Cut the Cords

A procrastinator? Not D. Crawford Allison. There's a perfectly good explanation why the family physician just bought an EMR for his practice last year -- 14 years after he started shopping.

When he first became interested, "none of the ... products were built to go as fast as we go. We just saw too many patients each day to actually be able to use an EMR efficiently," says Allison, managing partner at 29-physician Hillcrest Family Health Center in Waco, Texas. "The technology just was not ready for anyone in family practice and primary care."

Hillcrest didn't have the money or space to put a PC in every exam room, and besides, the physicians would have been forced to log in and out with every patient encounter. Deal-breaker. "The last thing primary care physicians want to do is add time to their days," says Allison.

But the maturation of wireless technology is solving most of these problems, which is why Hillcrest finally took the plunge. Doctors there tap into the EMR via mobile tablet computers -- which are about the size of a clipboard and weigh only a few pounds -- instead of being tied to and paying for stationary desktop PCs for each exam room.

Once the realm of tech geeks and gadget junkies, wireless computing devices such as tablet PCs, personal digital assistants, and ever-shrinking laptops are becoming indispensable at many physician practices.

Like Hillcrest, many are finding it makes more sense to implement an EMR via mobile technology. Others are using wireless computing devices for point-of-care prescription ordering and clinical decision support applications -- software meant to guide physicians through up-to-date clinical protocols. Some are even handing wireless devices over to patients to streamline the patient registration process (and reduce workload for staff).

But hold on. Wireless applications carry plenty of possibility and panache, sure, but before you race to Best Buy you first need to assess your computing needs. You should also have a wireless implementation plan prior to passing out the goodies.

Worth the wait

Hillcrest chose a wireless local area network -- also called a LAN -- for its EMR. A router is connected to a main desktop computer or server and used to send radio signals to access points and then to the physicians' tablet PCs. Sound fancy? It is. But at $2,500 per physician, it was half the cost of a conventional hardwired system.

The physicians are using M1400 Tablet PCs from Motion Computing to go with their EMR from e-MDs.

For Hillcrest, wireless isn't just cheaper -- it's better. Consider the benefits:

Security -- Because the doctors carry the tablets around, they maintain control over them -- and the information they contain. Computers in the exam rooms might allow nosy (or bored) patients to go snooping while they wait for the physician to come in. Even if the system were protected by passwords, it's possible a doctor could forget to clear the screen after examining someone, letting Mr. Feldman read all about Mrs. Overmeyer's bursitis.

Patient communication -- With desktop computers, the doctors most likely would have to face the computer -- with their backs to the patients - while entering information. With the tablets, the doctors sit right in front of the patient, enter information, and have eye-to-eye conversations. "The tablet PCs allow us to communicate with patients just as if we were carrying the traditional clipboard," Allison says. "It's very natural. We can do the documentation as we are interviewing and discussing the situation with the patient."

Convenience -- With the tablet PCs, the doctors can work from any location. For example, Allison frequently sits in the conference room with his tablet to access information on the EMR or do research on the Internet.

Mark Richardson, a physician with Holt (Mich.) Family Practice, is reaping many of the same benefits by accessing an EMR from A4 Health Systems via one of Motion's tablets. He especially likes that he can use the stylus to illustrate medical conditions to his patients, something that is difficult to do on desktop and laptop computers.

"I have always been someone who would take a piece of paper and draw what is going on for the patient. Now, I can do that right on my tablet and the picture can become part of the medical record," he says.

Not just for EMRs

And wireless isn't just for EMRs.

The 70 physicians at Esse Health Clinic, St. Louis, are upping the ante on evidence-based medicine and electronic prescribing by accessing WELLINX ePrescribe via wireless tablets.

Physicians get integrated evidence-based clinical decision support relevant to the specific conditions being treated as well as condition-specific prewritten prescriptions as they treat patients.

"It is very liberating. You don't have to go to a stationary desktop computer. All this functionality just goes with you. So, you don't have change the way you practice," Chuck Willey, an Esse physician, says. "It provides a mobile solution to what we do most -- and that is diagnose and prescribe."

