Chicago — Some physician group practices that are reinventing their workflows as they adopt electronic health records are concluding that wireless networks fit in well with their new approaches.

At Springfield Clinic, for example, doctors concluded that tablet computers were the most convenient option. "Physicians now don't see a patient unless they have their tablet; it's just like their stethoscope," says James Hewitt, CIO at the 195-physician practice.

Because physicians implementing EHRs will want easy access to clinical data from any location, wireless networks will be commonplace at clinics within five years, predicts Rosemarie Nelson, principal at MGMA Healthcare Consulting Group.

"A very large percentage of doctors' offices know that this is going to be in their future," adds Margret Amatayakul, president of Margret/A Consulting. "It's now more a matter of when they can afford it and how easy it will be for them to make the change."

But some early adopters are experiencing growing pains. For example, Hematology Oncology Associates of Central New York was moving to tablets but wound up also deploying thin clients linked to a wired network. That's mainly because its wireless network's reliability proved spotty, says Michael Cretaro, CIO.

And after carefully considering implementing a wireless network to support tablets, Rocky Mountain Gastroenterology Associates rejected the option as too costly and impractical.

Subjective Factors

The decision on whether to take the wireless plunge frequently hinges on subjective factors, says Barbara Drury, president of PriCare Inc. a Lakespur, Colo.-based consulting firm. "It's driven by the form of the device that the providers choose as well as totally subjective things that have nothing to do with technology," she says.

Timothy Laird, M.D., a family physician who practices at Health First Physicians, uses a laptop mounted on a mobile cart so he can maintain eye contact with his patients. "We had started out with thin clients and then laptops on a table," Laird says. "The problem was we still found we were looking at the computer, then at the patient, going back and forth. It's very difficult to put the computer somewhere where it's not a barrier between the doctor and patient."

Laird adjusts his cart up or down, depending on whether he's sitting or standing. He uses a wireless network from Cisco Systems Inc., to access electronic records from GE Healthcare.

Physicians' preferences vary widely by specialty, Drury says. A pediatrician, for example, might reject having a PC in each exam room out of fear a child might break it, she notes. Other practices, however, fear that tablet computers will be stolen. For some specialists, tablets can prove impractical because of their screen size. An orthopedic surgeon, for instance, might want a workstation with a large screen so he can show patients images of their broken bones.

But for many doctors, mobile devices linked to a wireless network have a strong appeal because the hardware enables them to easily view a record before entering an exam room, just as they do with paper records, Amatayakul says. In fact, that was a major factor in Springfield Clinic's decision to move to tablets, Hewitt says.

Laird likes using a mobile computer because it improves his workflow. "It may sound silly, but as I walk out of the exam room with my computer, there is no dead time. I can be typing, refilling prescriptions, checking lab results or sending notes to my staff. I can do it all no matter where I am."

Tablet computers also help doctors avoid the hassle of frequently logging on and off desktop computers to ensure security, Amatayakul the consultant notes. "Physicians seem to perceive logging in and logging out as taking way too much time," she says. But group practices also must weigh potential negatives about mobile devices, she adds, including slower access to data and limited battery life.

Nelson, however, claims that practices often use complaints about the slow speed of wireless networks as a "smokescreen" for resistance to change. She contends that wireless networks can easily be configured to offer adequate speed.

For example, the consultant worked with one clinic that sped up clinical data access on its wireless network by simply segregating large diagnostic image files on one server. Another practice, she says, belatedly determined that its 6-year-old servers needed to be replaced.

Zangmeister Center
, a 15-physician oncology practice in Columbus, Ohio, alleviated concerns about wireless network speed by pairing its tablets with application delivery technology from Citrix Systems Inc. This helped minimize the amount of data traversing the network, says Andrew Cooper, the group's information technology manager.

A new standard for wireless networks, 802.11n, promises much higher speeds than currently available options. The standard, developed by the Institute of Electrical and Electronic Engineers, is expected to be available in November 2009. But Nelson cautions against waiting for the next standard. "There is always an emerging standard and a next generation," she notes. "I don't think there is a problem with the current speeds being too slow."

Some group practice administrators and CIOs have struggled with so-called "dead zones" in their clinics where mobile devices cannot link to the wireless network. This was a major concern at Hematology Oncology Associates of Central New York, says Cretaro, the CIO.

"No matter how well I position the access points in the wireless network, they can still drop connections in places and it's not always the same places that are the problem," he says. "A wireless network is just not as stable a connection as a wired network."

In contrast, Cooper at Zangmeister says he was able to eliminate dead zones with a lot of fine tuning. Plus he says he took the additional psychological step of adding an extra access point "in one area where everyone can see it to reassure them."

Drury, the consultant, advises group practices to "buy good equipment and complete a good survey of the facility to make sure the placement of access points works well."

To maximize data security, Drury urges her group practice clients to encrypt every transmission of data over a wireless network, a step she says some clinics have not yet taken.

Zangmeister Center in Ohio uses several forms of encryption for all data transmissions, says Cooper, the information technology manager. Plus, the clinic uses Microsoft Active Directory to ensure only those with an active account can log into the network.

Amatayakul, the consultant, advises clinics to take the simple step of not identifying their wireless networks using the organization's name. That will minimize the possibility of someone trying to inappropriately access it.

Nelson is hopeful that the health care industry can improve security by developing a universal-and tough-standard for authenticating users of wireless networks.

