BBI Contributing Editor

ATLANTA, Georgia — In addition to the wireless infrastructures, products and vendors discussed in Part 1 of our coverage of this year's Healthcare Information and Management Systems Society (HIMSS; Chicago, Illinois) meeting (The BBI Newsletter, April 2002), there was much emphasis on security, Health Insurance Portability and Accountability Act (HIPAA) and HL7 interoperability. There also was the usual mix of new and current electronic medical record (EMR) and computer-based medical record (CPR) vendors, a cross-section of large and small companies with new approaches and refinements of current products showing their wares.

Although HIPAA transaction set standards originally were supposed to go into effect on Oct. 16 of this year, the Bush Administration has granted an extension until October 2003, to allow the industry more time to come into compliance.

Microsoft (Redmond, Washington), Washington Publishing Co. (Rockville, Maryland) and two system integrators announced a strategic relationship to provide operating system tools, testing, consulting and training services to the industry, a package of software and services priced at $65,000. The core component is Microsoft's new Biztalk accelerator, which has been available since October 2001. Washington Publishing, a domain expert in the X12N standards adopted by HIPAA for all transactions, contributed its OnlyConnect Gap Analysis Tools that assist with HIPAA compliance analysis. In addition, other Microsoft partners such as Neotool (Montrose, Colorado) were showing HL7 accelerators that could be seamlessly added onto Biztalk Server 2000, which supports the X12N standards. Amicore (New York), a physician software and services company, was launched through a collaboration of Pfizer (New York), IBM (Armonk, New York) and Microsoft. It was the first firm to implement these new products and make them available to physician group practices using the Amicore services, particularly to integrated lab results into the patient's EMR. The Neotools approach of accelerating HL7 messaging removes the pressure of keeping current with each new enhancement of HL7 off end users. It currently supports version 2.0 of HL7 and will support 3.0 once it is finally ratified. It currently supports all data types, message types and segments. Neotool's client base includes more than 2,200 users worldwide. This strengthens Microsoft's position as the operating system of choice for health care.

Indeed, in press briefings by rival Sun Microsystems (Santa Clara, California), there was a lack of specific interesting products, and not much push by this alternate OS vendor in building health care-specific infrastructure products. Rather, Sun seemed to be waiting on third-party integrators to build upon Java and Jini, but didn't have many new announcements to showcase.

In addition to software, a lot of ISM band infrastructure also was announced at the HIMSS gathering, all supporting 802.11b. 3Com (Santa Clara, California) showed its new NJ100 network jack, a device that fits into a standard duplex electrical box and offers an interior RJ45 Ethernet jack. It then acts as an active hub with uplink port and is available at only $140 list price and less on the street. It can support placement of hubs where electrical power is not available, making any location an Ethernet-enabled location. 3Com also was showing a Wireless Ethernet bridge, the equivalent of a stand-alone PC NIC card, but one that can support up to four MAC addresses. This device is particularly interesting if connected to the uplink port of the NJ100 hub, splitting it into four physical Ethernet connections that will fit in one duplex receptacle. It also was showing its 3CR990 NIC and Firewall Card, a firewall built into a PCI NIC card that is remotely programmable for security policies by the network administrator. This is a powerful piece of hardware that addresses the fact that most attacks come from inside the network, either because something has gotten through a corporate firewall or because someone inside the network is hacking it. This combination NIC/Firewall card allows every computing device on the network to have its own firewall. This type of hardware will be a must for health care infrastructures seeking to become truly secure against inside network attacks, an important factor in making patient data on large, enterprise-wide healthcare networks more secure and HIPAA-compliant. 3Com already has implemented such technology in the U.S. Department of Defense in many sensitive applications, and now offers it to hospitals.

HIMSS, usually about software applications, had its share of hardware vendors as well this year. One of the slickest was Advantech Technologies (Irvine, California), a hardware integrator that was showing a neat display and computer. The POC-153 medical-certified device offers a 15" active LCD display that is perfect for bedside color ultrasound flow images or DICOM quality radiology images. It includes optional 802.11b wireless LAN and wired 10/100 base-T Ethernet. There is a PC bus expansion slot for OEM boards, and the whole package is about 16 pounds. Add the front-end box and you have an instant wired or wireless Passport-type bedside monitor based on a PC architecture. Advantech has medical display technology down pat. We watched as the medical channel manager for the company dropped a Windows CE computer with active matrix LCD from chest height onto the concrete exhibit floor and saw the system simply reboot itself and restore the display. Advantech is working with GE Medical (Waukesha, Wisconsin) in its next-generation portable monitor, and supplies some components used in Siemens (Malvern, Pennsylvania), Picis (Arlington, Virginia), Philips (Andover, Massachusetts) and Drager (Telford, Pennsylvania) devices and is becoming the vendor of choice with McKesson HBOC's (Alpharetta, Georgia) cart-mounted systems.

