In my last Technology Column I discussed the wireless broadband revolution and the convenience seen when broadband transmission rates are available in the home care environment with a wireless modem. With fast digital connectivity "anytime, anywhere," the home care nurse or housecall physician has numerous options for medical "telephony," or the transfer of voice and data, including e-mail, lab results, and a complete electronic medical record. Unfortunately, few cities have mature wireless "always-on" networks at reasonable costs, and those of us that do are wondering what the recent Chapter 11 filings of Metricom (maker of the Ricochet modems) and Broadband2wireless means to our future.

The tech newsletters I follow all seem to predict an extended delay beyond 2002 for the arrival of 3G, the so-called third generation of wireless systems that will support all sorts of useful tools for the mobile professional. Although kids in Japan are now streaming movies into the small screens of their DoCoMo-enabled cell phones, the United States is far behind as the telephone pole and cable lobbies pour money into Congress to protect their investment in copper wires. The current spate of medical "niche" solutions seems focused on palm pilots and non-private connectivity options that meet only part of the mobile physician's needs.

The intense limitations of communications technologies affect the convenience and quality of home care at every interaction and should be approached from a functionality perspective. For purposes of discussion, let us assume there are three critical, "must-have" features of a home care program: scheduling, messaging, and charting. Each of these has a different need for telephonic communication, or at least a better solution than leaving voicemail messages.

Scheduling:

The office-based physician finds scheduling of visits virtually transparent, since the front office does it all for him. In a housecall program, or a home health service attempting to predict response times to referring physicians, the need for geographic location of field personnel and timely synchronization of the central schedule to those of multiple people in the field becomes critical. At the time of a physician home visit, the physician needs to know their future schedule on site, so as to mitigate the clinical need for follow-up with their normal routing patterns, vacation times, and possible interference from caregiver/family member schedules. The moment they commit to a follow up visit, how does the central office know that slot is committed, so they don't overbook the physician in another capacity? How does a sick patient know a two hour response time is actually guaranteed?

Messaging:

Perhaps the most complicated issue in managing a fleet of Xray vehicles, twenty physicians in the field and associated physician extenders all coordinated through a Call Center is messaging. Having read books and taken executive management courses in communications through the military (where the importance of messages like "engines all STOP" is critical), I believe this area is the most maligned and least respected of all in home care. Whereas a doctor's order to "hang two units of packed red cells within the next two hours" in a hospital is virtually foolproof, it is considered fungible or impossible in home care.

Understanding the complexities of messaging involves dissecting the intracacies of knowing when to send a message, how to priortize it, what medium to use, how to receive it, how to store it, how to recover it, and when to time-stamp it, just for starters. Some physicians type fast, some a little, most not at all; the use of handwriting recognition software (allowing the computer to digitally recognize each letter), or allowing the computer to recognize speech are all options in the marketplace now. How does one recover a message for quality assurance purposes? When was it sent? Can you prove it? When was it read? Can you prove it? The biggest risk I see in home care communications is the "he said, she said" conundrum when something is missed.

The Electronic Medical Record:

Using telephony to transfer the mobile EMR is now gaining great attention in our field, yet few physicians or nurses appreciate the difficulties involved. They include meeting the new HIPAA privacy standards, deciding on a web-based or web-enabled architecture, modem speeds, compression software, compatibility of local systems with firewalls and other security measures, committing to a server-based system or peer-to-peer architecture, and meeting the seemingly infinitely variable demands of clinicians for keyboards, no keyboard, templates, macros, voice commands, voice transcription etc.

Having become familiar with all of the above problems and seen the incredible efficiency of a few physicians in our medical group using a paperless, mobile office, I must confess I have not found or seen demonstrated the critical next step: providing a complete, scalable system that any number of physicians could use (analogous to the partial low-tech solutions many are familiar with using a handheld computer and a wireless modem).

The costs of such a complete "Final Solution" is not insignificant. It is easy to spend $1 million on just a virtual private network (VPN) at present, although many handheld computer operators are making false claims of "HIPAA compatibility." However, just having a VPN that meets privacy standards does nothing to help a clinician in the home communicate with mobile home health nurses with adequate documentation, create a robust, compliant EMR, or receive updated critical lab values in a prioritized way which protects staff from needless phone calls and insecure voicemail messages.

