11 Disruptive Technologies That Will Change the Face of Healthcare IT – and How Your Competition is Using Them

Quintin Armour, Healthcare Architect, MacadamianDidier Thizy, Director of Healthcare Solutions, Macadamian

October 2010

©2010 Macadamian Technologies

08Fall

2

With more than 25,000 attendees and thousands of exhibitors, the annual HIMSS conference gave us the opportunity to talk directly with Electronic Medical Records (EMR) and other Healthcare IT vendors about what makes them unique.

At the conference, our team of healthcare software specialists visited every booth and asked one question:

“With hundreds of competitors out there, what is your product's differentiator? What innovative feature or technology makes you stand out from the crowd?”

This question seemed to stump many of the vendors. Most replied with answers that we later dubbed as “false differentiators.” One such answer from EMR vendors was “being the first to enable physicians to achieve meaningful use.” While this is critically important, this is not a differentiator – everyone is focused on meaningful use.

Other answers revolved around features like a offering data to patients via a web portal, an iPhone add-on, or integrated e-prescription and billing. These can also be important, but are no longer differentiating features– they've become prerequisites. To stand out, vendors need to take their product to the next level and serve their users in a unique and innovative way.

Using Technology to Innovate

At HIMSS, the vendor answers that impressed us always revolved around a basic theme:

“Our solution is innovative because it uses modern technology in a unique way to make clinicians’ jobs easier and more fulfilling.”

In this paper, we look at the opportunities for innovation that new technologies like mobile devices, modern UI design frameworks, and voice and handwriting recognition provide to health software companies. A lot of the examples are given in the context of EMRs, however they can equally to differentiate PACS, HIS, E-Prescription, and any other healthcare solutions that need to stand out from the crowd.

With each technology, we’ll examine:

• The opportunities for healthcare innovation the technology provides• How the technology is currently being used by forward-thinking vendors • The limitations of the technology, and how you can overcome them to break new

ground

Using this information, your organization can decide which technologies can best help you develop your product into a stand-out that the healthcare world will embrace.

©2010 Macadamian Technologies

3

Contents

........................................................................................................................................................1. The Tablet PC 4

.......................................................................................................................................................2. Smart Phones 7

......................................................................................................................................................3. Touch Screens 9

..............................................................................................................................................................4. Digital Ink 11

.............................................................................................................................................5. Voice Recognition 13

......................................................................................................................6. Patient Health Records (PHR) 15

................................................................................................7. UI Design and Rich Internet Applications 17

................................................................................................................................8. Unified Communications 19

...............................................................................................................................9. Clinical Decision Support 21

.........................................................................................................................10. Mobile Home Care Devices 23

.............................................................................................................................................11. Cloud Computing 25

©2010 Macadamian Technologies

4

1. The Tablet PC

While tablet PCs have been around for a while, healthcare IT applications are only now beginning to take advantage of the unique features of these devices. In particular, slate-type tablets like Apple’s iPad and the Fijitsu Stylistic ST6012 Tablet PC are starting to gain traction with users.

Figure 1: Apple iPad

Because of their unique size and their wireless capabilities, slate-type tablets offer a balance between portability and usability and allow for more natural and convenient ways to fit into a clinician’s workflow.

What are the opportunities for innovation?

Traditionally, EMRs have been limited to workstations at reception desks, doctors’ offices and nursing stations. With tablet PCs, however, users now have the ability to access medical records from any location that has a wireless connection. Ultimately, tablet PCs could replace the traditional paper-based patient chart.

In particular, a tablet PC can allow healthcare users to:

• Explain clinical results to a patient at the bedside or in the consultation room. An interactive mobile device can enhance a discussion of test results or possible courses of treatment with a patient. The doctor can sit next to the patient and display test results, show graphs, look at numbers and access clinical decision support material or other

©2010 Macadamian Technologies

5

informative websites while explaining the results. In particular, the software could display a “patient view” which displays only the information a patient needs and can understand, then revert back to a more complete and detailed physician’s view when done.

• Look up resources on the fly. Having a tablet PC at the ready can be just the thing that physicians need when a drug name slips their mind or they need to look up options for a differential diagnosis. The ability to hook into the hospital’s infrastructure without having to walk to a computer station can also save critical steps for nurses. As we discuss later, integrating an EMR with a clinical support system empowers the clinical worker by providing access to the right information. Mobile tablets can ensure that this information is then accessed at the right place and right time.

• Consult data before just before treatment. Usually before surgery or another type of medical intervention, a surgeon will consult with diagnostic images or other results as a precautionary measure. With the right infrastructure in place, a tablet PC can save the surgeon from making an extra trip to the lab to check this data.

How are Tablet PCs used in healthcare today?

One Healthcare tablet PC stand-out is Intel’s Mobile Clinical Assistant which is marketed as a replacement to the bedside clipboard. It features attachments that include a barcode scanner, an RFID scanner, an integrated camera, a casing that can be wiped clean and a battery pack that can be replaced without powering the system down.

