11 Disruptive Technologies That Will

Change the Face of EHRs—and How

Your Competition is Using Them

Quintin Armour, Didier Thizy

October 2010
2
 Table of Contents
Introduction ................................................................. 5

The Tablet PC ............................................................... 7

Smart Phones ............................................................10

Touch Screens ........................................................... 13

Digital Ink ................................................................... 16

Voice Recognition ...................................................... 18

Patient Health Records (PHR) .................................... 21

UI Design and Rich Internet Applications ...................23

Clinical Decision Support ...........................................27

Mobile Home Care Devices ....................................... 29

Cloud Computing ....................................................... 31

3
 With more than 25,000 attendees and thousands of exhibitors, the
annual HIMSS conference gave us the opportunity to talk directly
with EHR and healthcare IT vendors about what makes them unique.
At the HIMSS10 conference, our team of healthcare software
specialists visited every booth and asked one question:

“With hundreds of competitors out there, what is your product’s differentiator?

What innovative feature or technology makes you stand out from the crowd?”

This question seemed to stump many of the vendors. Most replied with
answers that we later dubbed as “false differentiators.” One such answer
was “being the first to enable physicians to achieve meaningful use.” While
this is critically important, this is not a differentiator – everyone is focused on
meaningful use.

Other answers revolved around features like a basic patient portal website,
an iPhone add-on or integrated e-prescription and billing. These can also
be important, but are no longer differentiating features– they’ve become
prerequisites. To stand out, vendors need to take their product to the next
level and serve their users in a unique and innovative way.

Using Technology to Innovate

At HIMSS, the vendor answers that impressed us always revolved around a
basic theme:

“Our solution is innovative because it uses modern technology in a unique way

to make clinicians’ jobs easier and more fulfilling.”

In this paper, we look at the opportunities for innovation that new technologies
like mobile devices, modern UI design frameworks, and voice and handwriting
recognition provide to EMR and health software companies. More importantly,
we will look at how you can use them to differentiate your product from the
masses.

With each technology, we’ll examine:

• The opportunities for healthcare innovation the technology provides
• How the technology is currently being used by forward-thinking vendors
• The limitations of the technology, and how you can overcome them to break
new ground
Using this information, your organization can decide which technologies can
best help you develop your product into a stand-out that the healthcare world
5 will embrace.
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1
DISRUPTIVE TECHNOLOGY # 1

The Tablet PC

While tablet PCs have been around for a while, healthcare IT applications are only
now beginning to take advantage of the unique features of these devices. In par-
ticular, slate-type tablets like Apple’s iPad and the Fijitsu Stylistic ST6012 Tablet
PC are starting to gain traction with users.

Because of their unique size and their wireless capabilities, slate-type tablets
offer a balance between portability and usability and allow for more natural and
convenient ways to fit into a clinician’s workflow.

What are the opportunities for innovation?

Traditionally, EMRs have been limited to workstations at reception desks, doc-
tors’ offices and nursing stations. With tablet PCs, however, users now have the
ability to access medical records from any location that has a wireless connec-
tion. Ultimately, tablet PCs could replace the traditional paper-based patient
chart.

In particular, a tablet PC can allow healthcare users to:

• Explain clinical results to a patient at the bedside or in the consultation room.
An interactive mobile device can enhance a discussion of test results or
possible courses of treatment with a patient. The doctor can sit next to the
patient and display test results, show graphs, look at numbers and access
clinical decision support material or other informative websites while explain-
ing the results. In particular, the software could display a “patient view” which
displays only the information a patient needs and can understand, then revert
back to a more complete and detailed physician’s view when done.
• Look up resources on the fly. Having a tablet PC at the ready can be just the
thing that physicians need when a drug name slips their mind or they need to
look up options for a differential diagnosis. The ability to hook into the hospi-
tal’s infrastructure without having to walk to a computer station can also save
7
 critical steps for nurses. As we discuss later, integrating an EMR with a clinical
support system empowers the clinical worker by providing access to the right
information. Mobile tablets can ensure that this information is then accessed
at the right place and right time.
• Consult data before just before treatment. Usually before surgery or another
type of medical intervention, a surgeon will consult with diagnostic images
or other results as a precautionary measure. With the right infrastructure in
place, a tablet PC can save the surgeon from making an extra trip to the lab to
check this data.

How are Tablet PCs used

in healthcare today?
One Healthcare tablet PC stand-out is Intel’s Mobile Clinical Assistant which is
marketed as a replacement to the bedside clipboard. It features attachments
that include a barcode scanner, an RFID scanner, an integrated camera, a casing
that can be wiped clean and a battery pack that can be replaced without power-
ing the system down.

³
Through user
research, your
Other vendors such as Pulse Systems and Epic are already in the process of of-
fering an iPad version of their EMR solution.

What constraints do Tablet PCs face?

We have listed a set of commonly-cited iPad and related tablet limitations, below.
organization may You should interpret each limitation, however, as an opportunity for innovation.

