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    The Medical Palm Review

    October, 2005 (V6N8) - Something In The Air

    Wireless technology is everywhere, except in hospitals. Are we Luddites? Nope, just careful. But just how much trouble can cell phones and networks cause?

    Promises, Promises

    First the good news. Wireless technology has all kinds of interesting potential in health care settings. For example:

    • Wireless networking potentially lets you bring the patient's entire health care record to the bedside, clinic or on a housecall. If the wireless devices can be used to order tests as well as review results then ward rounds would be radically expedited.
    • No more telemetry beds in your medical ward? Move a few wireless monitoring devices and a wireless webcam into any patient room. Monitor the patient from the nursing station down the hall or from a handheld computer. Need to go to the bathroom? Have staff at a nursing station on a different floor or even in a different building keep an eye on your patients' wireless monitoring systems - distance is irrelevant to the web-based software. Of course this won't work if you think you need physical proximity to the patient for safety reasons.
    • Voice Over Internet Protocol devices (VOIP) could replace your cell phone, desk phone, pager, and PDA. Even better, a pager notification could now include a text note, a voice message, a link to data in the health record, and so forth. More detailed messages would make it easier for recipients to prioritize return calls. Pocket PC users can use the popular Skype software to make and receive phone calls. You could use wireless PDAs as videophones as well.
    • Wireless handheld devices could also help link prescription-writing to pharmacies, and dictated notes to transcription services.
    • We could also use wireless technology for patient notification and reminders about appointments, follow-up of test results and more. Patients could carry around their health care record and giver permission to providers to access the information when required.
    • Radio Frequency Identification (RFID) tags could replace bar codes to identify hospital equipment and supplies. Similar tags in patient armbands and staff ID badges would help monitor people. With a network of tag reading devices in elevator lobbies, corridors and clinical areas you could perform inventory checks in real time. Need a few wheelchairs? Wandering patient? Melding a network of tag readers with GPS and a handheld computer with site maps would enable staff to find anything and everything anywhere in the site.
    • Alternatively, you could use WiFi tracking technology instead of RFID, as in South Carolina or Washington State. This strategy dispenses with specialized tag readers and relies upon wireless access points instead. Since the wireless network can also be used for other applications it may be more cost effective.

    Of course, all this snazzy gear costs money. Not everyone agrees that it is money well-spent. RFID may not be cheaper than bar-codes, according to Spyglass Consulting. Portable records can also be carried on USB key drives or smartcards. Wireless networking is never the only option for any one of the tasks noted above. The most value comes from the integration of WiFi into so many parts of health care delivery that it becomes indispensable infrastructure.

    What You Don't See Can't Hurt You

    I don't know how many times I have been told that electromagnetic fields and broadcast energy from cellular phones, wireless computing devices and radios interfere with medical equipment. I had never really looked closely at the basis of these claims. But then one enthusiast of VOIP telephony told me that this was "safer" for the hospital environment than old-fashioned mobile phones. I thought that a strange assertion: both are basically high-frequency radio technologies. So I did a MEDLINE search. I found many research articles on the vexed question of whether cellular telephones were a menace to life support equipment.

    The most recent systematic review on the subject is from Australia. The authors conclusions were that at least 4% of any devices tested (in the studies they reviewed) were vulnerable to electromagnetic frequency interference (EMI) from cell phones. Restriction of mobile phone use in hospitals, such as keeping back at least one metre from equipment or avoiding cell phone use altogether in clinical areas, was recommended by all the studies under review. (Lawrentschuk N, Bolton DM. Mobile phone interference with medical equipment and its clinical relevance: a systematic review. Med J Aust. 2004 Aug 2;181(3):145-9).

    There have been numerous interesting, although small scale, efforts to study modern medical equipment and cellular phones. Here are some I found particularly interesting:

    • Jones RP, Conway DH. The effect of electromagnetic interference from mobile communication on the performance of intensive care ventilators. Eur J Anaesthesiol. 2005 Aug;22(8):578-83. Summary: at distances of less than one metre, high power two-way radios caused significant problems (e.g.. shut down one ventilator); medium power cell phones caused some ventilator displays to give erroneous readings; Bluetooth devices were innocuous.
    • Irnich W, Tobisch R. Effect of mobile phone on lifesaving and life-sustaining systems. Biomed Tech (Berl). 1998 Jun;43(6):164-73. Summary: most devices (1997 era) are immune to EMI from cellular phones at distances over one metre. Cordless phones (higher power) need 1.5 metres of separation. Shielding and other measures would be prudent for devices which will be used outside the hospital environment.
    • Shaw CI, Kacmarek RM, Hampton RL, Riggi V, Masry AE, Cooper JB, Hurford WE. Cellular phone interference with the operation of mechanical ventilators. Crit Care Med. 2004 Apr;32(4):928-31. Summary: at distances of less than 30cm some mechanical ventilators can be shut down by EMI from cellular telephones. Safety at distances of at least three feet makes it reasonable to use cellular phones in ICU setting.
    • Fung HT, Kam CW, Yau HH. A follow-up study of electromagnetic interference of cellular phones on electronic medical equipment in the emergency department. Emerg Med (Fremantle). 2002 Sep;14(3):315-9. Summary: compared to 1997, later model PCS phones have no impact on a range of ED equipment except in a few isolated examples and at very close proximity.
    • Trigano A, Blandeau O, Dale C, Wong MF, Wiart J. Reliability of electromagnetic filters of cardiac pacemakers tested by cellular telephone ringing. Heart Rhythm. 2005 Aug;2(8):837-41. Summary: current model implantable pacemakers are resistant to interference from ringing cellular phones.
    • Hekmat K, Salemink B, Lauterbach G, Schwinger RH, Sudkamp M, Weber HJ, Mehlhorn U. Interference by cellular phones with permanent implanted pacemakers: an update. Europace. 2004 Jul;6(4):363-9. Summary: "Anticipating a correct setting of ventricular sensitivity, currently available pacemakers equipped with feedthru filters do not show any interference with cellular phones." There was, however, interference from the tested GSM phone with some pacemaker models when the latter were set at very low ventricular sensitivity.
    • Kanz KG, Kay MV, Biberthaler P, Russ W, Lackner CK, Mutschler W. Effect of digital cellular phones on tachyarrhythmia analysis of automated external defibrillators. Eur J Emerg Med. 2004 Apr;11(2):75-80. Summary: "Shock advisory systems of automated external defibrillators are not susceptible to electromagnetic interference of 900 MHz cellular phones. Voice prompts, however, could be distorted by the operation of nearby digital mobile phones. During automated external defibrillator training this issue needs to be addressed."
    • Deji S, Nishizawa K. Abnormal responses of electronic pocket dosimeters caused by high frequency electromagnetic fields emitted from digital cellular telephones. Health Phys. 2005 Sep;89(3):224-32. Summary: when radiation workers' cell phones were transmitting, their digital dosimeters gave falsely high readings.
    • Djajaputra D, Nehru R, Bruch PM, Ayyangar KM, Raman NV, Enke CA. Cell-phone interference with pocket dosimeters. Phys Med Biol. 2005 May 7;50(9):N93-9. Epub 2005 Apr 13. Summary: Simple measures, such as positioning radiation dosimeters farther from the cell phone, and putting dosimeters inside antistatic bags, were sufficient to prevent interference.

    Bottom line: wireless telephones can make trouble for life support equipment under the right conditions. The solutions: build medical equipment with better shielding (which is already happening) and keep cell phones at a distance from patients (requires clear policies and training as well as staff vigilance).

    As for WiFi or VOIP, although they use similar frequencies to some mobile phone technologies, there is not much published information about their potential to disrupt medical equipment. We can take similar precautions as with cell phones - but keeping WiFi at arm's length from the patient or health care worker diminishes the perceived value.

    Lock Up Your Valuables

    What are the security risks of using WiFi and VOIP instead of hardwired computer networks and plain old telephone service (POTS)?

    The most obvious concern for privacy and data security of hospital records is plain. It takes careful planning to prevent someone in the hospital parking lot from snooping into the wireless network. Handhelds are easier to steal than desktops. How do you prevent theft of patient data that is on such devices if they walk out the door?

    As handhelds and smartphones become more powerful and ubiquitous, expect more malicious programmers to take a run at them. Security issues (viruses, Trojans, fraudulent messages) that are all too familiar to desktop PC users now will become a problem for mobile users tomorrow.
    The Cabir worm and Skulls Trojan for Symbian phones showed it can be done. Even handhelds that are not primarily telephones but which link to the Web, that have computer-like functions, or that synchronize with desktop computers are all vulnerable. This covers alot of existing and planned devices and systems.

    In addition, as handhelds get more powerful, they will increasingly share file and data formats with their desktop brethren. Already one can edit a MS Word or Excel file on a PDA. As we exchange or synchronic e-mail and data files with with other computers, we may help passively spread nasty attachments, Word macro viruses, etc.

    The security risks may not be fatal but they will need countermeasures. Firms such as McAfee, Symantec and Trend Micro all sell software to help protect PDAs and Symbian handhelds.

    OK, Maybe It Can Hurt You...

    Equipment may be vulnerable, but how about flesh? Quite apart from potential interference with pacemakers and implantable defibrillators, can these devices have negative effects upon the health of users or bystanders? Is there even a "secondhand smoke" effect on children standing nearby?