Figure 2: Motion Computing’s C5v based on Intel’s Mobile Clinical Assistant

Other vendors such as Pulse Systems and Epic are already in the process of offering an iPad version of their EMR solution.

©2010 Macadamian Technologies

6

What constraints do Tablet PCs face?

We have listed a set of commonly-cited iPad and related tablet limitations, below. You should interpret each limitation, however, as an opportunity for innovation.

Tablet PCs may:

• Detract from doctor’s bedside manner. Technology can sometimes get in the way. When meeting a patient for the first time, the focus should be on the patient and his or her medical problems. A tablet PC may also not be able to capture data effectively as the doctor speaks. Consultation is narrative in nature and doctors need a free-form method of text entry with the ability to recognize this text for data storage. Some tablet PCs do not have – or do not ship with – a stylus or an application to record handwritten text, which can limit their effectiveness. When developing a tablet PC solution, be sure to take these user needs into account. Proper user research and usability testing may be required to ensure that the solution is tailored to suit actual user behavior.

• Increase resource management on the ward. The most popular choice for technology on the ward is a computer on wheels (COW) since it cannot be removed from the ward. Tablet PCs, unless personal to the doctor, can easily be misplaced – especially when they are set down to charge the batteries. An EMR that works on a tablet would have to compete with COWs, which are full-featured mobile computers that charge via an electrical outlet in a wall.

• Risk of theft. Often, when a patient is seen at a hospital for the first time, routine forms must be filled in. Sometimes these are completed by a clinical worker or by the patient himself. With a mobile device, this process needs to be performed by the clinical worker as mobile devices can be easily stolen. Optimizing your device to accept routine intake forms may therefore not be a smart investment of resources and time as these forms are best entered into a kiosk-type machine or on paper.

• Small screen size. While screens on tablet PCs are larger than those on mobile phones, a tablet PC’s screen size may not be big enough to accurately view medical results such as ECGs, MRI scans, and X-rays. Most medical interpretation is done with multiple monitors and it may not be possible to replicate the required level of detail on a tablet PC. Through user research, your organization may be able to uncover common medical activities and/or information that are well suited to a tablet PC. By focusing the design and functionality

©2010 Macadamian Technologies

7

of your application on the information that can best be displayed on a tablet screen, it will stand a much better chance of being adopted by its users.

Despite its constraints, mobile technology is generally recognized as the fastest-growing technology segment today, with major advancements continually pushing the trend forward. Tablet PCs are very popular – especially among younger medical professionals and students. Today’s young iPad users are tomorrow’s leading clinicians so it is important to consider this technology, and how it can be best used, in your development plans.

2. Smart Phones

Smart phones are generally the smallest mobile computers available today, offering a high degree of portability. Two of the most popular devices on the market today, the iPhone and the HTC Desire, offer comparable feature sets that include touch interfaces, a camera and a phone as well as Wi-Fi and GPS capabilities.

People have become used to carrying a cell phone, so EMR access over a smart phone can be both intuitive and helpful. Smart phones offer personal mobility and allow clinical workers greater flexibility over how they manage their time. With a smart phone, users can perform routine tasks from any convenient location. A home care provider who visits patients at home, for example, could have mobile access to an EMR and receive and enter information over the course of a workday.

What are the opportunities for innovation?

While vendors know that there is a lot of potential in developing “something” for smart phones, a question we are commonly asked is “Which parts of our desktop application should we port to iPhone?”

Smart phones are best used for productivity-type tasks in which time spent per action is short. Starting from this principle and working through product strategy, concept design, and user research is the best way to determine your product’s smart phone feature set.

Some healthcare tasks in which time spent is short include report review, order entry, and appointment management. In this case, the innovation does not come from the basic features themselves, but the ability of the device to meet user expectations and overcome traditional smart phone limitations.

Another area of innovation lies in finding novel ways to leverage the hardware and software features of smart phones. A product that incorporates a smart phone’s built-in camera would allow EMS workers to take photos of injuries and forward them to the emergency room for consultation before the patient actually arrives. As another example, an application could make use of a smart phone’s GPS to automatically notify a hospital when the patient arrives.

©2010 Macadamian Technologies

8

Finally, the majority of vendors that provide a smart phone solution today are actually offering a web application for mobile browsing, rather than applications that are native to the device. Investing in a device-specific application (such Epic’s Haiku) is another opportunity to differentiate – it allows for enhanced responsiveness and availability, better control over the device’s hardware and software features, as well as a richer more interactive user interface.

How are smart phones used in healthcare today?

There are a number of lists that detail smart phone applications offered by EMR vendors, such as this list of 12 EMRs with remote iPhone apps. Most of these applications provide a mobile interface to an existing enterprise-level EMR – albeit with limited functionality and via a web interface. Common features across most offerings provide the ability to:

• Review patient information

• View, schedule and book appointments

• Take dictation

• Charge capture (capturing procedure and disease codes)

• View Laboratory results

• Review or create prescriptions

• Bill patients

• Manage out-of-office visits

• Find pharmacies

• Manage clinical messages

What constraints does smart phone technology face?