Tablet PCs may:

be able to uncover
• Detract from doctor’s bedside manner. Technology can sometimes get in the
common medical way. When meeting a patient for the first time, the focus should be on the
patient and his or her medical problems. A tablet PC may also not be able
activities and/or to capture data effectively as the doctor speaks. Consultation is narrative in
information that nature and doctors need a free-form method of text entry with the ability to
recognize this text for data storage. Some tablet PCs do not have – or do not
are well suited to a ship with – a stylus or an application to record handwritten text, which can
limit their effectiveness. When developing a tablet PC solution, be sure to take
tablet PC.” these user needs into account. Proper user research and usability testing may
be required to ensure that the solution is tailored to suit actual user behavior.
• Increase resource management on the ward. The most popular choice for
technology on the ward is a computer on wheels (COW) since it cannot be
removed from the ward. Tablet PCs, unless personal to the doctor, can easily
be misplaced – especially when they are set down to charge the batteries. An
EMR that works on a tablet would have to compete with COWs, which are full-
featured mobile computers that charge via an electrical outlet in a wall.
• Risk of theft. Often, when a patient is seen at a hospital for the first time,
routine forms must be filled in. Sometimes these are completed by a clinical
worker or by the patient himself. With a mobile device, this process needs to
be performed by the clinical worker as mobile devices can be easily stolen.
8
 Optimizing your device to accept routine intake forms may therefore not be a
smart investment of resources and time as these forms are best entered into
a kiosk-type machine or on paper.
• Small screen size. While screens on tablet PCs are larger than those on
mobile phones, a tablet PC’s screen size may not be big enough to accurately
view medical results such as ECGs, MRI scans, and X-rays. Most medical
interpretation is done with multiple monitors and it may not be possible to
replicate the required level of detail on a tablet PC. Through user research,
your organization may be able to uncover common medical activities and/
or information that are well suited to a tablet PC. By focusing the design and
functionality of your application on the information that can best be displayed
on a tablet screen, it will stand a much better chance of being adopted by its
users.

Despite its constraints, mobile technology is generally recognized as the fastest-

growing technology segment today, with major advancements continually
pushing the trend forward. Tablet PCs are very popular – especially among
younger medical professionals and students. Today’s young iPad users are
tomorrow’s leading clinicians so it is important to consider this technology, and
how it can be best used, in your development plans.

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DISRUPTIVE TECHNOLOGY # 2

Smart Phones

Smart phones are generally the smallest mobile computers available today, offer-
ing a high degree of portability. Two of the most popular devices on the market
today, the iPhone and the HTC Desire, offer comparable feature sets that include
touch interfaces, a camera and a phone as well as Wi-Fi and GPS capabilities.

People have become used to carrying a cell phone, so EMR access over a smart
phone can be both intuitive and helpful. Smart phones offer personal mobility
and allow clinical workers greater flexibility over how they manage their time.
With a smart phone, users can perform routine tasks from any convenient
location. A home care provider who visits patients at home, for example, could
have mobile access to an EMR and receive and enter information over the course
of a workday.

What are the opportunities for innovation?

While vendors know that there is a lot of potential in developing “something” for
smart phones, a question we are commonly asked is “Which parts of our desktop
application should we port to iPhone?”

Smart phones are best used for productivity-type tasks in which time spent per
action is short. Starting from this principle and working through product strategy,
concept design, and user research is the best way to determine your product’s
smart phone feature set.

Some healthcare tasks in which time spent is short include report review, order
entry, and appointment management. In this case, the innovation does not come
from the basic features themselves, but the ability of the device to meet user
expectations and overcome traditional smart phone limitations.

Another area of innovation lies in finding novel ways to leverage the hardware
and software features of smart phones. A product that incorporates a smart
phone’s built-in camera would allow EMS workers to take photos of injuries and
10
 forward them to the emergency room for consultation before the patient actually
arrives. As another example, an application could make use of a smart phone’s
GPS to automatically notify a hospital when the patient arrives.

Finally, the majority of vendors that provide a smart phone solution today are
actually offering a web application for mobile browsing, rather than applications
that are native to the device. Investing in a device-specific application (such
Epic’s Haiku) is another opportunity to differentiate – it allows for enhanced
responsiveness and availability, better control over the device’s hardware and
software features, as well as a richer more interactive user interface.

How are smart phones used in healthcare

today?
There are a number of lists that detail smart phone applications offered by EMR
vendors, such as this list of 12 EMRs with remote iPhone apps. Most of these ap-
plications provide a mobile interface to an existing enterprise-level EMR – albeit
with limited functionality and via a web interface. Common features across most
offerings provide the ability to:
• Review patient information

• View, schedule and book appointments

• Take dictation

• Charge capture (capturing procedure and disease codes)

• View Laboratory results

• Review or create prescriptions

• Bill patients

• Manage out-of-office visits

• Find pharmacies

• Manage clinical messages

What constraints does smart phone

technology face?
Some caveats to be aware of when considering the deployment of an EMR to a
smart phone include:

• HIPAA compliance. Storing medical information on a mobile device can violate

HIPAA regulations. Smart phones may need, instead, to temporarily store data
on the device’s memory while the application is running. Before developing
your application, be sure to speak with an expert in HIPAA compliance. And, if
you plan to work with a development partner, make sure that this partner has
extensive healthcare experience and an understanding of current regulations.