The HIMSS show in some ways was a quest for a good, low-cost ISM band infrastructure (other than 802.11), that is both suitable and commercially viable, for patient-worn monitoring applications in hospitals. HomeRF is technically viable, but commercially dead. Original Bluetooth (802.15) is commercially viable but lacking the power to support roaming applications. The higher power mode of 802.15 is both technically feasible and commercially viable, but its adoption will be troublesome for 802.11b networks, as it hops on top of them much more frequently than 802.11 FH (with its slower hopping rate). There is an even more limited total data rate in 802.15, which was not originally intended as a LAN, but instead as a wireless point-to-point connector to replace infrared ports at short distances (such as wireless mice, keyboards, speakers, displays, etc.). The key limitation is that even high-power 802.15 is too slow as a viable wireless network for patient monitoring applications. This is a valid argument for a large network with many roaming devices, but this may not be as much of an obstacle for smaller hospitals.

Thus, there are three technologies with different characteristics that have application to health care. Bluetooth (802.15) is a technology for "personal space," as its range is limited in the low power version to transmissions of less than 20 feet and would generally have one access point. Offering slightly more range per access point and multiple access points is 802.11b DS. This, however, has difficulty being scaled up into larger enterprises due to the complexities of reusing the three channels available in the U.S. and the difficulty of minimizing dropout areas. The third technology would therefore be multiple 802.11 FH access points or more likely 802.11a infrastructure working at 5.7 GHz. This newer technology could work to distances of 1,000 feet or more with multiple access points, and would be similar to cellular phone technology. The bottom line is that none of this is good news for many of Symbol Technologies' (Holtsville, New York) existing partners, if demand or willingness to adopt 802.11 infrastructure suffers. Of course, that may not happen. Just as suddenly as Symbol has seemed to change course by dropping its health care vertical market channel support and becoming silent about 802.11 support and development going forward, this widely-implemented medical wireless telemetry partner may suddenly speak up and assure the health care vertical market that it is going to support this technology for a decade to come.

Some vendors also were showing 802.15 (Bluetooth) that is already integrated into one version of the Compaq (Houston, Texas) I-paq personal data assistant (PDA). Indeed, NEC (Tokyo) now is offering 802.15 Bluetooth chipsets for around $6 in "automotive" quantities (presumably millions of units), so the Bluetooth infrastructure is finally meeting its originally projected price targets. This is likely to greatly accelerate the adoption and dispersion of Bluetooth devices now in many medical, general computing (wireless keyboards, mouses, trackballs, scanners, printers) and other specialized applications (like automotive). The NEC chip is just the hardware layer. Data structures must still be added above this layer for practical products. The price offered reaches the original price point set for this important, short-distance replacement for irDA technologies. Code Blue Communications (Seattle, Washington) is one company that offers excellent medical applications using Bluetooth technologies.

Several point-of-care (POC) computer-based patient record vendors exhibited at HIMSS along with some physicians' office electronic medical record automation vendors. This is always interesting at HIMSS, because of the growing number of vendors each year, now totaling over 600. Apart from the largest ones, it seems as though more than half never make it back for a second or third year. One that has returned yearly since its start in 1997 (and one of our favorites to watch) is JMJ Technologies (Marietta, Georgia), a growing and profitable EMR vendor offering the Encounter Pro family of physician office patient record and workflow systems, now in version 4. This new version offered disease management, treatment regimens and integration of other vendors devices and applications. The system already has 1,850 users in 25 states and has captured more than a million patient records. It will grow dramatically this year by offering a variety of software options customized to specific types of practices. Currently available are systems specialized for cardiology, family practice, internal medicine, ob/gyn, pediatrics and occupational medicine. Announced at HIMSS were new systems for dermatology, orthopedics, ophthalmology and neurology/neurosurgery. The key that separates JMJ Technologies from others we have seen is that it offers a product designed from the ground up for workflow enhancement, not an EMR chart with some work-flow optimization added on. One of the differences is a design that supports parallel tasks and simultaneous access by several medical professions to the same patient record and chart. Different caregivers can simultaneously be entering immunizations, test or lab results, charting procedures and ordering medications. The screens are organized around where the patient is in the process, starting in the waiting room and tracking through triage, exams, tests, etc., until discharge from this encounter. EncounterPro keeps all patient encounters to build a lifelong clinical record of visits to the physician.