Some caveats to be aware of when considering the deployment of an EMR to a smart phone include:

• HIPAA compliance. Storing medical information on a mobile device can violate HIPAA regulations. Smart phones may need, instead, to temporarily store data on the device’s memory while the application is running. Before developing your application, be sure to speak with an expert in HIPAA compliance. And, if you plan to work with a

©2010 Macadamian Technologies

9

development partner, make sure that this partner has extensive healthcare experience and an understanding of current regulations.

• Interference with medical devices. Most hospitals do not allow the operation of cellular devices around medical equipment out of safety concerns. There is certainly an opportunity around novel “hospital mode” solutions (similar to the “airplane mode”) that alleviate the problem based the device location and context.

• Medical interpretation. While this issue is under debate for tablet PCs, it is generally accepted that the small screen size of a mobile phone does not allow for a detailed review of medical results such as ECGs, MRI scans, x-rays, etc.

Even with its limitations, smart phone support is quickly becoming a prerequisite for successful healthcare IT and EMR applications.

Clinical workers personally own smart phones, and if their IT solution allows them to get work done on the go via their phones, this is perceived as a major advantage.

3. Touch Screens

While touch screen technology has existed in one form or another for years, the technology of resistive and capacitive touch detection has recently flourished, allowing for pressure sensitivity, multi-touch and gesturing. From a usability point of view, a touch screen can be more intuitive than a mouse since the user can select an item directly without having to first drag a pointer. Moreover, touch screen technology allows for more robust computer installations – particularly in public areas, where a traditional keyboard and mouse that require regular maintenance tend to be the first things to fail.

Touch-ready operating systems are now available such as Windows 7, Apple iOS and Linux. This software allows for the handling of touch actions such as touch begin, touch moved, touch end and can be used to recognize the mouse-like events (click, drag and double click), as well as complex actions such as flick, pan, zoom, pinch and rotate.

What are the opportunities for innovation?

EMRs can benefit immensely from touch screens. A touch screen can offer:

• Enhanced usability in specific settings. In a hospital setting, for example, where clinicians use gloves or other protective apparel (ER, surgery, infectious diseases), or

©2010 Macadamian Technologies

10

a setting where a small number of repetitive tasks need to be done quickly (ER admittance, drug orders).

• Innovative user interfaces. A richer user experience exists with advanced touch features such as inertia in which objects continue to exhibit a behavior after they are released, e.g. a scroll panel that considers the velocity of the user’s finger swipe.

• Easy navigation. 3-D diagnostic models (such as those from a cardiac CT scan) can be manipulated with swipes and multi-touch rotation.

• Data to all levels of users. Inpatients can be provided with touch screen consoles in which they can have a direct connection to their data in the EMR and make decisions about their care.

On modern software platforms such as .NET, libraries exist to support complex touch screen actions. This is an opportunity in and of itself to innovate – leveraging this software framework will allow you to rapidly enable touch screen functionality in your healthcare solution.

Language Framework Used By.NET Windows

Touch Windows 7, Windows Phone 7, Silverlight (with browser support)

Java MT4j Any Java supported platform including Android, LinuxObjective-C UIKit iPhone, iPod Touch, iPad

How are touch screens used in healthcare today?

Some EMRs, such as 3Plus and Encounter Notes, are marketed specifically as “touch screen EMRs.” While these EMRs are not known as leaders in the market, their value proposition is certainly something all vendors could draw inspiration from.

Most leading EMR vendors are offering ad-hoc touch screen solutions as they begin their foray into tablet PCs, smart phones and digital ink. Other common uses of basic touch screens include:

• Patient kiosks. Offering patients the ability to enter their basic information without needing a clerk. This data is then entered directly into the EMR.

• Bedside devices. Touch screen technology frees up space by not requiring a keyboard and mouse. The information displayed is sourced from the EMR.

• Home care devices. Well-designed touch interfaces can be easier for patients to use at home as they offer a more simple and intuitive interface.

©2010 Macadamian Technologies

11

What constraints does touch screen technology face?

Touch screens introduce a new paradigm for user input. This step away from the traditional keyboard and mouse is not without its limitations and controversies, however. These constraints include:

• Repetitive stress disorders. Researchers from Arizona State University believe that touch screens could lead to new types of musculoskeletal problems.

• Device contamination. Diseases can be exchanged from person to person via the touch screen. It’s important to be able to clean the touch screen often if it is being used by patients.

• Text input. Although touch screens are meant to be more natural in terms of usability, text entry is a challenge that can result in typos and wrongly auto-corrected words.

There is a definite opportunity for innovation in terms of text entry, spell check and auto-correction, particularly around medical and prescription nomenclature.