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 •Interference with medical devices. Most hospitals do not allow the operation of
cellular devices around medical equipment out of safety concerns. There is cer-
tainly an opportunity around novel “hospital mode” solutions (similar to the “air-
plane mode”) that alleviate the problem based the device location and context.

• Medical interpretation. While this issue is under debate for tablet PCs, it is gen-
erally accepted that the small screen size of a mobile phone does not allow for a
detailed review of medical results such as ECGs, MRI scans, x-rays, etc.

Even with its limitations, smart phone support is quickly becoming a prerequisite
for successful healthcare IT and EMR applications.

Clinical workers personally own smart phones, and if their IT solution allows
them to get work done on the go via their phones, this is perceived as a major
advantage.

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DISRUPTIVE TECHNOLOGY # 3

Touch Screens

While touch screen technology has existed in one form or another for years, the
technology of resistive and capacitive touch detection has recently flourished,
allowing for pressure sensitivity, multi-touch and gesturing. From a usability point
of view, a touch screen can be more intuitive than a mouse since the user can
select an item directly without having to first drag a pointer. Moreover, touch
screen technology allows for more robust computer installations – particularly in
public areas, where a traditional keyboard and mouse that require regular main-
tenance tend to be the first things to fail.

Touch-ready operating systems are now available such as Windows 7, Apple iOS
and Linux. This software allows for the handling of touch actions such as touch
begin, touch moved, touch end and can be used to recognize the mouse-like
events (click, drag and double click), as well as complex actions such as flick,
pan, zoom, pinch and rotate.

What are the opportunities for innovation?

EMRs can benefit immensely from touch screens. A touch screen can offer:

• Enhanced usability in specific settings. In a hospital setting, for example, where

clinicians use gloves or other protective apparel (ER, surgery, infectious dis-
eases), or a setting where a small number of repetitive tasks need to be done
quickly (ER admittance, drug orders).
• Innovative user interfaces. A richer user experience exists with advanced touch
features such as inertia in which objects continue to exhibit a behavior after
they are released, e.g. a scroll panel that considers the velocity of the user’s
finger swipe.
• Easy navigation. 3-D diagnostic models (such as those from a cardiac CT scan)
can be manipulated with swipes and multi-touch rotation.

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 • Data to all levels of users. Inpatients can be provided with touch screen con-
soles in which they can have a direct connection to their data in the EMR and
make decisions about their care.

On modern software platforms such as .NET, libraries exist to support complex

touch screen actions. This is an opportunity in and of itself to innovate – leverag-
ing this software framework will allow you to rapidly enable touch screen func-
tionality in your healthcare solution.

LANGUAGE FRAMEWORK USED BY

Windows 7, Windows
.NET Windows Touch Phone 7, Silverlight (with
browser support)
Any Java supported
Java MT4j platform including
Android, Linux

Objective-C UIKit iPhone, iPod Touch, iPad

How are touch screens used in

healthcare today?
Some EMRs, such as 3Plus and Encounter Notes, are marketed specifically as
“touch screen EMRs.” While these EMRs are not known as leaders in the market,
their value proposition is certainly something all vendors could draw inspiration
from.

Most leading EMR vendors are offering ad-hoc touch screen solutions as they
begin their foray into tablet PCs, smart phones and digital ink. Other common
uses of basic touch screens include:
• Patient kiosks. Offering patients the ability to enter their basic information
without needing a clerk. This data is then entered directly into the EMR.
• Bedside devices. Touch screen technology frees up space by not requiring a
keyboard and mouse. The information displayed is sourced from the EMR.
• Home care devices. Well-designed touch interfaces can be easier for patients
to use at home as they offer a more simple and intuitive interface.

What constraints does touch screen

technology face?
Touch screens introduce a new paradigm for user input. This step away from the
traditional keyboard and mouse is not without its limitations and controversies,
however. These constraints include:

14
 • Repetitive stress disorders. Researchers from Arizona State University believe
that touch screens could lead to new types of musculoskeletal problems.
• Device contamination. Diseases can be exchanged from person to person via
the touch screen. It’s important to be able to clean the touch screen often if it
is being used by patients.
• Text input. Although touch screens are meant to be more natural in terms of
usability, text entry is a challenge that can result in typos and wrongly auto-
corrected words.
There is a definite opportunity for innovation in terms of text entry, spell
check and auto-correction, particularly around medical and prescription
nomenclature.
• Unwanted input. When using a conventional computer, the user has control
over the input devices. With a touch screen it is easier for others to provide
undesired input – another opportunity for innovation around security and ac-
cess control.

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DISRUPTIVE TECHNOLOGY # 4

Digital Ink

The ability to have touch-sensitive screens has made it possible for users to
write on a screen just as they would on a piece of paper. This technology has
long been integrated into the EMR, but there has been a recent resurgence with
the ability to convert the ink strokes to structured text, via technologies like
Microsoft Ink.

