Tuesday, December 28, 2010

Distinguishing Remote Access From Mobile Access

We frequently encounter folks who ask us about remote access via mobile devices. There's an important distinction to be made here. The usage intentions, patterns, and requirements for remote access and mobile access are very different. [1]

The purpose of remote access is to work in your computing environment when you are not on location. An example of remote access would be accessing hospital information systems and applications via a PC or laptop from your office or home. Often, remote solutions involve a VPN connection, a Windows desktop and/or web browser, and perhaps a remote license to allow the user to interact with the applications they are accessing. Mobile access is a different animal. Mobile users want to do specific tasks - check a lab value, view a waveform, see a medication list, check allergy status - while on the go. Providers want the data transformed into accessible, meaningful chunks, they don't want to have to navigate the entire medical record from their Droid in order to make a time sensitive decision. See table 1.

Some organizations have considered using Citrix to provide interpreted or emulated application access or a pdf view of EHR data and clinical information systems via a mobile device. That's like reading the New York Times on your smartphone using the internet browser. You can do it, but it doesn’t really work. Use the native application provided by the publisher. Native applications are built to run on a specific device and operating system.

We also do not recommend accessing any patient monitoring data via a non-native solution, because visual distortion is almost certain when things like medical aspect ratios cannot be controlled. Further, be advised that the FDA is mandated to regulate medical devices, including mHealth applications on cell phones and associated products. [2], [3]

We know that the reasons for and usage of remote and mobile access differ. We have learned that patient safety and provider efficiency are paramount in mobile application delivery. To optimize your provider access strategy, both approaches must be accommodated.


[1] Madden, B. 2010. Remote desktop access vs. mobile access: What’s the Difference? http://searchvirtualdesktop.techtarget.com/feature/Remote-desktop-access-vs-mobile-access-Whats-the-difference.

[2] Thompson, B., Kendall, L. 2009. How to Get FDA to Clear a Mobile Health App. http://www.ebglaw.com/showarticle.aspx?Show=12184

[3] Kumar, R. 2010. The FDA’s Regulation of Mobile Technology as Medical Devices. http://www.law.uh.edu/healthlaw/perspectives/2010/kumar-fdamobile.pdf.

Tuesday, December 7, 2010

Meaningful Mobility for Cardiology Care

A 12-lead ECG is a snapshot in time of 3 spatial views of the heart's electrical activity from 12 angles. It is generated by placing 10 electrodes on various parts of the body including the arms, legs, and chest. With a 12-lead, we are simply taking a multi-dimensional picture of heart conduction from right to left, top to bottom, and front to back.

Once the electrodes are placed, the ECG recorder is run. The recorder digitally captures the multi-dimensional picture. Although the machine will virtually record all 10 seconds of data per lead, all traditional ECG print outs and the current pdfs currently used in most mobility solutions only provide 3 seconds of data for each lead, and those three seconds are printed, static, flat, and non-interactive.

The output of an ECG recorder is a tracing on a graph. Time is represented on the x-axis, and voltage, or amplitude is represented on the y-axis. Look at the following picture describing the time and voltage for a traditional ECG tracing. Notice, for example, how one small 1 mm x 1 mm block represents 40 milliseconds in time and 0.1 millivolts in amplitude? (See Figure 1).

Now let’s look at how mobility providers can add serious value to the ECG equation. One way is to mobilize a pdf version of the ECG tracing. (See Figure 2). Helpful - but where is our data transformation in this equation? Consider it’s time to move to the next generation mobile solution. (Figure 3).

Figure 1

Figure 2

Figure 3

AirStrip Cardiology ™ provides the ability to scroll through a full 10-second ECG for all 12 leads and set any of the leads as the rhythm strip – clinicians choose the beats used for analysis. In addition, the dynamic ECG layout functionality grants full control over how leads are rendered, providing the option to see all 12 or 15 leads for the ECG or selectively, in various comparative layouts and zoom levels.

AirStrip Cardiology can help clinicians detect changes in mV signal as low as .05 mV (0.5 mm). That’s a twentyfold increase in amplitude detection over paper tracings. End users clearly see sub-millimeter variations, as well as being able to visually scan all 12- or 15-leads at once and see any relative deviations.

In terms of playback control, marking the grid with the measurements coming from GE Marquette® 12SL™algorithms, we also allow play modes for the 10 second digital segment to be full, 1/2, 1/4, or 1/8 speed, as desired. Added features such as user-driven lead selection, maintaining relevance across leads with synchronized pinch and zoom, make this exponentially more interactive. Now that’s meaningful mobility.

