveling to homeless shelters and inner-city areas. The organization, which is affiliated with Montefiore Medical Center in the Bronx, did careful research before introducing (in January 2000) wireless LAN technology using handheld pen tablets for recording and displaying patient information. The tablets are equipped with wireless LAN card antennae to communicate with computers mounted in the van. Unlike the old paper-based process, the tablets provide immediate access to patient information including medical concerns during previous visits and all the details from past interactions, regardless of the location. If a child shows up in one shelter at one time and then in another years later, the caregivers have all of the patient’s information. And they can print out any information during the visit so patients can leave with printed prescriptions and instructions.4 Wireless Internet Wireless Internet, also known as the wireless Web, provides mobile computing access to data using the Internet and specially equipped handheld devices as depicted in Figure 3. Using a Web phone or the latest PDA phone (see Figure 5) with a micro Web browser, the user can display data accessible from the Internet. Technically speaking, the mobile device connected to the cellular system sends the request to a computer link server. This server acts as a gateway that translates signals from the handheld device into language the Web can understand, using an access and communication protocol. One of the leading protocols is called WAP (Wireless Application Protocol). The server also forwards the request over the Internet to a Web site, such as Yah...
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