What are the opportunities for innovation?

Although ink-to-text solutions like those from Microsoft are gaining in popularity,
there is still a significant issue around the accuracy of the conversion. A charting
system that accepts stylus input and converts to text will not be acceptable if
there is a chance of error converting the charting details to structured data.

The possibilities for innovation therefore fall into 2 categories: the use of digital
ink in innovative ways that are not error-prone, and the creation of new solutions
that reduce or eliminate conversion errors.

Some examples of the former are listed below (while the latter is discussed more
in the next section):
• Drawing images. In fields such as plastic surgery, it is often useful to draw
pictures to facilitate communication between doctor and patient.
• Annotating diagnostic images. The doctor can add ink to x-rays or MRI scans to
indicate important properties and describe the judgment made for it.
• Inputting text naturally. In some cases, the patient is unable to communicate
and digital ink can be used to write a note to the doctor to explain something
or to direct the course of treatment.
• Authenticating reports. Physicians can use digital ink to authenticate reports
quickly and easily.
16
 How is digital ink used in healthcare today?
Just as some EMRs are marketed specifically around touch screen technology,
others such as MedConnex, Aprima and Medscribbler tout the advanced use of
digital ink for stylus-based charting.

Aprima highlights the utility of ink data entry since it allows physicians
to maintain eye contact with patients during a consultation. MedConnex
emphasizes a fast learning curve when going from the paper world to their stylus-
based charting.

What constraints does digital ink

technology face?
As discussed, stylus entry and digital ink introduces an intuitive and natural way
to enter data into a patient’s chart, but is not without its constraints:

³
Handwritten data
does not facilitate data
• Loss of precision, illegible handwriting, and error-prone conversion to text. Pen
and paper are as precise as they need to be. Touch screens are often not as
precise as their real world analogs. Writing with digital ink tends to resemble
writing with a marker on a piece of paper. One of the reasons for developing
EMRs was to reduce the amount of ambiguity in handwritten notes. Digital ink
may duplicate or increase this ambiguity. There is a definite opportunity for
exchange and analysis.” innovating new methods of auto-correcting or translating ink to text on the fly,
in a way that is highly accurate but does not interfere with usability.
• Auditing is more complex. A very strict auditing mechanism should audit the
digital ink for every logical set of strokes. Otherwise, users could leave the
page open for several hours and write notes. In this case, it will be unknown
which strokes were written at which time. The audit logs would have to record
the time of the strokes, not just the time the “save” button was clicked.

• Handwritten data does not facilitate data exchange and analysis. Solutions of-
fering ink-only input that cannot convert to structured data may be more suit-
able for small clinics where data entry and recall is all that is needed. Without
structured data, a solution is very limited in what it can exchange with other
systems and what meaningful analysis it can perform on the data.

17
5
DISRUPTIVE TECHNOLOGY # 5

Voice Recognition

Physicians are trained in dictation. Classic physician consultations are dictated

and transcribed for the patient record. Typing out these clinical notes has a cost
associated with it, namely the transcriptionist’s time. Voice recognition (VR)
promises to one day eliminate this step by automatically performing this transla-
tion from speech to text and eliminate the cost of transcription.

Voice recognition in an EMR is in high demand as both a convenience and cost

saving tool. The accuracy of the technology, and especially the usability of the
solution, will be key differentiators for EMR vendors.

What are the opportunities for innovation?

Innovation for VR in EMRs can come from enhanced integration of the
technology into existing EMR solutions with an emphasis on usability. Voice
recognition can offer:
• Broader access to dictation. Any device that supports a microphone, a network
connection and a speaker (for system feedback) could conceivably support
VR. This means that a doctor could dictate notes into his phone and enter a
text note into the EMR from anywhere.
• Direct entry of rich content to the EMR. Patients and other healthcare provid-
ers can have access to the raw data entry. Having this access would allow
them to get a sense of subtle diagnostic nuances that may not be captured in
text or as a way of dealing with any errors with the recognition process.
• More natural voice commands. Having to learn VR system commands can
sometimes be a daunting task for clinical workers who are already squeezed
for time. One improvement that can be made to VR is to improve how the user
interfaces with the system itself so that it can be more natural.

18
 • Voice-print identification. This would allow physicians to perform more tasks
over the phone by authenticating them using their voice.

How is voice recognition used in

healthcare today?
Voice recognition is used in several existing EMRs. EMR vendors such as Epic,
Allscripts, Cerner, GE, McKesson, NextGen, eClinicalWorks have incorporated
Dragon NaturallySpeaking into their products.

An example of VR use within a practice is with clinical note dictation. After a

consultation with the patient, the physician can dictate his note into the patient
chart using VR. The note can then be automatically entered into the patient
chart. Traditionally, this process would be performed using a Dictaphone and
then transcribed into the patient chart by a medical assistant.

Dragon certifies EMRs according to how well they integrate with their solution.
The details of the certification test include emphasize dictation and correction
capabilities in the EMR, as well as audio preservation and other support tools.