• Unwanted input. When using a conventional computer, the user has control over the input devices. With a touch screen it is easier for others to provide undesired input another opportunity for innovation around security and access control.

4. Digital Ink

The ability to have touch-sensitive screens has made it possible for users to write on a screen just as they would on a piece of paper. This technology has long been integrated into the EMR, but there has been a recent resurgence with the ability to convert the ink strokes to structured text, via technologies like Microsoft Ink.

What are the opportunities for innovation?

Although ink-to-text solutions like those from Microsoft are gaining in popularity, there is still a significant issue around the accuracy of the conversion. A charting system that accepts stylus input and converts to text will not be acceptable if there is a chance of error converting the charting details to structured data.

The possibilities for innovation therefore fall into 2 categories: the use of digital ink in innovative ways that are not error-prone, and the creation of new solutions that reduce or eliminate conversion errors.

©2010 Macadamian Technologies

12

Some examples of the former are listed below (while the latter is discussed more in the next section):

• Drawing images. In fields such as plastic surgery, it is often useful to draw pictures to facilitate communication between doctor and patient.

• Annotating diagnostic images. The doctor can add ink to x-rays or MRI scans to indicate important properties and describe the judgment made for it.

• Inputting text naturally. In some cases, the patient is unable to communicate and digital ink can be used to write a note to the doctor to explain something or to direct the course of treatment.

• Authenticating reports. Physicians can use digital ink to authenticate reports quickly and easily.

How is digital ink used in healthcare today?

Just as some EMRs are marketed specifically around touch screen technology, others such as MedConnex, Aprima and Medscribbler tout the advanced use of digital ink for stylus-based charting.

Aprima highlights the utility of ink data entry since it allows physicians to maintain eye contact with patients during a consultation. MedConnex emphasizes a fast learning curve when going from the paper world to their stylus-based charting.

What constraints does digital ink technology face?

As discussed, stylus entry and digital ink introduces an intuitive and natural way to enter data into a patient’s chart, but is not without its constraints:

• Loss of precision, illegible handwriting, and error-prone conversion to text. Pen and paper are as precise as they need to be. Touch screens are often not as precise as their real world analogs. Writing with digital ink tends to resemble writing with a marker on a piece of paper. One of the reasons for developing EMRs was to reduce the amount of ambiguity in handwritten notes. Digital ink may duplicate or increase this ambiguity. There is a definite opportunity for innovating new methods of auto-correcting or translating ink to text on the fly, in a way that is highly accurate but does not interfere with usability.

• Auditing is more complex. A very strict auditing mechanism should audit the digital ink for every logical set of strokes. Otherwise, users could leave the page open for several hours and write notes. In this case, it will be unknown which strokes were

©2010 Macadamian Technologies

13

written at which time. The audit logs would have to record the time of the strokes, not just the time the “save” button was clicked.

• Handwritten data does not facilitate data exchange and analysis. Solutions offering ink-only input that cannot convert to structured data may be more suitable for small clinics where data entry and recall is all that is needed. Without structured data, a solution is very limited in what it can exchange with other systems and what meaningful analysis it can perform on the data.

5. Voice Recognition

Physicians are trained in dictation. Classic physician consultations are dictated and transcribed for the patient record. Typing out these clinical notes has a cost associated with it, namely the transcriptionist’s time. Voice recognition (VR) promises to one day eliminate this step by automatically performing this translation from speech to text and eliminate the cost of transcription.

Voice recognition in an EMR is in high demand as both a convenience and cost saving tool. The accuracy of the technology, and especially the usability of the solution, will be key differentiators for EMR vendors.

What are the opportunities for innovation?

Innovation for VR in EMRs can come from enhanced integration of the technology into existing EMR solutions with an emphasis on usability. Voice recognition can offer:

• Broader access to dictation. Any device that supports a microphone, a network connection and a speaker (for system feedback) could conceivably support VR. This means that a doctor could dictate notes into his phone and enter a text note into the EMR from anywhere.

• Direct entry of rich content to the EMR. Patients and other healthcare providers can have access to the raw data entry. Having this access would allow them to get a sense of subtle diagnostic nuances that may not be captured in text or as a way of dealing with any errors with the recognition process.

• More natural voice commands. Having to learn VR system commands can sometimes be a daunting task for clinical workers who are already squeezed for time. One improvement that can be made to VR is to improve how the user interfaces with the system itself so that it can be more natural.

• Voice-print identification. This would allow physicians to perform more tasks over the phone by authenticating them using their voice.

©2010 Macadamian Technologies

14

How is voice recognition used in healthcare today?

Voice recognition is used in several existing EMRs. EMR vendors such as Epic, Allscripts, Cerner, GE, McKesson, NextGen, eClinicalWorks have incorporated Dragon NaturallySpeaking into their products.

