Handy Handhelds

Tablet PCs and PDAs are bringing radiology images anywhere they need to go around the healthcare enterprise. See how a variety of healthcare providers in radiology, cardiology, orthopedics and neuroradiology are using handheld computers in innovative ways.

Handheld computers - tablet PCs and PDAs - are being deployed across the healthcare enterprise. Emergency physicians, orthopedic surgeons, neurosurgeons, cardiologists and a few radiologists are discovering these handy devices can improve the business of medicine and enhance patient care by providing anytime/anywhere access to critical patient data. Key points to remember are:

• There is a handheld device for everyone. The key is deciding what works for each individual, not forcing a certain device on every user, says Ben Bresnick, coordinator of physician relations and technology for Central DuPage Hospital in DuPage, Ill. Even 'tech-phobics' who prefer pen and paper can now go high-tech.
   
• The image quality of even the highest resolution handheld devices is debatable for diagnostic viewing. But if users consider images in terms of informational quality (vs. diagnostic quality), handhelds' utility for image display becomes apparent. A surgeon, for example, may determine whether or not he needs to see a patient immediately via an image viewed on a handheld.
   
• A number of enabling technologies are poised to converge on the market. Vendors are improving hardware with more rugged tablets and larger, higher-resolution screens on next-generation PDAs. And more applications for the handheld uninitiated, particularly for radiology and cardiology users, are hitting the streets.

PDAs: GOOD THINGS COME IN SMALL PACKAGES

Jerome Kolavo, a partner with Orthopedic Associates of DuPage (DuPage, Ill.), uses a palmOne handheld (palmOne of Milpitas, Calif.) equipped with Horizon MobileCare Rounding (McKesson of Alpharetta, Ga.) to simplify the business of medicine and better meet his patients' needs. Kolavo's palmOne is tied into the hospital server, allowing him to access radiology reports, patient vital signs, lab results, dictations and patient census information. "Basically, what I'm looking for is data," he says. "The palmOne is user friendly, portable and multifunctional. With one device I can view patient data, send and check emails and receive phone calls. Eventually, this will replace my pager."

Kolavo admits that the palmOne isn't great for images, but says it doesn't need to be. "If I really need to view images, I want a good high-resolution monitor," explains Kolavo. Still, he admits, he is just scratching the surface of the device's capabilities. Bresnick, who initiated the PDA program at Central DuPage Hospital, believes surgeons can realize the biggest gains from handhelds because they can remotely view photos and x-rays of injuries, such as dog bites or severed fingers.

While clinicians like Kolavo are riding on the PDA bandwagon, radiologists have been slower to climb on board. Adam Flanders, MD, professor of neuroradiology at Thomas Jefferson University Hospital (Philadelphia, Pa.), explains why. "The biggest problem with handheld computers right now is that there are no killer applications for radiologists. It's hard to build a compelling application for radiologists who are surrounded by $80,000 high-resolution, high-fidelity workstations with instant access to voice recognition, HIS and other tools."

Radiologists using PDAs generally limit their use to PIM (personal information management) applications. Radiology-specific applications include Elsevier's (Philadelphia) PocketRadiologist. The walking reference library provides decision-support through images, diagrams and text. But power applications for radiologists may be right around the corner.

"The big growth area for PDAs is the digital dashboard," Flanders says. The digital dashboard could allow mobile radiologists to monitor their practices, providing instant access to patient wait times, number of cases and other critical information that can help the radiologists optimize their time. Flanders relies on an internally developed dashboard tool for his PDA to keep an eye on his work when he's away from the office. "I can check on the number of cases piling up when I'm on the train and decide whether I should go to my office or straight to the reading room."


THE IMAGE QUALITY ISSUE

Right now, the display resolution on PDAs is not sufficient to deliver diagnostic-quality images. But, Flanders says, "Resolution is right at the cusp now. It's almost full VGA." Standard VGA (800 x 600 resolution) devices may suffice for some content, such as ultrasound and functional images. CR and digital mammograms, on the other hand, require 3 megapixel monitors.

In addition to image resolution, another issue is screen size, says Christopher Beaulieu, MD, PhD, chief of musculoskeletal radiology at Stanford Hospital and Clinics (Palo Alto, Calif.). PDAs' 1.8 inch screens are clearly too small for the human eye, but three- or four-inch screens may suffice for some uses, such as checking examinations and image protocoling. Even when the image quality hurdles are crossed, Flanders questions when radiologists would really require diagnostic image-viewing capabilities.