Today’s VR technology, when trained to the speaker’s voice, has reached rela-
tively high levels of accuracy compared to just a few years past. Dragon Natu-
rallySpeaking, for example, boasts 99% accuracy when properly trained to the
speaker’s voice.

What constraints does voice recognition

technology face?
Although it can be useful, VR poses limitations that have prevented widespread
adoption in the healthcare industry to date. These include:
• Need for a quiet station. Most VR is done in a quiet corner or in the doctor’s of-
fice. The presence of noise can affect VR. This limits the mobility of computing
since it cannot be done in any location.

• Training is required. Although speech is natural and doctors are used to

dictation, all VR systems take time to train in order to reach a high level of
accuracy.

• Usability. Typing is fast for those who are expert at it but VR systems are good
when dictating large portions of text. If the VR system is remote and the user
has to keep correcting it, navigating backwards, or replaying certain parts, as
is often the case with a physician’s progress notes, it can take a lot of time to
input data.
• Unseen errors. Often a word can be misheard by the system and a different
(but correctly spelled) word can be used in its place. These “typos” are often
hard to detect and pose a risk for patient safety. These errors happen more
often than is acceptable. With a VR system that is 97% accurate, there are 1 to
2 errors on average every 50 words. This leads to about 37% of dictated notes
containing at least one error.

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 For an in-depth review of physician impressions of VR systems, we recommend
the publication “Acceptance of speech recognition by physicians: A survey of
expectations, experiences, and social influence” by Alexandre Alapetite.

Despite these constraints, VR has the potential to reduce the cost of healthcare
delivery by automatically transcribing clinical notes. Organizations that can
resolve these constraints and integrate with or develop VR systems that are both
accurate and easy to use will certainly stand out from the pack.

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6
DISRUPTIVE TECHNOLOGY # 6

Patient Health Records (PHR)

The future of healthcare is one in which the patient is more actively in charge of
his health data. As proclaimed in a widely publicized CNN report early this year,
patients are demanding control of their data. The California Health Foundation
reported that although only about 7% of adults use a Personal Health Records
(PHR) system today, 40% express interest in using one.

As patient-centric platforms such as Microsoft HealthVault and Google Health

gain in popularity, EMR vendors have an opportunity to stand out by offering
novel connections to these types of platforms.

What are the opportunities for innovation?

By creating innovative applications for patient health records, companies have
the opportunity to help healthcare organizations:

• Improve patient tracking. Clinicians can closely track patients who regularly
enter data into a PHR and can perform disease management, oversee
progress and track medication dosage.
• Encourage patient participation. When patients become interested in their
health, they often take better care of themselves. Having the EMR push data
to their PHR will help them to learn more about their health.
• Save administration costs. A major advantage of a well-designed PHR system is
to allow patients to book their own appointments or upload diagnostic results
from a specialist themselves.
• Provide Clinical Decision Support (CDS) to the patient. As discussed in the next
section, alerts and other elements of CDS could be provided to the patient.
• Offer social network integration. The growing Health 2.0 movement is exploring
the integration possibilities between social networks and healthcare systems.
21
 Through PHRs, patients could interact with one another. Physicians can also
participate and provide support on forums or in online group discussions.

Providing a patient with easy access to their records also satisfies the regulatory
requirement that patients be given copies of the record should they ask for it.

How are PHRs used in healthcare today?

Most EMRs are currently implementing their own quasi-PHRs via patient portals.
The eClinicalWorks patient portal website is a good reference for the types of
features offered. These are not PHRs in the classic sense because the patient is
not able to transfer his data to another application, unless he does it manually.
The current lack of truly accessible PHRs means that there is an excellent market
opportunity for an organization that can develop a PHR that is robust and easy-
to-implement.

What constraints does PHR

technology face?
While PHR systems are theoretically only constrained by the state of web soft-
ware technology, there are some concerns around their use by patients:
• Security and Privacy. Patients may be apprehensive about putting their health
data online. There is ongoing debate around the level of security and access
control that is required for a secure PHR.

• Standardization. PHRs should use a standard coding system such as ICD-9 for
diagnoses. They must also define a standard format for data exchange such as

³
CCR or CCD. Many patient portals today used proprietary standards that can-
not be easily exchanged with other systems.

The current lack of • Connectivity. Having to re-enter data into different individual EMRs will only
frustrate users and encourage them to find alternative points of care. The
truly accessible PHRs more interoperable the data, and the more built-in interconnections it has, the
more value the solution has for all levels of users.
means that there is
• Usability. Systems must be designed with a high degree of usability or patients
an excellent market will quickly abandon them.

opportunity for an In short, there is a definite market opportunity for PHR differentiation.
Organizations that can develop a PHR with a highly intuitive user interface built
organization that can around the patient’s expectations will stand out from competitors and offer a
truly valuable service.
develop a PHR that
is robust and easy-to-
implement. ”

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7
DISRUPTIVE TECHNOLOGY # 7

UI Design and Rich Internet

Applications

One of the most challenging aspects of developing an EMR is designing the

user interface. With an EMR, there is so much information and so many data
elements, forms, tasks and actions to organize due to the large variety of user
behavior patterns. As a result, most EMR applications tend to look the same,
leaving UI design as a major opportunity for differentiation.