An example of VR use within a practice is with clinical note dictation. After a consultation with the patient, the physician can dictate his note into the patient chart using VR. The note can then be automatically entered into the patient chart. Traditionally, this process would be performed using a Dictaphone and then transcribed into the patient chart by a medical assistant. Dragon certifies EMRs according to how well they integrate with their solution. The details of the certification test include emphasize dictation and correction capabilities in the EMR, as well as audio preservation and other support tools.

Today’s VR technology, when trained to the speaker’s voice, has reached relatively high levels of accuracy compared to just a few years past. Dragon NaturallySpeaking, for example, boasts 99% accuracy when properly trained to the speaker’s voice.

What constraints does voice recognition technology face?

Although it can be useful, VR poses limitations that have prevented widespread adoption in the healthcare industry to date. These include:

• Need for a quiet station. Most VR is done in a quiet corner or in the doctor’s office. The presence of noise can affect VR. This limits the mobility of computing since it cannot be done in any location.

• Training is required. Although speech is natural and doctors are used to dictation, all VR systems take time to train in order to reach a high level of accuracy.

• Usability. Typing is fast for those who are expert at it but VR systems are good when dictating large portions of text. If the VR system is remote and the user has to keep correcting it, navigating backwards, or replaying certain parts, as is often the case with a physician’s progress notes, it can take a lot of time to input data.

• Unseen errors. Often a word can be misheard by the system and a different (but correctly spelled) word can be used in its place. These “typos” are often hard to detect and pose a risk for patient safety. These errors happen more often than is acceptable. With a VR system that is 97% accurate, there are 1 to 2 errors on average every 50 words. This leads to about 37% of dictated notes containing at least one error.

©2010 Macadamian Technologies

15

For an in-depth review of physician impressions of VR systems, we recommend the publication “Acceptance of speech recognition by physicians: A survey of expectations, experiences, and social influence” by Alexandre Alapetite.

Despite these constraints, VR has the potential to reduce the cost of healthcare delivery by automatically transcribing clinical notes. Organizations that can resolve these constraints and integrate with or develop VR systems that are both accurate and easy to use will certainly stand out from the pack.

6. Patient Health Records (PHR)

The future of healthcare is one in which the patient is more actively in charge of his health data. As proclaimed in a widely publicized CNN report early this year, patients are demanding control of their data. The California Health Foundation reported that although only about 7% of adults use a Personal Health Records (PHR) system today, 40% express interest in using one.

As patient-centric platforms such as Microsoft HealthVault and Google Health gain in popularity, EMR vendors have an opportunity to stand out by offering novel connections to these types of platforms.

What are the opportunities for innovation?

By creating innovative applications for patient health records, companies have the opportunity to help healthcare organizations:

• Improve patient tracking. Clinicians can closely track patients who regularly enter data into a PHR and can perform disease management, oversee progress and track medication dosage.

• Encourage patient participation. When patients become interested in their health, they often take better care of themselves. Having the EMR push data to their PHR will help them to learn more about their health.

• Save administration costs. A major advantage of a well-designed PHR system is to allow patients to book their own appointments or upload diagnostic results from a specialist themselves.

• Provide Clinical Decision Support (CDS) to the patient. As discussed in the next section, alerts and other elements of CDS could be provided to the patient.

• Offer social network integration. The growing Health 2.0 movement is exploring the integration possibilities between social networks and healthcare systems. Through

©2010 Macadamian Technologies

16

PHRs, patients could interact with one another. Physicians can also participate and provide support on forums or in online group discussions.

Providing a patient with easy access to their records also satisfies the regulatory requirement that patients be given copies of the record should they ask for it.

How are PHRs used in healthcare today?

Most EMRs are currently implementing their own quasi-PHRs via patient portals. The eClinicalWorks patient portal website is a good reference for the types of features offered. These are not PHRs in the classic sense because the patient is not able to transfer his data to another application, unless he does it manually. The current lack of truly accessible PHRs means that there is an excellent market opportunity for an organization that can develop a PHR that is robust and easy-to-implement.

What constraints does PHR technology face?

While PHR systems are theoretically only constrained by the state of web software technology, there are some concerns around their use by patients:

• Security and Privacy. Patients may be apprehensive about putting their health data online. There is ongoing debate around the level of security and access control that is required for a secure PHR.

• Standardization. PHRs should use a standard coding system such as ICD-9 for diagnoses. They must also define a standard format for data exchange such as CCR or CCD. Many patient portals today used proprietary standards that cannot be easily exchanged with other systems.

• Connectivity. Having to re-enter data into different individual EMRs will only frustrate users and encourage them to find alternative points of care. The more interoperable the data, and the more built-in interconnections it has, the more value the solution has for all levels of users.

• Usability. Systems must be designed with a high degree of usability or patients will quickly abandon them.

In short, there is a definite market opportunity for PHR differentiation. Organizations that can develop a PHR with a highly intuitive user interface built around the patient’s expectations will stand out from competitors and offer a truly valuable service.

