BBI Contributing Editor

DALLAS As was noted in the May issue of BBI, the Healthcare Information and Management Systems Society's (HIMSS; Chicago) 2005 conference in March was marked by an obvious surge of interest in the electronic health record (EHR). That surge was demonstrated both by a greater number of physician attendees and a broader range of EHR exhibitors on the Dallas Convention Center exhibit floor.

One issue that every adopter of the EHR has to wrestle with is what to do with existing paper patient charts. SRS Software (Montvale, New Jersey) suggested scanning the charts not a new or novel solution, but SRS offered more. Scanning a chart creates an optical image of the entire chart but one that is not granular at all, meaning there is no way to recognize, parse and drill down into the various data elements that the chart contains such as specific lab results or history of present illness or history and physical summaries of the specific encounters. SRS's twist on this solution is to print a series of labels on tape, which can be directly applied to the paper records immediately before the scanning process begins.

Coupled with its software that recognizes these tags, that allows the scanner to know where one section of the paper chart stops and another starts. The scanning software then uses these logical section tags to index the scanned paper chart. Thus, getting the older paper records into the system in an indexed format requires two steps first, sticking the section tags onto the paper chart, and second, scanning it into the system using a conventional scanner. What results is not an index to every data element, but at least an index to every data section.

These indices are then presented to the physician (or other office caregiver) on a computer system, becoming somewhat of an "easy EHR" of the existing records. The company claims that sites that adopt this solution are (over the first five years of sales) 100% successful, in stark contrast to the 50% failure rate that national healthcare information technology czar David Brailer, MD, noted during his presentation as applying to EHR roll-outs nationwide. SRS points to 180 live sites, including installations at U.S. Navy facilities, at New York University and Yale University (New Haven, Connecticut), among others. Our feeling in looking at this system was that it would appeal to older physicians who might not be willing to go completely electronic or change from handwriting their records. It would have substantial limitations, however, for retrospective searching of records, based on one or more specific criteria; even simple ones like creating a list of all patients for whom recalled drugs (such as Vioxx) were prescribed, an especially important task when the drug is removed suddenly from the market. For such tasks, a more robust solution would be required, and there were many of those on the HIMSS exhibit floor this year, pointing out their capabilities.

Dealing with legacy paper records when a practice does go electronic is a real issue. Xerox (Stamford, Connecticut) was showing its DocuMate 252 (a product it licenses from Visioneer) in its booth. This sheet-fed scanner has a dynamite combination of speed, low cost and duplex paper handling. For black and white scanning, it cranks in 25 to 50 pages per minute at 200 dpi resolution (ideal for optical character recognition applications). It offers resolution up to 600 dpi at 48-bit color depth (16-bit for each of the three primary colors). At less than $1,000, it hits a price point approached by no other scanners we have seen. The duty cycle is rated at 2,500 pages per day, surpassed only by the Bell & Howell (Wheeling, Illinois) Sidekick 1200 model that costs about $1,550 (50% more) and sacrifices color resolution to 8-bits (256 shades) per primary color (24-bit total color depth).

Surprises on the exhibit floor

One doesn't usually think of HIMSS as a venue for patient monitoring companies to show new products, and we were surprised by the number of medical device-oriented companies that were exhibiting, including very small ones such as Zoe Medical (Topsfield, Massachusetts). Zoe is an OEM supplier with a limited set of patient monitors, yet they had a booth and were showing their Nightingale bedside and central monitors.

The company was established in 1997 by an engineer and a marketer who left Siemens' operations in nearby Danvers. The two basic models range in cost from $3,500 to $5,000. Zoe also is the source for Invivo's (Orlando, Florida) M6 and M8 monitors. However, it is not at all clear how committed to the general monitoring business Invivo is after its acquisition by Intermagnetics General (Latham, New York). Zoe is aiming its product at the subacute care (general ward) market, a growing sector that is attracting a lot of interest and will be a hotbed of competition as larger competitors, including Welch Allyn (Skaneateles Falls, New York), Philips Medical Systems (Andover, Massachusetts) and others target new monitors for this area in 2005.

The most innovative company at HIMSS was HP (Hewlett Packard; Palo Alto, California), which was showing amid many products its new HP Forms Automation Product, a digital pen-and-paper solution that was very novel. The system is aimed at automating the 10 billion forms that are processed each year in healthcare (as well as 90+ billion more processed elsewhere). Called Forms Automation System 1.2, the system has been live at the Cherokee Indian Health Center (Cherokee, North Carolina) for some time.