When an interface design needs to be created for the web (be it an ASP web-
based EMR or a patient portal) it can become even more difficult to make it
visually impressive and highly usable. The emerging rich internet application (RIA)
technology provides the opportunity to design rich and consistent web-based
user interfaces.

RIA technologies include Adobe Flex, Google Web Toolkit, Silverlight, and, to
some extent, the upcoming HTML5/CSS3.

What are the opportunities for innovation?

The opportunities to create innovative UIs are limited only by the creativity of the
designers and developers. Today’s designers should certainly take advantage of:
• A rich look and feel for user interface widgets. Menu animation, drag and drop
components, and more advanced controls such as stack panels are available
out of the box with today’s RIA technologies.

• Multimedia content. With RIAs, it is easier than ever to include rich content
such as graphs, audio and video using built-in controls.
• Faster responsiveness. Since these applications run in the client browser, pro-
gram responsiveness is quick. Technologies like Silverlight can take advantage
of hardware acceleration to speed up video rendering.

An important thing to remember with RIA technologies is that they don’t have
to be used throughout the entire application. The richness they provide can
23
 be applied in choice areas in order to augment the experience offered by the
application as a whole.

How is RIA technology used in healthcare

today?
Due to the advantages a rich web interface provides, many EMR vendors already
use such technologies. Examples of EMR vendors using RIAs to deliver their solu-
tions on the web include:

• Practice Fusion
Adobe Flex elements • Hello Health
• Care Cloud

Google Web Toolkit • Care360™

elements • Medrium

Silverlight elements • UniCharts™ EMR

What constraints does RIA technology face?

Despite the advantages of a rich web interface, the use of RIAs has some
limitations.
• Upgrade runtime environments. RIA containers for Flash and Silverlight need
to be upgraded in order to function properly. Functionality changes from one
version to the next and it requires support from the developers.
• Risk of data loss. With client-side browser applications, data is entered on the
client and periodically sent to the server. Users can accidentally close the
browser or navigate away from the page and data can be lost. Well implement-
ed auto-save functionality will avoid this.
• Slower initial page load. Since the client is heavy, the initial load of the page is
often slower. Once loaded, however, the application is more responsive.

When designing an innovative UI, be sure to consider more than just the look and
feel. A good UI is both visually attractive and easy to use. Working with a devel-
opment partner that has both usability and RIA experience can help you create a
user interface that is both appealing and intuitive.

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8
DISRUPTIVE TECHNOLOGY # 8

Unified Communications

Hospital team members are spread across departments and have different
working hours. Patients at home using self-monitoring devices can encounter
a problem at any time. As institutions continue to adopt software solutions,
there is a growing opportunity to enhance their work and communication
through Unified Communications (UC), which merges real-time methods of
communication such as voice, video and chat with others such as email, SMS
and voicemail.

UC solutions such as Microsoft OCS, Cisco HealthPresence, Avaya and Telus -

Community Health Care can help organizations fully integrate EMRs into their
clinical workflows. An open source UC solution, Asterisk, is also quite popular.

What are the opportunities for innovation?

The component technologies of unified communications are of benefit to EMRs
by facilitating professional-to-professional, professional-to-patient and patient-to-
professional contact in order to create a much more fluid environment. With such
technologies deployed, the EMR would become a meeting place where there
would be:
• Recording of physician and patient consultations. These can be added to EMRs
for patient playback in case something was missed.
• Virtual waiting rooms. Patients can queue remotely and wait in the comfort of
their home, coming to the clinic only when the office is ready for them. The
patients would be able to perform this action through the patient portal com-
ponent of the EMR.
• Virtual consultations. Video conferencing would allow patients to visit physi-
cians without having to actually come into the office.
• Supervised tests. Currently, with EMRs like GE Centricity, physicians can
25 supervise tests via remote monitoring diagnostic systems. With integrated UC,
 they would be able to monitor both the computer terminal as well as the video
from the examination room.
• Telehealth with video conferencing. At present, Telehealth solutions require
users to call an expert by telephone. With the functionality of UC, video
conferencing would be possible – giving the expert on call the ability to see
symptoms and give more accurate advice.

By incorporating UC into your offerings, your organization could add a great deal
of value to a hospital’s EMR since it would bind all communication services into
one package.

How is UC applied in healthcare today?

Cisco and Allscripts have formed a partnership to integrate UC with their EMR
solution, offering solutions like patient reminders, messaging, and intelligent call
routing. GE Healthcare piloted Microsoft’s UC solution with fanfare, but these
two software solutions currently operate independently.

What constraints does the technology face?