©2010 Macadamian Technologies

17

7. UI Design and Rich Internet Applications

One of the most challenging aspects of developing an EMR is designing the user interface. With an EMR, there is so much information and so many data elements, forms, tasks and actions to organize due to the large variety of user behavior patterns. As a result, most EMR applications tend to look the same, leaving UI design as a major opportunity for differentiation.

When an interface design needs to be created for the web (be it an ASP web-based EMR or a patient portal) it can become even more difficult to make it visually impressive and highly usable. The emerging rich internet application (RIA) technology provides the opportunity to design rich and consistent web-based user interfaces.

RIA technologies include Adobe Flex, Google Web Toolkit, Silverlight, and, to some extent, the upcoming HTML5/CSS3.

What are the opportunities for innovation?

The opportunities to create innovative UIs are limited only by the creativity of the designers and developers. Today’s designers should certainly take advantage of:

• A rich look and feel for user interface widgets. Menu animation, drag and drop components, and more advanced controls such as stack panels are available out of the box with today’s RIA technologies.

• Multimedia content. With RIAs, it is easier than ever to include rich content such as graphs, audio and video using built-in controls.

• Faster responsiveness. Since these applications run in the client browser, program responsiveness is quick. Technologies like Silverlight can take advantage of hardware acceleration to speed up video rendering.

An important thing to remember with RIA technologies is that they don’t have to be used throughout the entire application. The richness they provide can be applied in choice areas in order to augment the experience offered by the application as a whole.

©2010 Macadamian Technologies

18

How is RIA technology used in healthcare today?

Due to the advantages a rich web interface provides, many EMR vendors already use such technologies. Examples of EMR vendors using RIAs to deliver their solutions on the web include:

Adobe Flex elements • Practice Fusion

• Hello Health

• Care CloudGoogle Web Toolkit elements • Care360™

• MedriumSilverlight elements • UniCharts™ EMR

What constraints does RIA technology face?

Despite the advantages of a rich web interface, the use of RIAs has some limitations.

• Upgrade runtime environments. RIA containers for Flash and Silverlight need to be upgraded in order to function properly. Functionality changes from one version to the next and it requires support from the developers.

• Risk of data loss. With client-side browser applications, data is entered on the client and periodically sent to the server. Users can accidentally close the browser or navigate away from the page and data can be lost. Well implemented auto-save functionality will avoid this.

• Slower initial page load. Since the client is heavy, the initial load of the page is often slower. Once loaded, however, the application is more responsive.

When designing an innovative UI, be sure to consider more than just the look and feel. A good UI is both visually attractive and easy to use. Working with a development partner that has both usability and RIA experience can help you create a user interface that is both appealing and intuitive.

©2010 Macadamian Technologies

19

8. Unified Communications

Hospital team members are spread across departments and have different working hours. Patients at home using self-monitoring devices can encounter a problem at any time. As institutions continue to adopt software solutions, there is a growing opportunity to enhance their work and communication through Unified Communications (UC), which merges real-time methods of communication such as voice, video and chat with others such as email, SMS and voicemail.

UC solutions such as Microsoft OCS, Cisco HealthPresence, Avaya and Telus - Community Health Care can help organizations fully integrate EMRs into their clinical workflows. An open source UC solution, Asterisk, is also quite popular.

What are the opportunities for innovation?

The component technologies of unified communications are of benefit to EMRs by facilitating professional-to-professional, professional-to-patient and patient-to-professional contact in order to create a much more fluid environment. With such technologies deployed, the EMR would become a meeting place where there would be:

• Recording of physician and patient consultations. These can be added to EMRs for patient playback in case something was missed.

• Virtual waiting rooms. Patients can queue remotely and wait in the comfort of their home, coming to the clinic only when the office is ready for them. The patients would be able to perform this action through the patient portal component of the EMR.

• Virtual consultations. Video conferencing would allow patients to visit physicians without having to actually come into the office.

• Supervised tests. Currently, with EMRs like GE Centricity, physicians can supervise tests via remote monitoring diagnostic systems. With integrated UC, they would be able to monitor both the computer terminal as well as the video from the examination room.

• Telehealth with video conferencing. At present, Telehealth solutions require users to call an expert by telephone. With the functionality of UC, video conferencing would be possible – giving the expert on call the ability to see symptoms and give more accurate advice.

By incorporating UC into your offerings, your organization could add a great deal of value to a hospital’s EMR since it would bind all communication services into one package.

©2010 Macadamian Technologies

20

How is UC applied in healthcare today?

Cisco and Allscripts have formed a partnership to integrate UC with their EMR solution, offering solutions like patient reminders, messaging, and intelligent call routing. GE Healthcare piloted Microsoft’s UC solution with fanfare, but these two software solutions currently operate independently.

What constraints does the technology face?

In addition to the general high cost of teleconferencing and videoconferencing hardware, integrating UC into the EMR poses the following limitations:

• Larger installation. An EMR is already a daunting task for a healthcare facility. Grouping a UC solution with that of an EMR would require an even larger overhaul of existing infrastructure. It may be better to install them separately with adapters in the EMR to allow for integration.

