Development of a Mobile Web for Healthcare Data Collection Using Tablet PC and Mi-Forms Technology
Hospitals are currently in a data collection crisis. Accrediting bodies, healthcare payers and governmental agencies are gathering data to compare the quality of care delivered by hospitals. These efforts are placing considerable strain on healthcare institutions to collect high-quality data with the limited human resources that are available. The situation is further exacerbated by the redundant data collection processes that often occur in hospitals. It is not uncommon for the same piece of clinical information to be collected multiple times by different departments during a patients hospitalization. Hospital staff members responsible for abstracting this information face an equally daunting task of searching in multiple places to retrieve the required data. Systems are needed that reduce redundancy and increase the efficiency of data collection and retrieval. It is imperative that the right information is collected by the right person at the right time. Over the past two years we have been developing a technology that utilizes tablet PC technology with an innovative software product called Mi-Forms (Mi-Co, Inc., Research Triangle Park, N.C.). The beauty of this technology is that it makes data collection and validation concurrent and portable, incorporating information that already exists in the hospital information system with data at the point of care.
The Mi-Forms server/client software system is a digital recognition technology that runs on a tablet PC. It allows the user to interface from anywhere on the network. Through the Mi-Forms software, the user can develop data input forms that incorporate sophisticated features that facilitate data collection and allow the implementation of rules and algorithms to provide sophisticated data checks. The software runs on a tablet PC (Motion Computing, Inc., Austin, Texas) that provides an easy user interface via a pen-based technology and excellent recognition. The two products combine to make an intelligent data collection system. The tablet PC can be connected to the network via wireless technology for concurrent data processing, or data can be held in the tablet PC via a store and forward mechanism where the tablet can later be docked and synchronized with the Mi-Forms server software (see Figure 1).
We conducted a pilot project to determine if this technology
could significantly improve one of our most intensive data collection
processes in cardiology. This project focused on collecting extensive data on patients admitted to the hospital for treatment
of a condition called acute coronary syndrome (ACS). These
patients are admitted with chest pain and have elevations in tests
that indicate that the heart is being damaged by variations in
blood flow. It has been well-established in clinical trials that these
patients need to be identified quickly, and drug and interventional
therapies must be initiated as rapidly as possible.
There is currently a national data registry for these patients called CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patient Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines). This national registry is coordinated by Duke Clinical Research Institute (DCRI) and accumulates data from hospitals around the country to provide critical benchmarking for treatments and outcomes in these patients. Hospitals currently collect data for CRUSADE using manual paper collection with entry into a website that provides feedback on data accuracy and completeness. Often, however, the person entering data is not the person who collected the data, and significant time may be wasted re-accessing charts or other hospital information systems. There is also an increased potential for keyboard data entry errors. Our goal was to design a system that provided the same functionality and accuracy as the current Web-based CRUSADE data collection system, but to enhance this with a more efficient process that would bring the Web validations to the point of data collection. In addition, our project included another feature in which data that already existed in hospital databases could be preloaded into the electronic data forms.We developed crosswalks for moving relevant data from a cardiac data repository to the tablet PC.
To test these concepts and the overall system we conducted a pilot study on 24 patients who qualified for CRUSADE during July 2005 (supported by a grant from Schering-Plough, Inc.). Patients were stratified by severity of illness and nurse coders were randomly assigned to code CRUSADE data elements using either the tablet PC or the standard Web-based application. This pilot study demonstrated that the average time for data collection using the tablet PC was significantly shorter than the Web-based approach and the total time was significantly less for patients who had available data that could be preloaded into the CRUSADE form on the tablet PC (see Figure 2). These same 24 patients also had their data collected using the standard Web-based approach, which gave us an opportunity to compare the accuracy of the two approaches.
In analysis of several data fields where we noted some variation
between the two approaches, review of patient medical charts
demonstrated that the Tablet-PC/Mi-Forms system was more accurate
than the Web-based system. This pilot project was successful
in helping us develop a set of data forms that could run on a tablet
PC and collect CRUSADE data for these ACS patients. In addition,
the pilot study demonstrated that data collection can be done significantly
faster than is possible using the Web-based system and,
in addition, provided more accurate data. The nurses using the
system were interviewed after the study was completed. They
were extremely satisfied with the technology and thought that
it was very easy to learn and to use. They were pleased with the
amount of time they saved and with the way in which this technology
simplified a very cumbersome process.
Why is the Tablet-PC/Mi-Forms technology likely to be a success in the healthcare environment? Healthcare professionals are most comfortable with using a paper-based approach to documentation of medical care. The paper medical chart is still the predominant form of record used in the American medical system. The Tablet-PC/Mi-Form system retains much of the feel of a paper-andpen approach, as a pen can be used to code and record data into a digital form running on the tablet PC and the Mi-Forms software that looks identical to the paper form. However, it has the advantages of sophisticated feedback to provide immediate information about the accuracy of the data collected. The data collector can also make notes on the digitized form that are permanently stored with the image of the form, similar to the way notes would be made in the margins of a paper-based data form. Since the system allows for translation of handwriting into digitized text, the use of a computer keyboard is not required.
The Tablet-PC/Mi-Forms technology incorporates three other features that offer advantages over a paper-based approach. The form can be constructed with navigation to any part of the data collection sequence using a tab or keyword search. For a complicated,multipage form, this feature makes the technology much more efficient and easier for the data collector. Second, the form can be constructed to hide sections that do not apply to the current patient. Since much of the data collection in healthcare involves branching sequences of data elements that depend upon the diagnosis of the patient or the treatment used, this feature allows a cascading down through levels of data elements through a series of tabs that guide the user. This can make a 10-page form feel more like a three-page form. And finally, if there is a change in the data collection form, it is simple to broadcast a new version of the form to everyone connected to the network, thereby eliminating the need to reprint new data collection forms.
Another feature of this system is its portability.Medical data tends to be scattered in many places in hospitals where access to the hospital information network is not always available.With the store and forward approach, the tablet PCs can be taken wherever they are needed and docked to the network later to update whatever information has been collected through the Mi-Forms software. In addition, the Mi-Forms software can be configured to provide help text that is specific for each field, eliminating the need for data collectors to carry around coding manuals. Data collectors are often faced with collecting similar data for multiple requirements. The Tablet-PC/ Mi-Forms system can be configured to have a suite of forms that can be blended together to customize the data collection for the requirements of a specific patient. A project is under way to interactively create a customized form from a smorgasbord of data items. It is well-known that physicians have been slow in adopting technology to digitize medical information.Most continue to use dictation systems as the primary mode for documentation. The Tablet-PC/ Mi-Forms system provides the capability of doing dictation, and can also be set up to very quickly combine standard text blocks into reports using key words. This system can serve as an effective front end for the electronic medical record, resulting in the documentation and coding of medical activities at the point of care. Development is now under way to construct an application service provider model for using the Tablet PC/Mi-Forms system to directly link to a central center for management of and distribution of data to multiple sources. The flexibility, efficiency and accuracy gained through this type of software/hardware technology offer many advantages for hospitals that are currently under strain to streamline the process of clinical data collection and documentation of medical care.