In addition to the general high cost of teleconferencing and videoconferencing
hardware, integrating UC into the EMR poses the following limitations:
• Larger installation. An EMR is already a daunting task for a healthcare facility.
Grouping a UC solution with that of an EMR would require an even larger
overhaul of existing infrastructure. It may be better to install them separately
with adapters in the EMR to allow for integration.
• Loss of personal contact. There is a strong value to face-to-face meetings in
healthcare. It may be some time before the quality of low-cost virtual meetings
is sufficient to inspire trust in workers and patients.

Despite these constraints, vendors are starting to explore how to best leverage
current technology and innovate. EMR/UC integration is still at an early stage,
however, which offers your organization the opportunity to be one of the first to
truly utilize and promote unified communications in the healthcare industry.

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9
DISRUPTIVE TECHNOLOGY # 9

Clinical Decision Support

As patient volumes increase, it can become difficult for providers to remember

medical background material specific to each and every case. A Clinical Decision
Support (CDS) system combines both background knowledge and case-specific
information to help the provider make better decisions. A CDS can point a
provider to reference material and information, perform certain actions, or supply
alerts.

What are the opportunities for innovation?

EMRs are benefiting from CDS system integration by keeping medical knowledge
at the fingertips of healthcare providers. Opportunities to push the envelope
include:
• Learning patterns of care. Some CDS systems do not require a pre-developed
knowledge base, but rather apply machine learning algorithms on medical
examples fed into the system. Others can apply machine learning to build
knowledge about user behavior. This concept exists in academic publications
but the challenge remains to make this a widespread commercial reality.
• Reducing alert fatigue. When users receive too many alerts, they may begin to
ignore serious alerts.
• Improving usability. Organizations can innovate by increasing the intuitiveness
and speed of access in CDS systems. To date, whenever a CDS has been
integrated into an EMR, the combined system has tended to behave as
two distinct systems with different flows. Companies that can address this
problem and improve usability stand a good chance of becoming leaders in
the space.
• Sharing CDS. Multiple healthcare facilities can share anonymous data about
clinical decisions so that they can benefit from each other’s behavior and
improve the quality of patient care.
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 • Improved matching algorithms. Strong algorithms that match case instances to
a knowledge base will deliver more pertinent information to users.

How are CDS systems used in

healthcare today?
Most of today’s CDS systems provide clinical reminders for patients, identify
possible risks for adverse events and errors, analyze clinical performance, and
encourage adherence to standards of care.

The most common use of CDS/EMR integration is to identify drug-to-drug

interactions. Popular solutions for e-prescription and drug interaction detection
include DrFirst, RxNT, Medi-Span and a host of others.

A CDS can also be deployed as a stand-alone package that provides a lookup of

medical knowledge. The Elsevier CDS tool currently offers this functionality.

What constraints does

CDS technology face?
• Patient data model accuracy. Patient data must be entered consistently for a
CDS to contain accurate information.
• CDS system accuracy. The CDS system needs to be intelligent enough to be
able to correctly identify similar cases and present them to the user when
requested.
• Alert fatigue. A CDS system must take care to only alert the user in critical
situations. Otherwise, the user will suffer from alert fatigue and ignore all
alerts.

• Usability. CDS systems are often developed independently from EMRs and
then integrated. This process limits the usability of the CDS. Users may
choose not to use the CDS or become frustrated when it takes them too long
to get to the information they need.

When a CDS becomes a nuisance as opposed to an aid – either because of inac-

curacies, poor usability or alert fatigue – the system loses value and users simply
abandon it. Organizations that can closely integrate their CDS with an EMR and
overcome the obstacles mentioned above will have the best chance to stand out
from the crowd.

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10
DISRUPTIVE TECHNOLOGY # 10

Mobile Home Care Devices

Mobile home care devices are pieces of hardware that allow patients to com-
municate the current state of their illness to a healthcare provider from home.
Although still in the development stage, the potential for managing chronic ill-
ness is clear, and development of home care devices is moving quickly to meet
the demand of our aging population.

Examples of existing mobile home care devices include blood pressure monitors,
weight scales, glucose meters, pulse oximeters, and peak flow meters. One such
device is Intel’s HealthGuide, which offers a variety of solutions to the patient in
his own home.

What are the opportunities for

healthcare innovation?
• Usability. Patients using these devices are often ill and/or elderly. The devices
must be intuitive and robust, putting home care ethnographic study and other
usability techniques at the forefront of innovation.
• Continuous data stream. Physicians can monitor patient activity and catch
problems before they become severe. The EMR will become a meeting place
for patient data.
• Access to CDS systems. A clinical decision support system can monitor patient
readings and alert physicians to cases that need special attention. This can
help physicians to be more efficient.
• Empowering patients. Inventive features could maximize the activities that
can be taken on by the patient remotely, such as picking up prescriptions and
scheduling interventional procedures.

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 How is this technology applied in
healthcare today?
At the time of writing, Intel and GE Healthcare recently formed a new company
in a joint effort to meet the future needs of telemedicine. In their vision, mobile
home care devices will interact with EMRs to deliver the data to those in charge
of the patient’s health. While this is the hot topic of the moment, most major
Healthcare IT vendors (as well as many smaller organizations) have a telemedi-
cine and home care product portfolio.