• Loss of personal contact. There is a strong value to face-to-face meetings in healthcare. It may be some time before the quality of low-cost virtual meetings is sufficient to inspire trust in workers and patients.

Despite these constraints, vendors are starting to explore how to best leverage current technology and innovate. EMR/UC integration is still at an early stage, however, which offers your organization the opportunity to be one of the first to truly utilize and promote unified communications in the healthcare industry.

©2010 Macadamian Technologies

21

9. Clinical Decision Support

As patient volumes increase, it can become difficult for providers to remember medical background material specific to each and every case. A Clinical Decision Support (CDS) system combines both background knowledge and case-specific information to help the provider make better decisions. A CDS can point a provider to reference material and information, perform certain actions, or supply alerts.

Figure 5: A Common Clinical Decision Support Configuration

What are the opportunities for innovation?

EMRs are benefiting from CDS system integration by keeping medical knowledge at the fingertips of healthcare providers. Opportunities to push the envelope include:

• Learning patterns of care. Some CDS systems do not require a pre-developed knowledge base, but rather apply machine learning algorithms on medical examples fed into the system. Others can apply machine learning to build knowledge about user behavior. This concept exists in academic publications but the challenge remains to make this a widespread commercial reality.

• Reducing alert fatigue. When users receive too many alerts, they may begin to ignore serious alerts.

• Improving usability. Organizations can innovate by increasing the intuitiveness and speed of access in CDS systems. To date, whenever a CDS has been integrated into an EMR, the combined system has tended to behave as two distinct systems with different flows.

©2010 Macadamian Technologies

22

Companies that can address this problem and improve usability stand a good chance of becoming leaders in the space.

• Sharing CDS. Multiple healthcare facilities can share anonymous data about clinical decisions so that they can benefit from each other’s behavior and improve the quality of patient care.

• Improved matching algorithms. Strong algorithms that match case instances to a knowledge base will deliver more pertinent information to users.

How are CDS systems used in healthcare today?

Most of today’s CDS systems provide clinical reminders for patients, identify possible risks for adverse events and errors, analyze clinical performance, and encourage adherence to standards of care.

The most common use of CDS/EMR integration is to identify drug-to-drug interactions. Popular solutions for e-prescription and drug interaction detection include DrFirst, RxNT, Medi-Span and a host of others.

A CDS can also be deployed as a stand-alone package that provides a lookup of medical knowledge. The Elsevier CDS tool currently offers this functionality.

What constraints does CDS technology face?

• Patient data model accuracy. Patient data must be entered consistently for a CDS to contain accurate information.

• CDS system accuracy. The CDS system needs to be intelligent enough to be able to correctly identify similar cases and present them to the user when requested.

• Alert fatigue. A CDS system must take care to only alert the user in critical situations. Otherwise, the user will suffer from alert fatigue and ignore all alerts.

• Usability. CDS systems are often developed independently from EMRs and then integrated. This process limits the usability of the CDS. Users may choose not to use the CDS or become frustrated when it takes them too long to get to the information they need.

When a CDS becomes a nuisance as opposed to an aid – either because of inaccuracies, poor usability or alert fatigue – the system loses value and users simply abandon it. Organizations that can closely integrate their CDS with an EMR and overcome the obstacles mentioned above will have the best chance to stand out from the crowd.

©2010 Macadamian Technologies

23

10. Mobile Home Care Devices

Mobile home care devices are pieces of hardware that allow patients to communicate the current state of their illness to a healthcare provider from home. Although still in the development stage, the potential for managing chronic illness is clear, and development of home care devices is moving quickly to meet the demand of our aging population.

Examples of existing mobile home care devices include blood pressure monitors, weight scales, glucose meters, pulse oximeters, and peak flow meters. One such device is Intel’s HealthGuide, which offers a variety of solutions to the patient in his own home.

Figure 3: Intel HealthGuide

What are the opportunities for healthcare innovation?

• Usability. Patients using these devices are often ill and/or elderly. The devices must be intuitive and robust, putting home care ethnographic study and other usability techniques at the forefront of innovation.

• Continuous data stream. Physicians can monitor patient activity and catch problems before they become severe. The EMR will become a meeting place for patient data.

• Access to CDS systems. A clinical decision support system can monitor patient readings and alert physicians to cases that need special attention. This can help physicians to be more efficient.

©2010 Macadamian Technologies

24

• Empowering patients. Inventive features could maximize the activities that can be taken on by the patient remotely, such as picking up prescriptions and scheduling interventional procedures.

How is this technology applied in healthcare today?

At the time of writing, Intel and GE Healthcare recently formed a new company in a joint effort to meet the future needs of telemedicine. In their vision, mobile home care devices will interact with EMRs to deliver the data to those in charge of the patient’s health. While this is the hot topic of the moment, most major Healthcare IT vendors (as well as many smaller organizations) have a telemedicine and home care product portfolio.