[1] http://en.wikipedia.org/wiki/File:ECG_Paper_v2.svg
[2] http://en.wikipedia.org/wiki/File:12leadECG.jpg
[3] © 2010. AirStrip Technologies. All rights reserved

Tuesday, November 23, 2010

Successful Physician Adoption of Mobile Solutions

The rate of adoption is the relative speed with which providers initially take up mobile technology. It is usually measured by the length of time required for a certain percentage of the affected clinicians within the organization or clinical care area to adopt the innovation. [1] That is, the application has been installed on their device, is ready for use, and the user clearly understands how to launch and interact with the program.
Within the rate of adoption there is a point at which usage reaches critical mass. [1] This is a point in time within the adoption curve that enough individuals have accepted the mobile application such that the continued adoption of the innovation is self-sustaining; the program becomes the standard of care, and its use is embedded in daily workflow. It is at the point of sustained adoption that benefits may ultimately be realized. Adoption rates are primarily determined by three factors:
  1. The strength and effectiveness of the communication plan and commitment by the facility to promote adoption by all targeted clinicians.
  2. The availability of an approved device and appropriate data plan to the adopting clinician [3] - allowing use of personal devices is preferred to requiring them to carry multiple devices.
  3. The availability and familiarity of an acceptable/effective use policy and procedure among providers and on the nursing units.
We know that organizations can improve the likelihood of adoption with good pre-implementation planning:
  • Involve physician and nursing thought leaders in the purchase decision and in scheduling the rollout.
  • Expose as many clinicians to the technology as possible prior to deployment
  • Be clear as to expectations for acceptable use, compatible devices and data plans, and allow time to meet these requirements.
  • Roll deployment projects out over time.
The way to ensure use is simple: make sure the product works every time, that it mobilizes data in visually meaningful ways, that it supports actual workflow, and that it's easy to use. Deliver value and usage will continue. If you don't deliver value, physicians will not adopt nor will they continue to use the product.
Finally, Lead. In writing. We are learning that the strongest adoption and utilization results are produced within hospital systems that have a defined policy and procedure regarding effective use of mobile solutions. This written policy and procedure is also helpful in assisting providers in understanding who may use the product, when to use the product, as well as to define the limits of effective use. All clinicians on the care unit should be clear that the mobility solution is not a substitute for the physical bedside availability of any team member at critical points in the care process.
[1] Rogers, E. M. (1962). Diffusion of Innovations. Glencoe: Free Press.
[2] Valente, T.W., 1995, Network Models of the Diffusion of Innovations, Hampton Press Cresskill, New Jersey.
[3] Markus, M. L., 1987, ‘Toward a ‘critical mass’ theory of interactive media: Universal access, interdependence and diffusion’, Communication Research, 14 (5), 491-511.


Tuesday, November 16, 2010

Improving Cardiology Diagnostics with Meaningful Mobility

Meaningful mobility transforms data into intelligence in a way that supports the improved performance of physician cognitive tasks such as diagnosis and triage. Consider the 12-lead ECG.

There are currently solutions on the market that allow the transmission of a .pdf of the EMS 12-lead ECG to emergency room physicians for AMI diagnosis and triage. [1] This has significantly shortened EMS-to-Balloon times. [2] There are also solutions that pull ECG data digitally and store the results centrally, for enhanced serial analysis. [3] But, where is our meaningful mobility data transformation in this equation?

Enter: AirStrip Cardiology. This product mobilizes the digital information obtained from 12 and 15 lead ECG so that providers can scroll through a full 10-second ECG for all 12 leads and set any of the leads as the rhythm strip – physicians choose the beats used for analysis.  It also grants the physician full control over how leads are rendered, providing the option to see all 12 or 15 leads for the ECG or in various comparative layouts and zoom levels.

Now, using a native AirStrip application on their mobile device physicians can:
  • Receive 12- and 15-lead waveforms and vitals wirelessly from EMS transport, which the clinician can then access from anywhere and review on their mobile device via a native AirStrip application.
  • Simultaneously scroll through a full 10 seconds for all leads while retaining the traditional 12-lead layout.
  • See a full presentation of results GE Marquette® 12SL analysis algorithms for 12 leads for EMS and inpatients.
  • Review and compare past ECGs, and do detailed serial comparisons of waveforms for their patients.
  • See clear and accurate waveforms and detect differences of less than .05 millivolts (.5 millimeter).
No more faxes, emails or .pdfs. Just transformative data that powers enhanced visualization and improved decision support by busy, on-the-go clinicians. Care is expedited. Outcomes will improve.