    There have been numerous investigations of potential links between cellular phone use and illness. These have been reassuring, although limited. Read more in these articles:

    • Habash RW, Brodsky LM, Leiss W, Krewski D, Repacholi M. Health risks of electromagnetic fields. Part II: Evaluation and assessment of radio frequency radiation. Crit Rev Biomed Eng. 2003;31(3):197-254.
    • Breckenkamp J, Berg G, Blettner M. Biological effects on human health due to radiofrequency/microwave exposure: a synopsis of cohort studies. Radiat Environ Biophys. 2003 Oct;42(3):141-54. Epub 2003 Sep 24.
    • Krewski D, Byus CV, Glickman BW, Lotz WG, Mandeville R, McBride ML, Prato FS, Weaver DF. Recent advances in research on radiofrequency fields and health. J Toxicol Environ Health B Crit Rev. 2001 Jan-Mar;4(1):145-59.
    • Valberg PA. Radio frequency radiation (RFR): the nature of exposure and carcinogenic potential. Cancer Causes Control. 1997 May;8(3):323-32.

    Researchers have no fundamental theory about how radiofrequency radiation should affect biological materials (read: humans) except by tissue heating. Since cell phones and WiFi devices use very low power, their ability to microwave us would seem to be limited. But there has been new work on the question of non-thermal effects. Although they are inconsistent, they cannot be completely dismissed. Better research is needed and is trickling out and is not always reassuring. These articles are worth perusing:

    • Kuster N, Schonborn F. Recommended minimal requirements and development guidelines for exposure setups of bio-experiments addressing the health risk concern of wireless communications. Bioelectromagnetics. 2000 Oct;21(7):508-14. Summary: criticizes the value of existing research recommends better study design parameters in order to get worthwhile answers.
    • Gaber MH, Abd El Halim N, Khalil WA. Effect of microwave radiation on the biophysical properties of liposomes. Bioelectromagnetics. 2005 Apr;26(3):194-200. Summary: EM fields caused by microwave radiation caused non-thermal changes in liposomes. Clinical significance was not determined.
    • Simko M, Hartwig C, Lantow M, Lupke M, Mattsson MO, Rahman Q, Rollwitz J. Hsp70 expression and free radical release after exposure to non-thermal radio-frequency electromagnetic fields and ultrafine particles in human Mono Mac 6 cells. Toxicol Lett. 2005 Sep 6. Summary: a variety of factors in "electrosmog" have an impact on free radicals.

    But researchers have also discovered a much more insidious problem (Maier R, Greter SE, Maier N. Effects of pulsed electromagnetic fields on cognitive processes - a pilot study on pulsed field interference with cognitive regeneration. Acta Neurol Scand. 2004 Jul;110(1):46-52). This is the study that got everyone talking last year, as it showed that 9 out of 11 test subjects performed worse on a cognitive task after exposure to pulsed GSM EM fields. Apparently cell phones can make you stupid. Who would have guessed?

    Clearly, there is still much to consider about the safety of wireless systems. All the EM emissions - natural, TV, radio, microwave, cellular phone and all the rest - have turned the world into a giant laboratory experiment with effects that we have not even hypothesized and cannot yet predict. In this context, are wireless medical systems a good idea? Sober stuff indeed.

    Department of Corrections

    I am indebted to Andrew Schechtman at MeisterMed again. In last month's issue I asserted that iSilo was available for RIM Blackberry. Andrew pointed out that this is not correct. He sent a link to a posting from the official iSilo Forum from April 2005 to prove his point.

    I also forgot to mention that now iSilo can read plain text files on your PDA's external memory card (if you have one). This makes it easy to share data with your PC. For example, using the File Link function in the Palm Desktop application you can maintain a text file on the PC and have it automatically updated on the PDA each time you HotSync. iSilo can actually open any file on a VFS memory card and display it as plain text. This is not useful for most formats (it won't allow you to read the information in a spreadsheet or view a picture file) but it will let you examine the file's Creator ID. This will help you find out what application actually uses the file in question.

    My wife pointed out that I forgot to mention one of the best things about taking a PDA on a cruise: using it as a flashlight to find the loo in the middle of the night in a pitch black, gently rolling, oceangoing hotel room - without waking the rest of the family. Of course, you only get sixty seconds to actually find the head before the battery saver kicks in and turns off the screen backlight....

    That's it. That's the first use my wife has found for PDAs in eight years.

    Medical "Doc" of the Month

    Rashes can be tough diagnostic challenges. Now there is help. You can choose between two iSilo files each with its own unique strengths.

    DermMesiter regional indexDermMeister is the latest free medical reference tool from MeisterMed. It divides rashes systematically in three ways: alphabetically, by body region, and by category. Within each category there is a brief description and thumbnail illustrations that can be enlarged with a tap of the stylus.

    Marc Roy created an iSilo file called Rash Algorithm with a diagnostic algorithm originally published in Annals of Emergency of Medicine in 1984. The algorithm helps one to diagnose difficult rashes. Subsequently he added numerous illustrations which are not, however, accompanied by any notes. The file is available from various download sites on the web.

