March, 2006 (V7N3) - HIMSS report

Do American health care computing firms disrespect Palm handhelds? More importantly, do they give away any cool Palm freebies at conferences?

Big, Bad and Busy

The annual HIMSS (Healthcare Information and Management Systems Society) conference is an opportunity for health care professionals, administrators, and computer folk to meet and exchange ideas. It also offers a massive trade show where vendors of everything from complete hospital management software systems to little carts for laptop computers are displayed and promoted.

I have been meaning for some years now to attend one of these shindigs. My Emergency Department is a heavy user of computer technology. I am involved in planning for mass casualty incidents in my community, and that also involves communication and computing tools. Last, but not least, I also write a newsletter about using Palm PDAs in health care. This year (the sixth annual event), HIMSS offered me something in all those roles.

Speakers were lined up for such topics as patient tracking, remote monitoring, electronic health records, mobile computing and pandemic surveillance. More than eight hundred vendors were signed up to present their wares. I was advised by friends that these vendors would offer discounts and give away all sorts of trinkets and freebies.

At the conference site there would be free workstations for downloading speaker notes and presentations, and for Internet access. The registration package also promised a local WiFi network for wireless access to the Internet. My hotel claimed to have free broadband Internet in each guest room, as well as a business centre with PC and printer. For a tech nerd like me, it seemed like the foundations had been laid for a week of serious tinkering without the distractions of walking the dog, household chores or patient care.

So in February this year I packed my bags and headed down to San Diego. The conference lasts about a week so I planned to travel light: a few drip-dry shirts, a change of slacks and a sweater would take care of the wardrobe. I decided to bring my laptop to keep up with e-mail, work on this issue of the Review, and do some other work. Unfortunately, once I packed the power transformer, the external CD drive, the memory card reader and a few pens my luggage had doubled in weight.

Did I really need the laptop or could I get away with just a PDA and some accessories? And, because I try to be a "belt-and-suspenders" kind of guy, what would be my backup in case my PDA stopped working? I did a little testing before I left and came up with the following:

• text editing. No way I was going to use the Treo 650's tiny built-in keyboard for text editing. Last month I noted that my folding Targus PA870 and Palm Portable keyboards were not compatible with the Treo 650. But they did work well with my old Handera HE330 PDA. This PDA with a folding keyboard and QuickOffice word processing software made for a twelve ounce word processor that could fit in a jacket pocket. Backup plan: use the hotel business centre PCs for editing files which would then have to be copied back to a memory card on my PDA. With a USB cable and SofTick's Card Export software I can copy files between the Treo and any PC with a USB port. The Treo can swap memory cards with the Handera. Perfect.
• e-mail and Internet access. No problem for my Treo smartphone although Bell Wireless wanted to charge me a frightful roaming fee: $0.33 per minute long distance (voice) and more than $1.00 per minute (data). Better plan: the HE 330 has a wireless networking card that eats battery life but is quite robust. It also has e-mail software and I added the Eudora browser. Access to my e-mail through the convention's wireless network would be free of charge. Backup plan: the PCs at the convention centre or my hotel's business centre would have high-speed Internet access and PCs.
• hardware redundancy. Both the Treo and the Handera have voice recorder capability. They can share Secure Digital memory cards. Appointments or contact information can be beamed from one to the other. The Handera will run for three weeks on a set of AAA batteries. Overall, a second PDA provides good backup and redundancy. Additional backup: Card Export software, as noted above, provides extra file copying capability.
• Palm data backup. Both the Handera and Treo can backup their internal memory onto an external memory card - but they don't share the same software or file formats. Backup plan: cut and paste important data to e-mail messages or attachments and send them to myself. In other words, use my e-mail account as a sort of online storage facility.

Other considerations:

• conference speaker notes. HIMSS organizers made all the speakers' notes available as Adobe PDF files before the conference. I could download them onto a laptop PC. Or I could copy them to a PDA memory card, install PDF reader software from Adobe (see more under Nuts and Bolts, below) and take the files along that way. Backup plan: print the notes at workstations in the conference centre.
• digital camera. The Treo's internal digital camera was just about good enough to take snapshots of hardware or brochures of interesting products on the trade show floor. So I left my Canon at home.

In the end, I was left with a small stack of two PDAs, a folding keyboard, a recharging/HotSync cable and a few matchbook-sized SD memory card cases. The bottom line: I traded a fifteen pound laptop case for about one and a half pounds of gear in my coat pockets. And that's what I packed to take with me.

Travel Can Be Broadening

The trip got off to a good start when I breezed through airport check-in and security with no problems. I even saved some money during the flight to San Diego because I had an adapter to plug stereo headphones into the Treo's nonstandard socket. The adapter let me plug my headset into the plane's armrest socket for the in-flight movie. I saved USD5.00 which I used to get an ersatz roast beef sandwich. Next time I need to find an airline with real in-flight food.... When the movie was over I pulled the adapter out of my armrest and plugged it back into the Treo to listen to some MP3 music files.