15.5% of emergency department patients arrive via ambulance. That's 18 million people. The leading reasons given by patients aged 15–64 years for visiting the ED were chest pain and abdominal pain, and for older patients (aged 65 years or over) the reasons were chest pain, shortness of breath, and abdominal pain. For adults 65 years of age and over, chest pain and non-ischemic heart disease were leading primary diagnoses for both men and women. Of the 16.7 million patients admitted to the hospital or transferred to another facility, 30% were admitted to critical care, stepdown or telemetry units. [4] Of 6 million chest pain patients, 400,000 were diagnosed with STEMI. [5]

We know that coordination of care for these cardiology patients is crucial to our health care system and the technology to support improved diagnosis and triage are vital to our ability to serve this growing population effectively. We are learning that superior diagnostic support is another way for hospitals and providers to win at meaningful use: engaging emergency room physicians, cardiologists, interventionalists, surgeons, critical care physicians and a host of others in the more timely and effective care of cardiac patients – anytime, anywhere.


[1] Physio-Control Case Study: Prehospital 12-Lead ECGs Help to Reduce EMS-to-Balloon Times http://www.physio-control.com/uploadedFiles/learning/clinical-topics/3300653.A%20Prehospital%2012-Lead%20ECGs%20Help%20to%20Reduce%20EMS-to-Balloon%20Times.pdf

[2] Rokos, I and Bouthillet, T. The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B alliance. STEMI Systems. 2007; Issue 2, May.

[3] The GE Muse System. http://www.gehealthcare.com/usen/cardiology/diagnostic_ecg/docs/ECGenius.pdf.

[4] Niska, R., Bhuiya, F., Xu, J. CDC Division of Health Care Statistics (2010). National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. National Health Statistics Report. Volume 26. August 6, 2010. Accessed online at http://www.cdc.gov/nchs/data/nhsr/nhsr026.pdf

[5] McCaig, L, Burt, C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. In: Advance Data from Vital and Health Statistics, Centers for disease control and prevention, Atlanta, GA 2005.

Monday, November 15, 2010

Engaging Physicians in Meaningful Use

Amid the hubbub about meaningful use, AirStrip has stayed true to helping hospitals and physicians achieve their greater goals of clinical decision support:
  1. Data access and data sharing – meaningful mobility with data transformation is a prerequisite to Stage 1
  2. Understanding clinical practice - making the data available in a meaningful way for users, especially physicians in Stages 1 and 2
  3. Guiding choices - incorporating concepts of evidence-based medicine in the offering in Stages 2 and 3
  4. Knowledge-based prompting - providing views of data and rules that promote proactive, rather than reactive interventions to accompany Stage 3.
For hospitals to win at meaningful use, physicians MUST be engaged users - “use” being the definitive term.

We know that every hospital and physician needs useful EHR technology which provides clinical decision support in fulfillment of safe, effective, and more profitable patient care.  They've been struggling with this for 15 years, with fewer than 10% having achieved any level of success. The biggest challenges are interoperability, physician adoption, and change management. Congress hopes to use meaningful use financial incentives and penalties [1] to force hospitals and physicians to accomplish over the next 5 years what they have not been able to achieve in the previous 15 years. [2]

If hospitals want physicians to use the EMR (and LIKE it), then give them mobile (not remote) access. With AirStrip OB, obstetricians are interacting with hospital information systems an average of nearly five hours per physician per month beyond the time they are spending on CPOE or entering progress notes via a workstation. If you have 30-35 obstetricians delivering patients at your hospital or health system, that’s like adding one laborist FTE – without the cost. We are learning that other specialists are engaging at even more staggering levels with our cardiology and patient monitoring products. We need only look to the role of the physician to understand why.

Physicians perform two kinds of tasks: cognitive and procedural. Cognitive tasks include things like “triaging admissions, deciding whether a white cell count of 24,000 × 109/L with a 38.4°C temperature warrants antibiotics, whether surgery is indicated, etc. Procedural tasks include things like performing surgery, intubating a patient, placing a central line, etc. A subset of procedural tasks is administrative (e.g. prescribing orders, documentation, scheduling imaging studies)”. [3] Mobility solutions can effectively support multiple physician job functions.

Meaningful mobility transforms data into knowledge and, in turn, delivers that intelligence in a way that supports the improved performance of the cognitive tasks by physicians (diagnosis, triage, and clinical management), while mitigating the time management challenges of procedural tasks (physical assessment, interventional treatments, and prescribing). Meaningful mobility is vital to physician engagement and alignment with HIT.

[1] Section 1848 (a)(7) of the HITECH Act provides that beginning in Calendar Year 2015, eligible professionals who do not demonstrate that they are meaningful users of certified EHR technology will receive an adjustment to their fee schedule for their professional services of 99 percent for 2015, 98 percent for 2016, and 97 percent for 2017 and subsequent years. 

[2] Sections 1848(a)(2)(A) and 1886 (n)(3)(A) of the HITECH Act includes Congress’ identification of the broad goal of expanding the use of EHRs through the term meaningful use.