Care providers start out with standard white paper and run it through an HP laser printer, which prints a predefined form onto it. The printed form looks normal to the naked eye, but in fact has a very fine pattern of dots superimposed on it as well. The users then write on the form with a special digital pen. While they are writing, the pen is capturing the marks and storing them, along with the form. The pen reads the dot pattern printed on the paper, much like a scanner reads a bar code in the supermarket. This allows the pen to recognize those areas on the form that are labels and those areas on the form where the user writes. The pen scans in the handwritten form data and performs character recognition on it. We worked with the pen and found that the character recognition was very good. One reason is that many of the fields can only have certain values, so the recognition software is really trying to resolve whatever it sees to the values it already knows. The forms we viewed also made clever use of scales (which the user would mark on) to indicate the extent of the parameter, such as the extent of blood loss (scale runs from "none" to "severe").

The data extracted from the form (form ID and pen strokes only) then populates a medical record for the patient, on the HP server. Because the data then is labeled and digital, it can be stored, indexed, searched and later retrieved. Because each user has his or her own pen, the system knows who is writing on the record. HP believes that after the initial investment, the system will quickly pay for itself in high-volume applications because the cost per form is reduced from around $1.50 in other systems to about 25 cents in the HP system. The workflow-select software that resides on the servers provides the ability to scan in any form that the hospital may currently be using, to create an electronic version of that form in less than two hours. Its appeal is that nurses, doctors or other providers simply write like they always have, but the data comes out digital, legible, indexed and stored.

The pens cost about $200 each (one per user), but the real cost is the central server and the application software that runs on it. That can cost $50,000 a year for a package of transactions. Each form, when printed and written on, counts as one transaction, even if you write on it two or three times. The approach cleverly minimizes network traffic by only sending the pen strokes to the server, which has the form and puts the two together. The upload to the server occurs when the pen is set back in its charger stand, which resembles an inkwell. Data is then downloaded from the pen and sent to the server. It's hard to describe how slick the entire process is. The approach provides the best of both the paper and digital world: The provider writes on the predefined form; the form supplies choices that allow the data to populate an actual back-end knowledge base or clinical repository; the handwriting is transformed into typed data on the archived form, which can then be searched.

The data output supports XML-tagged and other ODBC-compliant formats, making integration into other vendors' repositories a matter of matching data fields in the repository knowledge base scheme. This of course is a "razor blade" business model. With 100 billion documents at 25 cents each, HP stands to create a market that would dwarf even the inkjet-ink model that generates the majority of the company's revenues today.

While HP offered the most innovative product on the HIMSS exhibit floor, the most interesting company we found there was Emergin (Boca Rotan, Florida), a firm that acts as a communications messaging company. Emergin takes messages, alerts and alarms from diverse systems and reformats them to be delivered to caregivers on in-hospital, wireless phones (marquee displays and other end-user devices).

While it had no booth of its own, Emergin had components in several OEM partners' booths. Its middleware provides a strong foundation for companies as diverse as Radianse (indoor positioning), Philips (patient monitoring), Pyxis (computerized drug dispensing), Dukane (nurse call systems), Spectralink (in-hospital wireless phone systems), Vocera, Ascom and others.

The problem that Emergin has set out to solve is a critical one if all of the automation being pushed at the healthcare providers is ever actually going to result in workflow efficiency gains. The problem the company solves is that of integrating the data messages from diverse sources, consolidating them, prioritizing them and reformatting them to be delivered to the devices that caregivers use to receive messages. Today, that device is looking more like a portable, in-hospital wireless phone. Emergin provides message integration for over three dozen major vendors.

Growing interest in security solutions

Security and biometric hardware was a growing area at this year's conference. There were two important tracks one was the security of the individual computing platforms and the hospitals network backbone and external portals, the other was the security of individual user passwords and access to appropriate applications. We saw interesting solutions in both of these areas.

On the device front, Panasonic (Secaucus, New Jersey) was showing its Iris (eye scan) security devices, which can be used by itself or in conjunction with a machine-readable ID card. The system was fast (about 1-1/2 seconds) and the person being scanned doesn't sense the scanning as it uses infrared signals, similar to those used by a hand-held TV remote. The scanner was designed to be wall-mounted and was tamperproof. There also were a number of finger scanners shown.

Because providers need to know the security capabilities of EHR solutions being offered, HIMSS was a place where many EHR vendors were seeking help to complete the HIMSS Manufacturers Disclosure Statement for Medical Device Security (MDS^2 ) forms. When complete, this will help EHR prospects understand how secure the systems they are being offered can be, but they will still need assistance in actually configuring them.