Once in the USA I used the Treo to call home (cheaper than the hotel phone) but not for checking e-mail. The convention and hotel PCs provided good service without too much standing in line. I was a bit worried about someone spying on my password entries, but nothing happened. Of course, once I got home I changed all my access passwords anyway. Meanwhile, it was easy to check e-mail daily.

The HE330 and its wireless card worked very well once the convention support staff got over their amusement at my unique five year old PDA-wireless setup. They cheerfully kept waiting a legion of salesmen with uncooperative laptop PCs while they huddled over my antique gadget. At one point they even logged onto the Handera website for information. Remarkably, Handera maintains their PDA site even though they stopped making handhelds in 2002. Great company. What a pity they bowed out of the market.

Once we figured out the Handera's setup, the wireless network proved to be functional albeit slowed at times by the thousands of users. On a good day I could walk into the convention centre, turn on my HE330 as I stepped onto the escalator, and retrieve my e-mail from three different accounts before arriving at the second floor.

Each day I would leave my hotel with my PDAs. The daily schedule had been entered into my PC in Toronto then HotSync'ed to the Treo. Once in San Diego I had beamed the events to the Handera also. I could look at either device to see where I was supposed to go next. I could use the Adobe Reader software to review the speaker's notes beforehand. During the presentations, I could take notes on the Treo. At breaks I could take out the HE330 and the folding keyboard to write longer notes. However this setup is much less convenient for balancing on one's lap - a table is required if you are not to lose your sanity.

At the end of the day I would have most of my work already in order and could take an hour to plan for the next day's activities. Meanwhile, for the entire week, nothing crashed, broke or died. Overall, the PDAs held their own against laptop computing.

Lessons Learned

The conference was not geared to mobile computing in a narrow sense. There was discussion about the US Army's new electronic health record system that let's them access information on their millions of patients anywhere in the globe, including at sea or in the air. Most vendors of electronic medical record systems touted the ability of clients to use desktops, laptops, tablet PCs, and even handhelds to access the chart.

Palm was there with a large booth at which a few Treo 650s were raffled off daily. This attracted a large crowd for each raffle but everyone wandered off after the winner collected the prize. And many medical software partners only came by a for a few hours each day. Somehow I expected a bit more enthusiasm.

Despite that complaint, Palm does have a good story to tell, mostly revolving around its Treo line or the models which use wireless networking. Hospital or clinic electronic Health Record (EHR) systems such as BlueWare's Wellness Connection, can share data with staff via their PDAs. Similar capabilities can be found in McKesson's Horizon MobileCare products (test report messages and rounding). PatientKeeper enables PDAs to handle incoming data and also permits uploading dictation or templated notes for clinical encounters, prescribing and rounding tasks like patient handover. All of these products interact with PDAs wirelessly, by cellular telephony, or via HotSync. They use security measures like message encryption, user authentication, purging data from the PDA and locking out users after multiple log-in failures.

For software systems which don't intrinsically support handheld devices, a number of firms such as MercuryMD provide the interfaces and middleware to connect handheld devices to patient data. The company likes to describe its solutions as "vendor agnostic", meaning they can get anything to talk to your PDA via any wired or wireless technology.

I didn't spend all my time on the trade show floor. Presentations and seminars by physicians and corporations yielded lots of interesting ideas. For example research into PDA form factors revealed that outpatient clinic or office doctors preferred tablets to PDAs but hospital doctors preferred PDAs. Usage surveys continue to find that Palm devices are more popular than Pocket Windows by a wide margin. The popularity of tablets is due to the largish screen to facilitate data review and text entry. PDAs are preferred for their light weight and ease of use.

Clearly, the perfect mobile device for all users has not arrived yet. One wag suggested that if your PDA had a HUD (Head Up Display) affixed to your eyeglasses you would simulate a large PC screen but still have hassles entering handwritten notes.

Infection control issues were mentioned in passing during one seminar. The role of PDAs in transmission of infection in the hospital environment has not been extensively studied but may be comparable to other indirect vectors such as keyboards. Greater risk may be attributable to shared devices (more than one set of hands touch them), and mobile computers (because they move from one patient care area to another with the caregiver). Tablets may riskier than PDAs as they are more likely to be put down on a contaminated surface due to weight when one needs to examine a patient, etc. If the caregiver needs to wear protective clothing (isolation or decontamination areas) one panelist suggested putting PDAs in a ziplock bag: still accessible but less likely to be contaminated.

Related technologies that will continue to enhance the role of mobile computers in medical care were very popular at the show. RFID systems to track patients medications, hospital equipment were offered by vendors and integrators of all descriptions. Bar-code label generators and scanners continue to be popular. Every imaginable type of wireless networking was on offer. Readers and scanners that attach to PDAs were in evidence.

Tablet computers were displayed at a few booths. As I get older, the thought of hefting three or five pound computers around for a whole day ever more discouraging. Still, I like the large screens. If they ran Palm OS and were easier on my arm I might give them a try.

Content providers for handhelds were not well represented at this convention. Skyscape had a booth. They were offering institutional discounts on purchases of their reference tools. They also handed out CDs with demo versions of many products, such as The 5 Minute Medical Consult.