Three Lessons I Have Learned in 16 years of using telephony on housecalls:

1. Voice transcription (the computer recognition of free speech) has a role, but it isn't what you think. The fantasy of talking to a computer and having your chart printed is not here, no matter what the salesman says. Although new versions (such as version 5.0 of Dragon Naturally Speaking Mobile Professional) are infinitely better than the Kurzweil software we paid $25,000 for in 1986, they must be seen for their functionality.

   Voice transcription consists of a speech engine which accesses a personal file of your speech pattern and vocabulary created by hours of voice mapping (the more the better), coupled with an EMR setup that allows you access to voice transcription. Having created four separate personal voice files with four different software licenses, it suddenly occurred to me that it was stupid to continue separate voice mapping with the same speech engine on AOL Speaks (keyword "aol speaks") transcribing email messages, My Ivan (www.onevoice.com) for surfing customized web pages specifically modified to allow me to call out numbers instead of clicking, Dragon Mobile Professional (www.dragonsystems.com) to dictate into a digital recorder for later dowloading of files and messages, and Breveon (www.breveon.com) to dictate within the fields of a customized EMR. None of these programs crossed over to the other key functions without redundant voice mapping or additional, licensed features.

   Hope is on the way. A little known company (www.digitaldictate.com) is about to launch the product mobile physicians need: voice transcription middleware which allows you to use any device, including a phone, and any of the three major speech engines (which you probably already own if you are reading this article), and voice for commands or free text (within the limitations of the speech engine and your commitment to voice mapping) wherever your cursor lies on the screen.

   This means that one inexpensive product will allow you seamless talk to your computer while driving, and command it to read you your messages (text-to-voice), shift to the internet to check out traffic patterns, go to your GIS (geographic interfacing system) program and get directions, or finish a medical record dictation. Transcription costs will be reduced to a "proofing" function as you stream your audio wave files across your wireless broadband modem to a server somewhere else which can handle the huge memory needs for accurate voice transcription. Stay tuned.

2. HIPAA is no big deal. If you take the time to read the entire regulation, in effect since April 24, 2001, you will find the word "reasonable" used some forty times to describe the expected security standards. Although we must take the effort and expense to operate within a secure, 128 bit encrypted virtual private network for the transfer of digital information of patient matters, this effort will nearly always provide an adequate infrastructure for meeting HIPAA standards. The need for efficiency and protection against hackers, spoofers, and internal casual surfing will drive systems design more than HIPAA for the mobile, paperless physicians, unlike our paper-based peers in the hospital.
3. Don't wait for the next "new thing" before you launch your telephony solutions. It is quite frustrating to invest in software and hardware technologies in an industry that continues to ignore the realities of healthcare computing needs by designs meant only for the office. Telecom companies still think that putting the 'computer in the phone' is the answer, while physicians need such high memory and computing power that putting the 'phone in the computer' is the only final solution for a single device. However, VOIP (voice-over IP), which will allow you to talk live to your computer with real-time audio streaming to your server or peer client, is still beyond the pricing and computing power of most mobile professionals. Decide your budget, your scalability needs, your level of in house technology support and get started now; it will only get easier in the future.

We have come a long way since I started making housecalls in 1985 using a twelve pound, briefcase-sized cell phone in a van installed with the ETAK navigator. Now, we make housecalls with a broadband wireless modem always connected to our office and partners, scheduling patient follow-ups in the field with automatic instant synchronization to the office schedule, printing the EMR real-time thirty miles away at will, signing orders on a PEN computer, e-faxing or e-mailing prescriptions from the home, and messaging with time-stamped, archived handwritten or typed e-mails protected at the highest level of privacy within our wide area virtual private network. Paper is the enemy of telephony and it can be slain.

Dr. Bayne is the Founder and Chairman of The Call Doctor Company, dedicated to providing technology solutions for mobile physicians.