JMJ isn't the only vendor to organize around a work-flow model. Siemens announced its new Soarian product at HIMSS. Several Pennsylvania hospitals are involved as beta sites for this rollout. General release of this product is anticipated in 2003. This software, designed to serve inpatient points of care can run on the Siemens Infinity Explorer, a new bedside workstation that combines patient monitoring and clinical data management on a single, integrated hardware/ software system. Siemens has applied for more than 30 patents on the Infinity Explorer system. Siemens is one of the largest medical application service providers, hosting services for more than 1,000 of its 5,000+ health care clients. With the marketing presence of Siemens, this new system is likely to be a rapid success.

HIMSS also had several anesthesia information system vendors. Surgical Information Systems (SIS; Alpharetta, Georgia) attended and announced its new staff scheduling, budget planning and resource tracking modules. This broadens the scope of the solution for the perioperative setting that SIS is offering. Broadening the scope of perioperative systems is a trend that several SIS competitors also are pursuing. Philips Medical has been working toward this same goal since it purchased AIM a year ago, as have others. Companies are realizing that they need to solve and manage the entire perioperative processes, from physician credentialing, scheduling, resource planning and tracking, pre-op, interoperative, and postop charting to discharge planning and billing. This is raising the ante for niche players, particularly other patient monitoring or ventilator companies that offer systems which handle mostly the charting requirements but may lack the credentialing, resource tracking and billing components.

Picis was showing enhancements to its CareSuite for Critical Care and CareSuite for Anesthesia, as well as its equal outcomes analysis tool to mine data from these two products. The company's products are being migrated to be accessible as web browser-based applications. Picis announced its selection by Columbia-Presbyterian Hospital (New York) to automate its operating room environment, and it also reported selection by University Medical Center (Tucson, Arizona) for use in its critical care units, where data from Picis will be integrated into the hospital's Sunrise Clinical Manager from Eclipsys (Delray Beach, Florida). Picis also reported the formation of a HIPAA Task Force to help it gear up to make its applications with all seven HIPAA Title II regulations.

MedicaLogic (Hillsboro, Oregon), a vendor that has appeared at HIMSS over the years, was there in a virtual way, having sold its assets to GE Medical Information Systems (Milwaukee, Wisconsin) for $20 million in cash (see Acquisitions, page 139). This expands GE's Centricity EMR solutions beyond the hospital into the physician office provider space. With this latest purchase, GE Medical has now spent more than $1.5 billion in the last three years acquiring medical device and information system companies. Medicalogic was showing its Logician physician EMR system that has been recently web browser-enabled to provide lab results and in-network referrals, along with physician-to-physician messaging.

A very interesting and novel application was shown at HIMSS by Progeny Software (Wolfville, Nova Scotia) featuring software that maps genetic traits in family systems. The user could pick up to nine genetic traits, and then the software would generate a genogram of which male and female ancestors (and children) had each trait. It is useful for quickly seeing family patterns of genetically-based conditions related to blood disorders, obesity, alcoholism and drug addictions, cancers, etc.

Another company at HIMSS every year is Spectralink (Boulder, Colorado), the largest wireless telephone system currently installed in hospitals. These phones cost $1,000 per phone and feature a two-line, alphanumeric display of a few characters in length. These phones allow caregivers to speak with each other within a facility, or to dial outside numbers through the switchboard. The company has succeeded by expediting paging to nurses, which in an average facility can waste up to 900 hours per year. It also wastes up to 700 hours per year of physician time, when they are trying to reach nurses, or 500 hours per year of ward clerk time. The Spectralink phones eliminate such delays. However, its market niche is being encroached upon by new cellphone and personal data assistant (PDA) devices that integrate voice, data and paging on devices with larger, color graphical displays suitable for displaying waveforms, patient vital signs and even color imaging sequences.