Now that I am back, it's time to take stock. Was the trip worthwhile? Well, I got about a dozen good ideas for my department and hospital. I got some leads on gear for future disaster training exercises. I found all the source material for this issue of the Review.

I also escaped walking the dog for a whole week.

On the negative side, I think that there was less at this conference for front-line providers like me than there is at events like EMS Expo. This year it will be held in Michigan during April. My feet are still tired so maybe next year....

Another finding was that my junk e-mail count went from a mere twenty per day to one hundred and twenty per day within a week of the show. Coincidence?

On the Palm front, I saw little to suggest that handheld devices are the paradigm of the future. They are still handicapped by screen size and battery life issues. But at least vendors are making patient care data accessible to mobile workers and thinking about the problems.

Medical "Doc" of the Month

Bones of the Human Body for the PDA is available on Memoware. This is a database of all the bones in the human body and their anatomic location. This is in Mobiledb format. A converted version to HanDBase format is supposed to be available at The PalmDoc Chronicles but I was unable to locate it.

The solution is to do it yourself. Get DBConvert from Land-J Technologies or PDBConverter.

Both Memoware and PalmDoc have masses of other PDA goodies and news. Bookmark 'em, Danno.

Medical Computing

Imagine your ICU physician team as a flying squad. Sure they have a home base in the unit, but they also use high-tech linkages to all the floors so they can monitor patient vital signs and see patients with webcams. They also receive alerts based on preset filters for lab results, and patients who fit certain high risk parameters. Clinicians are able to request a consultation with an intensivist but the ICU doctors, nurses and respiratory therapists can choose to be only a telepresence, using the hospital network to gather clinical data, or may attend at the bedside in person, relying on cell phone, pager or PDA to alert them to problems with the patients temporarily left behind in the ICU itself. There will even be occasions when the squad will come to your ward unannounced because they have been alerted to abnormal parameters in a patient's vital signs or lab results.

Sound like science fiction? Well, they are already building variations on this theme at a hospital near you. VISICU is promoted as a solution to the "crisis in critical care". There were at least six vendors of such systems, and several speakers on the topic, at HIMSS. The idea seems based in part on the notion that regular ward staff are not picking up on critical situations until patients deteriorate to the point of needing ICU admission. If ICU staff could just intervene earlier, then patients would be rescued and expensive ICU beds could be reserved for other sorts of problems.

Whether you think this is the way to go or not, as long as staff shortages and financial restrictions apply, this strategy is bound to become more popular.

Nuts and Bolts

The phone and sound recording features in the Treo 650 have all sorts of interesting potential. I explored this a bit this month but I am still tinkering.

I found some very useful tools that exploit the sound or the cellular features of the Treo. Central for Treo is a very clever suite of utilities. Besides alarms and the ability to set Do Not Disturb intervals, it also has the SMS Kill Pill which will delete all your data and reset the handheld. SoundRec turns the Treo 650 into a dictation device that can use a SD card for the recordings. Also, record calls on your Treo using CallRec and an SD card. Check PalmLoyal for the Callrec software and a review. mVoice records voice notes and phone calls.

The MP3 music files I create for my Treo (or even for my PC) have a variety of tags embedded with info about the artist, the album, the date, and other comments. To edit the tags after the fact requires an editor. Mp3tag is the best one I have found so far.

Hack of the Month

There are now several ways to read PDF files on your Palm PDA. Adobe have their free Reader of course. Freebie PalmPDF as well as commercial products RepliGo and Documents to Go also have the ability to view these files. Look at the very interesting comparison on the handheldsfordoctors site? The author clearly favours RepliGo over the Adobe Reader. Which is truly best? My major beef with PalmPDF is its big file compared to Adobe but it can be moved entirely onto a memory card. Adobe requires you to convert PDFs before installing them on the PDA. PalmPDF just requires you to copy the PDFs onto a memory card. Conversion on the fly is not too slow.

How many PDFs do you need to read with your PDA? If the answer is not many then perhaps you can stick with the somewhat quirky PalmPDF interface. If you want more bells and whistles and need to view PDFs frequently, you may prefer to spring for the commercial stuff.

A note about memory. PDF readers for the Palm are rather like game emulators: they need lots of memory and if they don't get it you may not be able to view your document. A PDA loaded with software is likely to be short of elbow room.

The maker of PalmPDF encourages you to try memory managers and dynamic RAM resizing - FHR (Fargo Heap Resizer) for older Palms or UDMH (Unlimited Dynamic Memory Hack) for newer models. Theoretically these programs help to scavenge extra dynamic memory. This facilitates running large programs or multitasking (eg. playing music while browsing the Internet) but, in the case of UDMH, at the risk of overwriting other programs' data with exciting consequences. Try these at your own risk and only after a complete backup. Please note that a HotSync is not a complete backup for purposes of this discussion!

In Times to Come

Next month we will take our show on the road -- again. I am going on holidays and will take the same set of PDAs and accessories. This time I won't have access to so many backup systems. And I will need to take and store lots of photos with my digital camera. How is this going to play out?

Stay tuned....

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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