When nurses make rounds at the cardiovascular surgery unit of Miami Children's Hospital, there is one piece of medical equipment that is
missing: the clipboard. Instead of writing information about the patients
on pocket-size cards, nurses tap away on hand-held organizers.
As soon as the patient information is gathered, it moves by wireless
modem through a network to a server elsewhere in the hospital, making it
available through a password-protected Web site to doctors and other
health care providers.
In many workplaces, the process would hardly seem exceptional. But by
the standards of the medical community, the Miami system verges on
revolutionary. While medicine has long utilized sophisticated technologies
to diagnose and treat health problems, the methods doctors and nurses use
to record and track those diagnoses and treatments have remained
remarkably unchanged for almost a century.
But the hand-held computer may someday be as ubiquitous as the
stethoscope, as the medical industry adapts to new federal regulations on
the privacy of medical records, released earlier this month, and works to
overcome the problem of records and drug prescriptions based on the
infamously illegible handwriting of doctors, which studies have shown are
error prone.
For now, the cardiac unit in Miami has one of the most extensive
hand-held systems in the medical industry. A small but growing number of
hospitals are using palmtops for writing prescriptions, consulting
reference manuals and, in a few cases, keeping records, although generally
in a more limited way than Miami's system.
Dr. Edward H. Shortliffe, chairman of the department of medical
informatics at Columbia University, said that earlier initiatives to
expand computing in medicine bred mostly suspicion. "Why is medicine
behind other segments of society?" he said. "There's no simple answer. But
there is something about the ability of computers to disrupt rather than
improve the work flow of people who are very busy."
But, Dr. Shortliffe, said, the increased scrutiny of medical
record-keeping along with the general improvements in and awareness of
computers, may wash away the bad taste. "There's a climate for change
right now," he said.
When Dr. Redmond Burke became the chief of cardiac surgery at Miami
Children's Hospital seven years ago, it was apparent to him that the
records system was out of date.
"I was frustrated that Federal Express could keep better track of a
package than we could track patients," he recalled. "We were walking
around with 5-by-7-inch index cards as the hospital database. They got
lost. You couldn't access them. I wanted to have one hand on a sick baby
and in the other hand, I wanted to hold that baby's information. That's
where the hand-helds came in."
It was an earlier era of technological change that introduced the
record-keeping system that so frustrated Dr. Burke.
Dr. Joel D. Howell, who is a professor of history and internal medicine
at the University of Michigan, said, "In the early part of the 20th
century, people are explicitly saying that hospitals need to be more like
factories and if that happens, people's lives will be saved."
Until then medical records had been nothing more than pieces of paper
that were not always properly filed. One of the industrial practices that
hospital administrators adopted was the use of standardized forms. At the
same time, the expansion of specialists and the growing use of laboratory
testing and technologies like X-rays increased the paperwork. "Suddenly
you've got this burgeoning of forms," said Dr. Howell, the author of
"Technology in the Hospital" (Johns Hopkins University Press, 1995).
A century later, Dr. Howell relies on many forms of the same kind when
treating patients and making diagnoses. He does, however, use a Palm organizer to consult electronic drug reference manuals before writing
prescriptions.
Such electronic checking has become common among doctors who use
hand-held organizers. ( Harris
Interactive, a research firm, estimates that about 17 percent of
doctors use a hand-held in some way.) "The P.D.A. is much easier than the
P.D.R.," Dr. Howell said, referring to the Physicians' Desk Reference, the
bulky print volume containing much the same information.
In Miami, however, Dr. Burke wanted to go beyond using hand-helds as
reference books. To that end, he lured Jeffrey White, a former aerospace
engineer, away from his doctoral studies in biomedical engineering at the
University of Miami.
With Mr. White's help, Dr. Burke's department introduced its first
system using Palms in April 2001. It required doctors and nurses to put
their organizers into cradles regularly to download and receive patient
information. Unfortunately, harried doctors sometimes forgot to do that,
creating delays in updating information and potential privacy problems
because patient data stayed on their devices.
"They were literally walking out of the hospital with people's medical
records in their pockets," Mr. White said.
The system was soon abandoned. One key to the second system, he said,
is a series of Web servers, which take data from all the hospital's
computer systems, handling tasks like billing and test results, and
convert the information into standard Web pages. The servers also store
the digital patient files as Web documents, allowing them to be read by
any computer, hand-held or otherwise. Those digital files can include
photos and videos of procedures. The bedside information is entered on
organizers using a combination of on-screen forms and either a small
add-on keyboard or a shorthand handwriting program that works with the
Palm and Microsoft PocketPC operating systems.