Companies moving into the communications space occupied by Spectralink include Emergin (Boca Raton, Florida), with its Emergin Wireless Office. This product provides message dispatch, alarm notification and system integration with web-based messaging to pocket pagers, PDAs, wireless telephones and PCs. The product supports OAI, SMTP (email), SNPP, TAP and WCTP protocols. The system can handle up to 10,000 messages per hour, which would be fine for many hospitals, but somewhat limited for the largest health care enterprises. Another competitor is Dukane (St. Charles, Illinois). Its approach leverages any wireless telephone system by connecting it to their ProCare 6000 or 2600 nurse call systems. Popular phones compatible with Dukane's system include Spectralink, Ericsson (Menlo Park, California), Lucent (Murray Hill, New Jersey), NEC and Nortel (Alpharetta, Georgia).

If getting data about appointments, lab results, prescription refills, flu shots and referral authorizations to patients in an automated fashion is important to any health care enterprise, SmartTalk (Salt Lake City, Utah) is worth a look. Its product offers technologies specific to each notification modality, including recorded voice, synthesized speech, WAV files, HTML or just plain text. Multiple message to the same patient can be delivered sequentially or combined and delivered at once.

While much of the HIMSS conference focused on getting data into an electronic format and directing it into the hospital's clinical repository, companies such as MEDai (Orlando, Florida) were more concerned about helping hospitals mine the data for real-time clinical decision support as a means of reducing health care costs. The idea is to identify those patients who will become cost outliers and intervene early. The MEDai clinical decision support system (CDSS) has achieved impressive results at many hospitals. CDSS has been used to reduce length of stay for pneumonia patients by 39%, congestive heart failure patients by 38%, hip fracture LOS reductions of 2.3 days, myocardial infarct mortality by 4% and overall hospital mortality by 3%. It also has helped minimize charge master inaccuracies saving hospitals anywhere from $170,000 to more than $1.5 million per year.

eProcurement over the Internet also was a focus at HIMSS. Electronic business procurement and transaction processing is a struggling solution used by only 50% of hospital purchasing people. Of these, fewer than 30% describe themselves as "very happy" with their solution, although another 50% indicate they are "somewhat satisfied." This suggests there is room for innovative solutions, which several vendors at HIMSS were looking to provide. HIPAA itself may go a long way to making improvement by standardizing the transaction formats. One approach to cost-effectively making current electronic data interchange (EDI) applications compliant is to use a HIPAA interface engine, and See Beyond (Monrovia, California) was offering its for 834 (enrollment) and 837 (transactions) for claims at HIMSS. Lawson Software (St. Paul, Minnesota) was another vendor offering eProcurement solutions. The company was showing a range of web browser-enabled applications that allow a hospital to search multiple suppliers' catalogs, create requirement specifications, issue purchase orders and track transactions in real time.

The HIMSS exhibit floor had several vendors showing both smart ID cards and biometric ID security solutions. One challenge of all these systems is how to implement these without inconveniencing or slowing down health care providers. Keyware (Woburn, Massachusetts) offers a central authorization server that will run on Windows, Solaris or computers running Linux. It facilitates a one-point central server solution to managing user authentification and single-point sign-on with biometric ID using finger, face or iris plugins, along with PINs, passwords, PKI, tokens and other security methods that may already be in place today. Each machine has a companion SignOn application that interacts with the server.

Another newcomer to HIMSS, nSuite Technologies (Burlington, Massachusetts), exhibited its nSuite Privacy Shell, a set of applications that manage desktop security, including user validation (using biometric ID), application authorization (what the user is permitted to access) and proximity management (sensing when an authorized user is no longer at a workstation and it needs to be blanked or shut down). The product also provides a full set of audit trials to verify HIPAA compliance.

Another major focus at HIMSS was a topic that has received a lot of press lately — medical error reduction. Several HIMSS sessions focused on this topic. Donald Holmquest and Barry Chaiken ranked various errors leading to injury for medical and non-medical causes, as shown in Table 4.

Factors identified by the speakers as related to an increasing probability of error are processes that have multiple links and caregivers. The more complex the process, the more prone to error it was. Chaiken and Holmquest support the notion that computerized systems would enhance safety by improving legibility, providing real-time checks for known reactions, interactions, allergies and basic monitoring of the five Rs: Right drug, right dose, right route of administration, right patient, right time.

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