Regardless of whether or not radiologists use PDAs to view images, they may find that they can use them to store large radiology data sets. How does it work? PDAs pack a lot of capacity (five to 40 gigabytes) in a small package. Osman Ratib, MD, PhD, professor and vice chair of information systems for the radiology department at the University of California Los Angeles has developed Osirix, a Macintosh-based software application that allows radiologists to carry original DICOM image files for five to 10 studies on a Macintosh iPod. When the iPod is connected to a new-generation Macintosh equipped with ultrafast graphic capabilities, the software searches for medical images, which the radiologist can display and manipulate on the Macintosh, eliminating the need to copy images to CDs.

Ratib and his colleagues also are exploring another way around PDA image limitations. They've built a protoypte PDA that can be used to drive images to a high-resolution flat-panel monitor/viewbox attached to the wall. Radiologists or clinicians could initiate a connection with the viewer via the PDA and then select a patient from the patient list to display radiology images and lab results on the viewer. Ratib hopes to develop the hybrid device through a partnership with GE Healthcare (Waukesha, Wis.) and install them in a new UCLA hospital in several years.


TABLET PCs: THE PERFECT STORM

Orthopedic Associates of DuPage's Kolavo swears by his palmOne because it enables him to do away with his 'Batman toolbelt,' but other users hunger for the functionality, ergonomics and performance of tablet PCs. Flanders says, "I see the biggest gain for radiologists coming from tablet PCs rather than PDAs." That's because tablets can allow radiologists to interpret diagnostic studies and provide access to other clinical applications like voice recognition.

Mark Zielazinski, CIO of El Camino Hospital (Mountain View, Calif.), believes several factors drive acceptance among radiologists, cardiologists, orthopedic surgeons and neurosurgeons-image quality, video drivers and image management software. All of these factors are at or close to the point where it may be practical for image-dependent specialists to access informational quality images in a mobile environment, such as at the patient bedside and in consultation.

Vendors are banking on radiologists' affinity for tablets with some new applications. Stentor (San Francisco, Calif.) leapt into the handheld arena with both feet with the development of iSite Enterprise to deliver images to Microsoft Windows XP Tablet PCs. Carolinas HealthCare System (Charlotte, N.C.) is one of the first sites to offer iSite Enterprise on tablet PCs. According to Alan Smith, vice president information services-clinical applications, the real value of the tablet application is in patient education, not clinical decision making. For example, surgeons share images with parents of pediatric patients prior to surgery. They also use the tablet to access laboratory, transcription results, radiology results and medication orders via a Windows Internet Explorer-based portal. For the most part, radiologists and specialists, such as oncologists and emergency room physicians, who rely on images for preliminary or diagnostic reads are still shying away from reading images on tablet PCs. Smith opines, "That's because the resolution isn't of a high enough quality for them to make clinical decisions."

IDX Corp. (Burlingon, Vt.) offers ImageCast RIS and Enterprise Access, a web-based application that allows radiologists to view patient information via Microsoft Internet Explorer on Motion Computing (Austin, Tex.) Tablet PCs. John Paganini, The Cleveland Clinic Strategic Account Manager for IDX, is demonstrating the application to radiologists at The Cleveland Clinic (Ohio). He explains, "The focus is on improving workflow for radiology. I see the tablet as an enabling technology in our quest to go paperless and filmless."

Fujifilm Medical Systems (Stamford, Conn.) also may put more handhelds in the hands of radiology users with Flex UI, a new CR application that can be run on tablet PCs and PDAs. The CR software interface could be used in conjunction with a tablet PC with screen resolution of 1024 x 768 to increase technologists' productivity by allowing them to view CR images and complete quality control on the fly. Fuji expects to launch the Flex UI for tablet PCs this summer after the company determines that a tablet PC can be used practically in the portable/ICU environment. The company is collaborating with Motion Computing to use the application with a more rugged tablet.


CARDIOLOGY CUES

Although all of the technologies enabling radiologists and other specialists to maximize their tablets are not yet available, some clinicians are finding that tablets are an indispensable part of their practice. Take, for example, Arthur McDowell, MD. McDowell may be the epitome of the 21st century physician. He's a partner with Middlesex Cardiology Associates in Middletown, Conn., which maintains three full-time offices, and he's chief of cardiology at Middlesex Hospital across town. McDowell uses a both a PDA and tablet PC in his practice. He primarily relies on the PDA to track appointments. McDowell explains, "Although other specialists use the PDA to download lab results and patient lists, it's a little impractical to access the entire patient record on a handheld." McDowell reports that the Toshiba Tablet PC (Tustin, Calif.) crosses that hurdle and helps him manage his daily workflow and enhance patient care.