Mobile computers linked to a wireless network will prove to be more secure than a desktop computer, which requires users to log on and off with every use, contends Richard Helvig, M.D., chief medical information officer at Grand Itasca Clinic and Hospital. The organization is in the early stages of planning implementation of electronic records using mobile devices.

A Standard Approach

For many clinics, gaining a consensus among physicians on using a standard mobile device to access electronic records has proven to be a major challenge. A few pioneering group practices, however, have managed to pull it off.

At Springfield Clinic in Illinois, all 195 physicians, plus other clinicians, in 24 locations use tablets from Motion Computing to access electronic records software from Allscripts LLC (now Allscripts-Misys Healthcare Solutions Inc.). The practice has implemented more than 750 tablets.

The tablet computers were best-suited to the practice's workflow, enabling doctors and nurses to carry around electronic records just like they would tote paper records, says Hewitt, CIO of the Illinois practice. "The interesting phenomenon is that if you put PCs in exam rooms, the physician doesn't know in advance what's going on with the patient unless they go to a computer at the nurse station or their office," Hewitt says. "That was eye-opening for me. A PC in the exam room disrupts the usual office workflow. That tipped me toward taking a look at making mobile devices work."

Nevertheless, doctors remained concerned about the battery life of mobile devices. But Hewitt came up with a solution to the problem. The practice installed more than 1,600 docking stations in exam rooms, each with a keyboard and a mouse. When docked, the tablets recharge their batteries, removing the concern about battery life, he says.

Although physicians in various specialties initially complained that they each had unique computer needs, an I.T. committee and the full board eventually approved the standard approach because "the tablets are as powerful as a PC," the CIO says.

One big motivator for the automation project, Hewitt says, was the desire to end the paper chases involved in running a large practice with 24 locations. Because many patients see doctors at more than one location, clinic sites often created "shadow records" tied to specialty care, making it nearly impossible to locate and assemble a complete record.

As it phased in electronic records, the practice also scanned in older paper records, enabling it to eliminate all paper charts - and close 22 file storage rooms, he adds.

Now, physicians use the tablets to access complete outpatient records as well as clinical data from two local hospitals. As a result, physicians "have real-time access to clinical information from anywhere," Hewitt says.

"We knew that over the next few years there would be considerable cuts in our reimbursement rates from payers, so we had to become more efficient while providing better care," the CIO adds.

So far, the large practice has trimmed 100 medical records positions through attrition, Hewitt says. An added bonus of the automation effort is that the practice has earned a 2% cut in its malpractice insurance premiums thanks to greater availability of information to support clinical decisions.

Ahead of the Curve

Zangmeister Center in Ohio takes a similar approach. Its 15 oncologists all use "convertible" tablet computers with keyboards, from Hewlett-Packard Co.

"We created a panel of physicians and evaluated about 15 different devices from ultra-mobile computers with five-inch screens to convertibles, slates and PCs," says Cooper, the information technology manager. "They wanted to have a touch pad to use like a mouse, not just a pen, and they wanted the ability to use a keyboard. The convertible tablets gave both those to the physicians."

Cooper describes the practice as "technologically ahead of the curve." It's been using an electronic health record from Varian Medical Systems Inc. since 1998. So going wireless was part of a "natural evolution," he says.

"When we evaluated putting in desktop PCs or thin clients in every patient exam room, the cost and the security issue of ensuring that no other patients' records were viewable by the patient when the doctor was not in the room made those devices unfeasible," he says.

Instead of installing computers in each of its 80 exam rooms, the practice acquired about 20 tablets. The practice uses a wireless network from Aruba Networks Inc., Sunnyvale, Calif.

Physicians, however, also have a wired PC in their offices to use when not treating patients. Nurses use thin clients in a patient intake area. Cooper sees these steps as necessary to ensure business continuity should the wireless network ever fail.

It Don't Come Easy

While Springfield Clinic and Zangmeister Center have successfully implemented a standard approach to mobile computing, many other clinics have found that goal difficult, if not impossible, to achieve.

Hematology Oncology Associates of Central New York was a true trailblazer, installing a wireless network almost eight years ago at its four locations. But today, only one of its 17 physicians still uses a tablet computer to access an electronic records system, from IMPAC Software, Sunnyvale, Calif.

The other physicians have turned to desktop PCs. That's because they were frustrated with the slowness of the wireless network and dropped connections, says Cretaro, the CIO. Most of the doctors, however, still use PDAs linked to the wireless network to dictate their notes. And nurses and nurse practitioners still use the tablets to look up information.

"We've made things so flexible that the clinicians can choose whatever hardware option makes sense for them," Cretaro says.

"Wireless is great for specific applications and specific uses, but it is not ready to replace wired workstations," the CIO says. He predicts his practice, and many others, will continue to use a combination of wired and wireless hardware for many years to come.

McHenry Medical Group also is using a mix of wired and wireless devices. The 20-physician practice offers a variety of options for accessing its electronic records application from Sage Software. That's because each specialty "does things a little differently," says Linda Amato, information technology department manager.

A wireless network enables doctors to access records via tablet computers or laptops when treating patients. In addition, most exam rooms are now equipped with wired or wireless thin clients. "They take up less space than a full-size PC and they aren't as likely to walk out the door as a mobile device," Amato says.

The practice initially had hoped to standardize on wireless tablets, but found that impractical due to widely varying physician preferences, Amato says. As a result, she advises other group practices to "try different things and see what works" rather than putting all your eggs in one basket.

Source: Health Data Management

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