Many existing home care devices are standalone solutions that are used by the
patient at home and then brought to the hospital or clinic during a scheduled vis-
it. The data is then transferred into the EMR so that the physician can refer to the
data in his interpretation and clinical notes. This process is often cumbersome,
which has lead companies like Cardiac Science to offer a solution to bridge the
gap between device and EMR so that integration is more automatic.

What constraints does the technology face?

Probably the biggest limitation to widespread mobile homecare device adoption
is cost. Unless these devices can be cost effective, the average patient will not
purchase one. In most cases, the devices are loaned out to patients who need
special monitoring and reused by other patients down the road.

To counter this challenge, there is a growing push for home care software on
consumer devices. The LifeScan Diabetes Monitor and Zume Life self-care ser-
vice are both currently available on iPhone.

Vince Kuraitis, a thought leader in the growing home care industry, sums it up
nicely:

“Think about your user experience when you get into your car into the morning.
You are greeted by a dashboard of information about the vital processes in your
car -- fuel availability, fluid levels, driving speed, etc. You know that if something
goes wrong with a major system, you’ll get a “check engine” notice.

Now think about your user experience with your body. What do you know about
the vital processes going on in your body right now?

Remote patient technologies are beginning to provide the analogous dashboard

to help people monitor vital processes and to take appropriate actions if some-
thing goes wrong.”

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11
DISRUPTIVE TECHNOLOGY # 11

Cloud Computing

There is a lot of confusion in the industry around what “cloud computing” really
means. Often, marketing communications that refer to a “cloud solution” actually
mean an ASP offering with a SaaS business model.

True cloud computing is the use of virtualized servers that can be scaled on de-
mand based on varying levels of resource requirements at run-time. For example,
an application running on a cloud can programmatically turn on five servers in
response to a spike in demand for computing resources. Several mature solu-
tions include Microsoft Azure, Citrix, VMWare, Amazon Elastic Compute Cloud
and Google App Engine.

What are the opportunities for healthcare

innovation?
By making use of cloud computing, vendors can in theory enhance traditional
ASP solutions by offering:
• Scalable hardware. Additional hardware can be turned on based on need.

• Efficiency and performance. Since servers are virtualized, different instances

can reside on the same hardware. The instances can be moved around de-
pending on need to make the best use of the hardware without compromising
performance.

• Increased availability. Cloud hardware is distributed and fault tolerant. Cloud

providers promise 99.95% availability.

From a technical perspective, a cloud would be the best option for delivering a
solution on scalable and fault tolerant hardware while still delivering on perfor-
mance requirements.

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 What constraints does the technology face?
With ASPs, there is definite knowledge as to the location and ownership of
the housed data thus satisfying privacy and data security laws. True cloud
computing, on the other hand, is not in widespread use with EMRs since it is an
issue of controversy due to privacy and security risks.

Some platforms such as Microsoft Azure offer private clouds to organizations

facing trouble with compliance. At this time, however, this solution is intended
for very large organizations who are working with at least 1000 servers, likely
outside the scope of any major hospital. Microsoft has recently begun a push
into the Healthcare IT space, so the time may be right to look to Microsoft for
future innovations in cloud computing as it applies to EMR systems.

Until then, there are other ways for organizations to pump up their ASP offering
– for example offering a client application with a richer user interface, more logic
and even an “offline mode.” Technologies such as WPF and Adobe AIR represent
a first step towards the creation of such rich clients.

Innovating Through Technology

Modern technologies such as mobile devices, modern UI design frameworks,
and voice and handwriting recognition are becoming increasingly prevalent. The
examples outlined in this paper show that it is crucial to understand the oppor-
tunities for technological innovation in healthcare IT, how these technologies are
being used by your competition today and their current limitations.

To stand out from the crowd and go above and beyond the traditional methods of
helping clinicians, your organization needs to be aware of these technologies and
incorporate them in a way that will break new ground. Organizations that truly
understand the day-to-day workflows, needs and goals of healthcare providers
will be best positioned to develop innovative and usable technology solutions
that will get accepted by end-users.

We look forward to seeing you at the next HIMSS conference, and being im-
pressed by the innovative IT you’ve developed that truly differentiates you from
your competitors.

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 Technology Consultation with Macadamian
Macadamian is a global UI design and software innovation studio with signifi-
cant sector expertise in healthcare and life sciences. We work with Healthcare
IT vendors to create visually impressive, usable and ultimately successful soft-
ware products. Through our usability, design, and software engineering services,
Macadamian can help you transform your idea into a market-ready feature or
product that will stand out from your competition and delight end-users.

We are currently offering a limited number of free consultations with our senior
team. For the next 60 days we have ten available openings with our usability
and technology experts, who can meet with you to discuss your product plans,
and help determine how the technologies and approaches discussed in this
paper could help you innovate and further differentiate your product from the
competition.

Contact Us
For questions or comments about this white paper, or for more information on a
technology or usability consultation, please contact:

Didier Thizy
Director, Healthcare Solutions
[email protected]
+ 1 877-779-6336 x136
www.macadamian.com

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