To keep track of patients, the industry is evolving from simple bar-coded wrist bracelets to RFID-tagged bracelets, one of which was shown by Radianse (Lawrence, Massachusetts). This bracelet is about the size of a wristwatch and costs around $10. It is the latest in a family of RFID tags that can be attached to people or equipment that allows location to be cost-effectively tracked inside of healthcare facilities. Tracking is a technology that has become less expensive by a factor of five over the last five years and is now around $120,000 to $200,000 per hospital since Radianse entered the market.

Coupled with communication integration software from Emergin, locators solve a number of significant problems and help to insure both faster care and a safer patient environment. These integrated solutions are an answer to helping hospitals become compliant with the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO; Oakbrook Terrace, Illinois) Leadership Standard (LD.3.15) on managing patient flow, which became effective Jan. 1.

The integration also minimizes the loss of movable equipment in hospitals. Having completed pilot rollouts at beta sites including Massachusetts General Hospital (Boston) and others, Radianse's commercial solutions are rapidly being adopted by many hospitals ranging from small to larger.

Take one tablet and . . .

In the computer arena, Motion Computing (Austin, Texas) exhibited its excellent tablet PC. In addition, both Fujitsu and Panasonic were showing their lines of laptop and tablet PCs, both of which were impressive from different perspectives. The Panasonic Toughbook series was designed to be a bit more rugged, but the Fujitsu products, particularly its tablets, offered more features and seemed to have been designed more with medical applications and HIPAA security in mind. Other vendors such as HP and Dell (Austin, Texas) were present, but their products were simply consumer store models, not particularly tailored to the needs of healthcare users.

For healthcare providers who don't want to carry laptops or tablets around, there were a number of cart providers at HIMSS showing various computing solutions integrated into carts. Lionville (Exton, Pennsylvania) was showing its iCart solution for point of care charting. The basic cart is adjustable in height from 31" to 41" to accommodate caregivers who prefer either to sit and type or stand and type. The system comes with integrated hardware and LCD display, keyboard, mouse and bar code scanner, everything needed to assure the 5-R's of meds administration the application the iCart is clearly targeted to. The iCart integrates the Pelham Sloane PS 1500M computing platform, offering 802.11b/g wireless communications. The cart has a couple of lockable drawers and an integrated battery power is available in a standard (32 amp hour) and extended (52 amp hour) format.

Desktop computers seem to be giving way to centralized "blade" processor arrays. ClearCube (Austin, Texas), an originator of the blade concept, was joined this year by HP and others. As healthcare providers become more thin client-server aware, desktop CPUs are increasingly giving way to centralized blade configurations. One reason is HIPAA security, since centralized processors are easier to secure, patch and update, maintain and protect than multiple machines located around an extensive healthcare enterprise. This helps achieve five objectives of the HIPAA regulations: Facility Access Control, Work Station Use, Work Station Security, Controls on Devices and Media and Access Controls (User ID and Validation).

Almost everything was wireless at HIMSS this year. Vocera Communications (Cupertino, California) continued to show enhancements to its in-hospital, voice-over-IP, hands-free, voice activated phone system. The hardware hadn't changed but the network application software had become more feature rich, particularly the messaging interface and reports server software.

Reducing adverse drug events

With adverse drug events accounting for 61% of the most serious and costly medication errors, it is important to have systems that can manage and monitor these medications and there were plenty of companies at HIMSS willing to help with that problem. Cardinal Health's (Dublin, Ohio) Alaris (San Diego) division showed a wireless smart infusion information system. This wasn't vaporware, as more than 10,000 smart wireless infusion pumps already have been installed at U.S. hospitals. The wireless Alaris Network provides connectivity to a modular point-of-care platform that integrates infusion, patient monitoring and clinical best-practice guidelines for optimal outcomes at the point of care. This wireless network capability allows the real-time capture of medication infusion, patient monitoring and continuous quality improvement data from these devices. The analysis of such data improves patient safety and helps to prevent errors.

Alaris presented information on reductions in the medical intensive care unit (MICU) length of stay at the University of Pennsylvania Health System (UPHS; Philadelphia). Data from the IV devices can be continuously captured, and new or modified drug libraries used with the Guardrails Suite of safety software can be transferred, house-wide, with a single key push and with no disruption of clinical workflow. Alaris also discussed a new gateway that will allow the system to share data with other clinical applications to provide real-time information that hospitals can act on to improve best clinical practices and outcomes.