Using wireless organizers to link with servers also reduced the
potential for confidentiality problems. Now the hand-helds act as dumb
terminals; patient information is immediately sent to the servers for
storage and the hand-helds' memories are cleared. Similarly, records
viewed by doctors on their palmtops are never stored on the units.
When it comes to prescriptions, many systems go beyond providing a
simple drug reference. Dr. Eric Mankin, the chief medical officer of
Temple Physicians, a group affiliated with the Temple University Health
System in Philadelphia, said handwritten prescriptions do not inspire
confidence in patients.
"Imagine if they got their bank statement every month and found that it
was in handwriting," Dr. Mankin said. "How confident would they feel about
its accuracy?" He estimates that in the past, about half of the calls to
doctors in the Temple group were from pharmacists who could not decipher
the prescription.
Now the doctors in the group have replaced their prescription pads with
a system using iPaq hand-helds and software from Allscripts
Healthcare Solutions, a company in Chicago. The doctor enters a
patient's name and birth date, finds the appropriate diagnosis from a list
that includes the most common ones and, from menus, enters a prescription.
A red frowning face flashes on the screen if there is a potentially
dangerous drug interaction or if a misplaced decimal point or other
mistake has created an overdose.
From there, the information goes through the wireless network to a
printer or to a telephone line for faxing to a pharmacy.
Dr. Joel D. Howell consults reference manuals on his Palm. |
Dr. Howell said that the idea of relaying sensitive health information
through wireless networks might unnerve some people. "There's always early
concerns about privacy," he said. "There's a feeling that something
electronic is more vulnerable to invasions of privacy."
But it is not just individuals who are concerned about privacy. On Aug.
8, the Bush administration finished the first comprehensive federal rules
covering medical privacy. Dr. Burke and other advocates of electronic
records believe that their systems will meet the requirements. Dr. Howell
argues that properly managed electronic records will be more secure than
paper.
"There is an experiment I don't recommend or hope you try," he said.
"Put on a white coat, grab one on your way into a hospital, go up to a
ward and start pulling charts. Then see if anyone asks who you are. With
an electronic record, it's easy to track who is looking at it."
In addition, Dr. Howell noted, paper records are handled by clerical
workers who can potentially copy information or even steal the cards. By
contrast, an electronic system can track who examines every file and be
protected by encryption and security devices, like biometric thumbprint
readers, that can be defeated only by someone with sophisticated
skills.
There have already been some unexpected privacy problems. Dr. Mankin at
Temple said that Allscripts had warned his group that prescriptions were
arriving on fax machines at one drugstore chain, which he declined to
name, that were near cash registers and plainly visible to customers. The
Temple group stopped faxing prescriptions to those stores. Despite the
incident, Dr. Mankin is confident that digital records offer greater
privacy.
That is a view shared by Jeneane Brian, president of VNA Home Health
Systems, a nonprofit home nursing association in Southern California. The
association transferred the record-keeping of its nurses and doctors from
paper to Handspring Visors two years ago. "We've always had vulnerable
data," Ms. Brian said, noting that nurses have been known to leave bags
containing their records at airports or on the roofs of their cars.
"I do believe that with the hand-helds there is less vulnerability than
there might have been in the past," she said. "Even without additional
security on the hand-helds, it's no worse than it used to be."
The biggest hurdle facing advocates of the new systems, Dr. Shortliffe
said, is the relationship between most doctors and hospitals. "In most
hospitals, the doctors don't work for the hospital," he said, which can
make it hard to work out who should pay for the new systems or to even
reach agreement on what form they should take.
But Dr. Shortliffe added that there were several strong forces that
might accelerate the movement. In addition to improving patient care,
electronic systems should speed up and improve the accuracy of claims to
health insurers. "This is an area where people know they are losing money,
and money drives things," he said.
Dr. Burke's electronic system in Miami has produced an unexpected side
effect. With a small camera attachment, the doctors and nurses can use
their hand-helds to take digital photographs of their charges. The images
have restored a little of the humanity that the factory-inspired paper
records diminished. Now during the medical staff's weekly meetings, the
patients are no longer just charts and words.
"With the photos, we're actually bringing the babies into the
conference," Dr. Burke said. "There's an emotional element that used to be
missed."