Middlesex Cardiology first deployed tablet PCs three years ago when the practice implemented an electronic medical record (EMR). The first-generation solution, in tandem with the EMR, helped reduce paper, transaction time and space requirements, but didn't quite meet the needs of cardiologists. The tablet was somewhat unwieldy as it needed a docking station for keyboarding, and the practice's applications required keyboarding. Consequently, McDowell began shopping for a new solution, and late in 2002 implemented Toshiba Tablet PCs with an integrated keyboard.

The new technology was a giant step forward in ergonomics. McDowell explains, "The keyboard works like a real keyboard. Our hands fit on it." McDowell uses Amicore Clinical Management (Andover, Mass.) to facilitate information management and patient care. He also uses the handheld wireless pen tablet solution to retrieve clinical, financial and patient data.

Middlesex Hospital uses an electronic results repository, which works in parallel with Middlesex Cardiology Associates' EMR. McDowell carries his tablet into every patient appointment. If a patient was seen in the ER two days ago, McDowell simply clicks on the hospital icon to access laboratory results, radiology reports, ECGs and historical patient data. If a patient has a question during the appointment, McDowell can log onto Google to direct the patient to an appropriate website.

McDowell says the practice has realized pretty significant benefits since deploying Amicore-equipped tablets. "This gives us more time with the patient. The biggest gain is we can complete patient notes right in the room with the patient. We can even print everything out for the patient in the room."

The other primary benefit is the availability of patient data; it is literally at the physician's fingertips without the time lag associated with mailing or faxing and entering results on a paper chart. Nor do cardiologists need to run to the central station for lab or radiology results. Even with increased time with each patient, McDowell is seeing more patients - about 25 patients a day, three or four more than in his pre-tablet days.

PC Blades: not handheld, but very flexible

PDAs and Tablet PCs aren't the only ticket to flexibility. Oklahoma Heart Hospital (Oklahoma City) is an all-digital facility that strives to provide physicians with flexible solution to improve workflow and patient care. When the hospital opened in 2002, the IT department installed 120 PC Blades from ClearCube Technology (Austin, Tex.) across the enterprise in patient rooms, cath labs and surgical suites. PC Blades are compact computers; the front end at each client location is a keyboard, mouse and monitor linked to a central processor in a data closet. IT Manager Jeff Jones explains, "This replaces the clipboard at the end of the bed. As far as functionality, it's a PC on a stick. Physicians can chart in the room and access lab results."

The hospital installed 1024 x 768 flat panel monitors in patient rooms and 1280 x 1024 monitors in the OR, allowing physicians to view cath images and the EMR during surgical procedures.

Some users are just plain wedded to pen and paper; however, there are ways to integrate these tools in the digital workflow. Take Hewlett-Packard's (Houston) Digital Pen and Forms Automation System. The combination provides another option for database entry. Instead of using tablet PC, keyboard or conventional pen and paper, a user enters information onto a pre-populated form with an HP Digital Pen. The pen is inserted into a digital cradle connected to a client and the information is immediately available in the patient database, making paper part of the electronic process. The pen can be used to record physician notes on plain paper. After the pen is docked in its cradle, the notes are available in the patient record.

Tablet PC Buyer's Guide

Mark Zielazinski, CIO of El Camino Hospital (Mountain View, Calif.), successfully deployed 150 Hewlett-Packard Compaq Tablet PCs throughout the hospital. In one year, the hospital has realized some significant results. The facility recently completed a four-week test of HP Tablet PCs and the hospital's clinical information system with hospitalists. The benefits include:

• Improved access to the patient care system, including transcribed documents such as admission information, from everywhere in the hospital
   
• Immediate access to external patient-specific data at physician offices
   
• Ability to wirelessly print records throughout the hospital

El Camino Hospitalist Phil Strong explains, "Now, when a patient's primary doctor calls to say a patient is coming in to the hospital, we have access to that patient's entire medical history. We can review test results already in the patient's file with the primary physicians and then order only the additional labs, x-rays and EKGs that are really necessary. This head-start means the hospitalist can cut the patient's time spent waiting in the emergency room
by as much as two-thirds."

Such benefits don't occur in a vacuum and are, in fact, an outgrowth of Zielazinski's detailed analysis of tablet solutions. Some tips for prospective buyers include:

• Consider ease of use. A keyboard is key. Although slate machines have a better weight ratio than tablets, the lack of a keyboard is a drawback for many users.
   
• Battery life is critical, too. Reasonable life is three hours, which can be combated with strategically-located chargers and docking stations throughout the hospital. Expect battery life to double in the next 12 to 18 months.
   
• Ruggedness and durability are essential for users in hectic environments such as the ER and ICU. Be sure to assess the durability of various models.