    The diagnostic algorithm is very handy but the DermMeister illustrations and thumbnails are handier. My recommendation: download both files onto your PDA if memory permits.

    Nuts and Bolts

    Pen Computing offers reviews of PDAs and smartphones. In August WindowsSecrets listed forty recent product reviews from the Pen Computing site with links to pricing information. You may find what you are shopping for at these sites.

    But the biggest news in wireless this month has to be the announcement at the end of September that Palm would make a new version of the Treo smartphone with Pocket PC operating system instead of their own Palm OS This is a sweet victory for Microsoft which as recently as three years ago was a distant also-ran in the PDA stakes. But recently individual consumers buy far fewer PDAs and so most sales are to bulk buyers at large corporations. And they prefer the transparency of WinPC-to-PocketPC.

    The other winners are companies which manufacture cell phones. Their new devices have PDA-like features and a camera as well as telephony and paging. Individuals who might once have considered a handheld computer are flocking to these fancy gadgets instead.

    No wonder Palm PDAs are becoming niche products. If hospitals and health care services start using VOIP and other wireless devices then even that niche will be threatened. Whatever will I call this newsletter in a few years time...?

    Hack of the Month

    I want to check how websites look on my Kyocera PDA. I have wireless Internet access but it would cost air time minutes to log on that way. Is there another way?

    Fortunately, in the past I learned to plug my old Handera PDA into its cradle and use the desktop PC's Internet connection to funnel web pages to the handheld. Since my desktop uses a broadband connection that is paid by the month, I found this a cheap way to do some testing. Of course it wasn't exactly mobile, but I was interested in testing only.

    The serial port drivers for my Handera cradle could do that if I used MochaPPP, an inexpensive little program that lets browser and e-mail software on the PDA use the desktop PC's Internet connection.

    I reviewed MochaPPP in a previous issue (Nov, 2002 - V03N10) when I used older model PDAs which relied on the serial port for their connection to the PC, but the program has not kept pace with new developments in Palm hardware. It does not support USB ports, for example. It also doesn't like many Sony Clié models. I could use a serial port instead of USB for my Kyo HotSync cradle but that would slow down the connection and wouldn't help my Clié either.

    Configuring SoftickPPP, For newer devices, the solution is SoftickPPP, which picks up where MochaPPP left off but can handle USB ports. It works like a charm. All that's needed is to configure my Handheld's Network Preferences to access the Internet via its cradle rather than its wireless modem.

    After this tweak, when I want to scope out a URL, I put the Kyocera in its cradle, which is plugged into a PC with broadband Internet access. I can then browse all I want. Handy if I want a way to evaluate how a web site looks without racking up my phone bill.

    What's more, using SoftickPPP I can download my e-mail during a HotSync, and read it while going to work on the subway. In Toronto I cannot access e-mail (or anything else) wirelessly when riding the underground trains. I can fire off my replies when I get back to the office to my HotSync cradle again. It's not instant messaging but it suffices for most mail. If I do need to get deal with e-mail more promptly then I use the Kyocera's wireless modem. Thus I get the best of both worlds.

    I should add that I learned how to do this after reading the manual that came with the Kyocera smart phone. Sad but true, after more than two years I had only cherry picked some parts of the more than two hundred page booklet. This month I actually read the whole thing cover-to-cover. I learned about many neat features that had escaped my notice before. RTFM is a motto to live by.

    Of course, I could also use the Palm Emulator or Palm Simulator, with a appropriate software loaded, to browse or get e-mail while using my desktop PC, and no need for SoftickPPP either. But those two apps need some configuring to get them to access the Internet through the host PC so it's a zero sum game.


    Did you know that all the links in this newsletter are accessible by righ clicking on the underlined text of the link you are interested in? Just right click then Copy Link Location. This it's pretty easy to recover any particular link. I hope that this will make it fairly painless for those of you who want to see the full URL rather than just click on the links in my text.

    What this is leading up to is that I am going to stop posting separate links listings at the end of each issue. It is a fair bit of extra work and (what's more serious) changes the appearance of the Review site.

    I will review this decision in a few months and restore the listings if I get strong feedback from you, gentle readers, expressing an interest in having them back.

    In Times to Come

    So, now that I have got my wireless PDAs all souped up, what is wireless good for? I mean specifically. Surprisingly, I can get a fair bit of mileage out of wireless even though it is not deployed at work.

    We'll also look at creating web pages for small screen devices. There is help available for creating sites that work.

    Until November, then, enjoy!

    This is one of a continuing series of newsletters about Palm handheld computers, prepared for doctors, nurses, IT professionals, educators and other people who need tools that work. The Review is published monthly on our web site. Subscription is free; the principal benefit is receiving e-mail notification of new issues.

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