"It's a big plus to know that a system is in place to check for drug interactions," adds Tom Hastings, another of the practice's physicians.

All but two of the practice's 70 physicians are using the WELLINX application while only 15 are using the practice's EMR, which is accessed via desktop computers.

The mobile solution even enables the doctors to identify and then sell appropriate low-cost generic drugs through an in-office dispensary. As a result, patients who don't have prescription benefits through their insurance plans and can't afford branded drugs are now purchasing their needed prescriptions at a lower cost. At the same time, the practice has an additional source of revenue.

Getting patients into the act

Although many wireless applications zero in on doctors' work processes, front-office staff and patients are joining in. Woodhams Eye Clinic in Atlanta hands patients a tablet PC from ViewSonic.

 Here's how it works: When a patient walks in, the receptionist hands the patient a tablet PC loaded with registration software from Galvanon instead of clipboard overflowing with paper. The patient inputs her medical history and registration information. In addition, patients swipe their insurance card and a credit card and the device automatically collects the required copayment.

"It saves us so much time during the intake process. We don't need to have a staff person collect the information, copy the cards, and scan and input all of the data into our system," says Jan Granum, LASIK coordinator at Woodhams.

Eventually, the system will integrate directly with the clinic's EMR, completely eliminating the need to download data from one system to the other.

Using the tablet PCs makes it possible to offer the service in waiting rooms, which often don't have the space for wired desktop workstations. Plus, the patients feel more comfortable working with the tablets, which offer more privacy than desktop computers. Best of all, however, patients are able to complete the paperwork 40 percent quicker than using paper -- getting them out of the waiting room faster.

If you want to try it, make sure all your PCs come back when registration is done. They are just cool enough to entice itchy fingers.

Check for problems

Wireless applications certainly are cool, but that shouldn't push physician practices to adopt the technology. Practices should first analyze the applications that they want to run -- and determine if there is a true need for mobility before investing in wireless networks and devices.

Also, you'll need these components:

• An Internet connection, delivered via a T1 line, cable, or DSL modem -- not slow-as-molasses dial-up.
• A router, which is connected to the modem and used to send radio signals to the wireless devices.
• Wireless access points, which are used to boost reception at various points in the practice's office.
• Wireless network PC cards (internal or external), which are used to enable the wireless devices to tap into the network.
• Antivirus software and a firewall, which are used to protect the network from being unintentionally used by third parties or intentionally used by hackers.

Although setting up a wireless network is seemingly straightforward, most medical groups have had to deal with a number of obstacles, including:

Inadequate reception -- Getting optimal reception in all areas of the office proved troublesome for both Holt and Hillcrest.   
"Our building was built in the 1940s. So, there is chicken wire behind the plaster, which causes a lot of interference in the network," Holt's Richardson says. To solve the problem, he had to experiment and move around the access points.

Hillcrest's Allison was able to boost reception to the tablet PCs by switching from internal network PC cards to external cards.

Dropped connections -- Allison also discovered that interference from a cordless phone that was being used in a different office caused the practice to constantly lose the wireless connection. The practice had to make sure that the wireless system ran on a different frequency than the cordless phone.

User adaptation -- Although most doctors and staff members are able to quickly learn how to use wireless devices such as a tablet PC, some experience difficulties, says Allison.

"You need to have some dexterity in your hands. It takes a little training and effort to get there. While most of us have been able to master the pen tablet -- and can actually work faster on a pen tablet than on a desktop computer -- we do have an older doctor and an older nurse assistant who simply don't have the eye-hand coordination to do it," Allison says. These staff members will continue to access applications via desktop computers.

System maintenance -- Check-ups are required to keep wireless systems running optimally. Allison routinely taps into the expertise of the practice's information technology technician to make sure that the wireless system is up and running smoothly. Smaller practices, he says, should consider hiring a certified wireless technician to periodically check the system to make sure it is running properly. 

John McCormack can be reached at editor@physicianspractice.com.

This article originally appeared in the April 2005 issue of Physicians Practice.