[3] Fackler, J., Watts, C., Grome, A., Miller, T., Crandall, B., Pronovost, P. (2009). Critical care physician cognitive task analysis: an exploratory study. Critical Care. 2009; 13(2): R33. 

Wednesday, November 10, 2010

Mobile Solutions Improve Teamwork in Labor and Delivery

Labor and delivery is a great example of a clinical care area where mobility makes a huge difference in teamwork and communication.

In the nurse managed labor model, a registered nurse is responsible for recognizing problems, evaluating labor progress, providing hands-on care, and informing the physician or other team members when needed. [1] Nurses are trained to recognize, interpret and evaluate fetal monitoring data. In addition, they are aware of the autonomous interventions that can be instituted prior to calling the physician and the expected outcome of each. When approved interventions within the scope of nursing practice do not yield acceptable results, the nurse immediately notifies the physician or nurse midwife, who then collaborates in development of a plan of care in the best interest of mother and fetus. [2]

A challenging fact in obstetrics is that communication between the nurse and physician occurs as the nurse is providing direct care to the patient while the physician may be away from the bedside - in the office, another part of the hospital, or on call at home. [3]

In the past, nurses endeavored to describe the concerning fetal tracing via telephone, often a subjective assessment, when what they actually need is validation of their visual finding. Physicians had to try to envision what the nurses were seeing. Mobility solutions today can and must provide virtual viewing of data that is incomparable to verbal description alone.
AirStrip OB is an example of this kind of solution. It allows the physician to be in two places at one time and to actually see what the nurse is seeing. This extends the physicians' ability to make critical decisions based on real-time information that leaves no room for error related to verbal interpretation.

We know that prior to this mobility solution, there were delays in collaborative multidisciplinary assessment of patient data and medical management. There was no way to efficiently escalate differences of opinion via the established chain of command, and teamwork breakdowns and patient safety issues ensued. We have learned that when nurses identify a concerning CTG pattern, they notify midwives and/or physicians who can immediately view the CTG pattern on their smartphone and can discuss the treatment plan in a time sensitive fashion. Disagreements can be escalated up the chain of command immediately, regardless of the location of the providers involved. The net results are safer patient care, improved efficiency, and better relationships among clinicians.

1. Murray, M.L. & Huelsmann, G.M. (2009). Labor and delivery nursing: a guide to evidence-based practice. New York: Springer Publishing Company.
2. Simpson, K.R., & Knox, G.E. (2006b). Communication of fetal heart monitoring information. In E.F. Feinstein, K. Torgeren, & J. Atterbury (Eds.), Fetal heart monitoring: principles and practices (2nd ed.) Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nursing.
3. Simpson KR, Knox, GE (2003). Adverse perinatal outcomes: Recognizing, understanding & preventing common accidents. Lifelines: Promoting the Health of Women and Newborns, 7(3), 224-235.

Friday, November 5, 2010

Meaningful Mobility

Meaningful mobility is a prerequisite to Stage I Meaningful Use (data access and data sharing), especially by physicians. The key to success is to actually work with clinician workflow, rather than asking them to change it.  Mobility is important because it supports the actual multitasking and "on-the-go" realities and requirements of physicians, nurses, and clinical managers. Beyond anytime and anywhere access, mobility solutions must transform data into visually compelling information that supports better clinical decision making. Further, the mobility solution must guide better choices by incorporating evidence-based medicine and knowledge-based prompting. The goal is to improve clinical decision making at the point of care through data transformation.

It's not enough to provide interpreted or emulated application access or a .pdf view of EHR data via a mobile device. That's tantamount to booking airline tickets on your smartphone using the internet browser. You can do it, but it doesn’t really work. It’s awkward and time-consuming and lacks the value-added native application-quality data transformation that is critical to improved clinical decision-making. So, the patient's serum potassium level is 3.0 milliequivalents per liter. What is the relevance of that value in the context of that patient? Was the drop sudden or gradual? Is the low value chronic? What has been the patient's range? How does that map to the normal range? Has the patient been on potassium replacement of any kind? It is possible to present that data in an informative and visually compelling manner that promotes better choices by practitioners.

In health care we see time and again that those who make data access and data processes difficult for clinicians suffer adoption resistance and usage doldrums. We have learned that delivering mobile intelligence about assigned patients in concert with the workflow of providers is technology that is enthusiastically received and rapidly adopted, and we see high usage levels sustained over many years.

About AirStrip Technologies

AirStrip offers unique mobile technology that provides clinicians and leaders with access to real time and historic critical patient data from multiple and disparate sources. This includes waveforms, medications, lab results, and other trended, relevant clinical data presented in informative ways so as to improve the management of patients and patient populations - in particular those that are high volume, high risk, and high cost. Read more about the San Antonio Texas-based firm here.