Many existing home care devices are standalone solutions that are used by the patient at home and then brought to the hospital or clinic during a scheduled visit. The data is then transferred into the EMR so that the physician can refer to the data in his interpretation and clinical notes. This process is often cumbersome, which has lead companies like Cardiac Science to offer a solution to bridge the gap between device and EMR so that integration is more automatic.

What constraints does the technology face?

Probably the biggest limitation to widespread mobile homecare device adoption is cost. Unless these devices can be cost effective, the average patient will not purchase one. In most cases, the devices are loaned out to patients who need special monitoring and reused by other patients down the road.

To counter this challenge, there is a growing push for home care software on consumer devices. The LifeScan Diabetes Monitor and Zume Life self-care service are both currently available on iPhone.

Vince Kuraitis, a thought leader in the growing home care industry, sums it up nicely:

“Think about your user experience when you get into your car into the morning. You are greeted by a dashboard of information about the vital processes in your car -- fuel availability, fluid levels, driving speed, etc. You know that if something goes wrong with a major system, you'll get a "check engine" notice.

Now think about your user experience with your body. What do you know about the vital processes going on in your body right now?

Remote patient technologies are beginning to provide the analogous dashboard to help people monitor vital processes and to take appropriate actions if something goes wrong.”

©2010 Macadamian Technologies

25

11. Cloud Computing

There is a lot of confusion in the industry around what “cloud computing” really means. Often, marketing communications that refer to a “cloud solution” actually mean an ASP offering with a SaaS business model.

True cloud computing is the use of virtualized servers that can be scaled on demand based on varying levels of resource requirements at run-time. For example, an application running on a cloud can programmatically turn on five servers in response to a spike in demand for computing resources. Several mature solutions include Microsoft Azure, Citrix, VMWare, Amazon Elastic Compute Cloud and Google App Engine.

What are the opportunities for healthcare innovation?

By making use of cloud computing, vendors can in theory enhance traditional ASP solutions by offering:

• Scalable hardware. Additional hardware can be turned on based on need.

• Efficiency and performance. Since servers are virtualized, different instances can reside on the same hardware. The instances can be moved around depending on need to make the best use of the hardware without compromising performance.

• Increased availability. Cloud hardware is distributed and fault tolerant. Cloud providers promise 99.95% availability.

From a technical perspective, a cloud would be the best option for delivering a solution on scalable and fault tolerant hardware while still delivering on performance requirements.

What constraints does the technology face?

With ASPs, there is definite knowledge as to the location and ownership of the housed data thus satisfying privacy and data security laws. True cloud computing, on the other hand, is not in widespread use with EMRs since it is an issue of controversy due to privacy and security risks.

Some platforms such as Microsoft Azure offer private clouds to organizations facing trouble with compliance. At this time, however, this solution is intended for very large organizations who are working with at least 1000 servers, likely outside the scope of any major hospital. Microsoft has recently begun a push into the Healthcare IT space, so the time may be right to look to Microsoft for future innovations in cloud computing as it applies to EMR systems.

©2010 Macadamian Technologies

26

Until then, there are other ways for organizations to pump up their ASP offering – for example offering a client application with a richer user interface, more logic and even an “offline mode.” Technologies such as WPF and Adobe AIR represent a first step towards the creation of such rich clients.

Innovating Through Technology

Modern technologies such as mobile devices, modern UI design frameworks, and voice and handwriting recognition are becoming increasingly prevalent. The examples outlined in this paper show that it is crucial to understand the opportunities for technological innovation in healthcare IT, how these technologies are being used by your competition today and their current limitations.

To stand out from the crowd and go above and beyond the traditional methods of helping clinicians, your organization needs to be aware of these technologies and incorporate them in a way that will break new ground. Organizations that truly understand the day-to-day workflows, needs and goals of healthcare providers will be best positioned to develop innovative and usable technology solutions that will get accepted by end-users.

We look forward to seeing you at the next HIMSS conference, and being impressed by the innovative IT you’ve developed that truly differentiates you from your competitors.

Technology Consultation with Macadamian – Spots are Limited

Macadamian is a global UI design and software innovation studio with significant sector expertise in healthcare and life sciences. We work with Healthcare and medical device companies to create visually stunning, intuitive and commercially-successful software products. We can help you transform your ideas into market-ready products that will stand out from your competition. We are currently offering a limited number of free consultations with our senior team. For the next 60 days we have ten available openings with our usability and technology experts, who can meet with you to discuss your product plans, and help determine how the technologies and approaches discussed in this paper could help you innovate and further differentiate your product from the competition.

If you are interested in learning more, please contact us:

Didier ThizyDirector, Healthcare Solutionsdidier@macadamian.com+ 1 877-779-6336 x136www.macadamian.com

©2010 Macadamian Technologies