Mobile Healthcare: Patient Data DeliveryJuly, 2008 Market Traction Brief
DISCLAIMERInformation Advantage Group prepared this report as a general guide and basis for further discussions anddiligen...
Table of Contents (linked)                                                Hover on section title and ctrl clickI. EXECUTIV...
I. EXECUTIVE SUMMARYIn the hospital, a large part—50%--of many clinical worker’s time is spent moving from onepoint-of-car...
II. PROLOGUESince the concept of radiophones was first discussed                                Key Driver For Enterprise ...
outside the walls of a hospital.Booming numbers of patients, who require care from multiple specialties and the financialn...
 ePrescribing – Prescriptions can be sent and checked for drug interactions and other related  patient safety issues. Di...
 Professional Services – ongoing vendor supportVendor’s pricing is customized according to the number of physicians, modu...
 Surveyed physicians stated they access handheld devices 5.4 times per day. 14   The time saved using mobile devices all...
 Surveyed physicians thought point of care computing devices pose significant infection control  risks. 20   Poor physic...
 Network access was provided by: 28   73% - VPN access.   43% - Citrix Remote desktops.   35% - offer portal access 4...
 Mobile Computing Carts: Mostly used by nursing, but as stationary units in the hall rather that  room to room.   76% of...
 Clinical information systems are being used, but not always in real-time or at point of care.   Often double-documentat...
 Because most are soft dollar returns, the argument for mobile devices weakens under the  weight of ROI and total cost of...
N otebooks Dominates Mobile ComputingThe largest share of the $88.9 billion global mobile computing market belongs to note...
HEALTHCAREHospitals are actively deploying wireless networks and buying systems that call for activephysician usage. The p...
V III. TRENDS – Outside the WallsIn healthcare, we can expect numerous wireless                Remote Access In Healthcare...
Mobile Testing The POC testing device market will continue to expand outside the acute care arena due to the  need to tes...
 A global survey of IT decision makers concluded the                                    Mix Wired/Wireless Networks  need...
Market Distribution of Vendors                                  Based on Annual Revenue When Available 2                  ...
Market Distribution of Vendors                                  Based on Annual Revenue When Available 2                  ...
RegulatoryThe more relevant regulatory considerations for mobile patient data delivery are focused onprivacy and security ...
StandardsThe Certification Commission for Healthcare Information Technology (CCHIT) providescertification that vendors pro...
Bibliography1  Cook, B. (2008, June 9). Twilight of the beeper: Todays technology offers other ways of keepingconnected. A...
19   (2007). HIMSS Annual Report on US Hospital IT Market. HIMSS Analytics. Retrieved 6/16/08 from:http://www.himss.org/fo...
36   (2007, October 8). 65% Of Physicians Fear Infection Risk By Using Mobile Computing Devices At PointOf Care — 160% Inc...
Mobile Healthcare: Patient Data Delivery by Jim Bloedau
Mobile Healthcare: Patient Data Delivery by Jim Bloedau
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Mobile Healthcare: Patient Data Delivery by Jim Bloedau

  1. 1. Mobile Healthcare: Patient Data DeliveryJuly, 2008 Market Traction Brief
  2. 2. DISCLAIMERInformation Advantage Group prepared this report as a general guide and basis for further discussions anddiligence on the select area of healthcare—Mobil Healthcare: Patient Data Delivery.This report includes qualitative and quantitative statements that reflect plans, estimates, data, consensusviews and beliefs of vendors, industry experts and commentaries provided by public sources and IAGanalysts. Best efforts have been made in assessing the reliability of these statements. IAG disclaims allwarranties, express or implied, as to the accuracy, completeness or adequacy of such information andfitness of this research to a particular purpose. IAG shall have no liability for errors, omissions orinadequacies in the information contained herein or for interpretations thereof. IAG advises that anydiscussion or listing of a company or product of any kind in this report should not be deemed to be anendorsement of said company or product. The opinions expressed herein are subject to change withoutnotice.This report is intended to be one of the many information sources including other published information andanalysis of these sources by the reader. The reader assumes the sole responsibility for the selection ofthese materials to achieve its intended results. The reader is urged to exercise the utmost discretion makingthe information enclosed in this report available to others that may need to analyze such material in thecourse of their evaluations.Each resource cited in this report is the property of the originating author or publisher and will not beindividually reproduced or distributed by the reader.Copyright 2011 by: IAG LLC 3757 Webster Street, Ste. 306, San Francisco, CA 94123. All rights reserved.Duplication or distribution of this document as presented without express written permission from IAG LLC isprohibited. Page 2 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  3. 3. Table of Contents (linked) Hover on section title and ctrl clickI. EXECUTIVE SUMMARY................................................................................................................4II. PROLOGUE ..................................................................................................................................5III. OVERALL DESCRIPTION ...........................................................................................................6 Mobile Patient Data Delivery Systems – Multiple Applications ....................................................6 The Right Computing Device Is Situation Dependent ..................................................................7 Costs – From Cow Paths to Country Roads ................................................................................7IV. BENEFITS RETURNS - Quality of Care Leads ...........................................................................8 Financial .......................................................................................................................................8 Operational...................................................................................................................................8 Clinical Effectiveness ...................................................................................................................9 Patent Safety................................................................................................................................9 Workforce Improvement .............................................................................................................10 Patient Perception ......................................................................................................................10 Community Perception ...............................................................................................................10V. IMPLEMENTED, USED, SERVICED..........................................................................................10 Virtual Private Networks Are the Leading Method of Access – WLAN & Bluetooth the Leading Wireless Tech.............................................................................................................................10 Physician Adoption of Mobile Devices Are Mostly For Personal Use ........................................11 Smartphones Are the Leading Devices Used By Physicians .....................................................11 Extra Work and Age-Dependent Preference Lead Physician Adoption Challenges ..................12 Mobile Nursing Offers Greater Challenges ................................................................................12 Security Concerns – Same as Other Industries .........................................................................13VI. BUYERS & USERS ...................................................................................................................13 Buying: Decision By Committee - Top Clinical Influencers ........................................................13VII. MARKET ...................................................................................................................................14 Overall - Mobility Technology Continues Strong Growth............................................................14 Notebooks Dominates Mobile Computing ..................................................................................15 Converged Mobile Devices (CMD) – Leading Handheld Device Market....................................15 HEALTHCARE ...........................................................................................................................16 Strong Growth for Healthcare Wireless Deployment..................................................................16 Mobile Patient Data Delivery Market ..........................................................................................16VIII. TRENDS – Outside the Walls ..................................................................................................17 ePrescribing ...............................................................................................................................17 Mobile Nursing ...........................................................................................................................17 Home Health Mobility: ................................................................................................................17 Mobile Testing ............................................................................................................................18 Mobile Learning..........................................................................................................................18 RFID & Bar Coding.....................................................................................................................18 Unified Communications – Not Yet Prime Time .........................................................................18 Wireless Skills To Be #1 In Five Years – Healthcare To Lead Demand ....................................18IX. VENDORS .................................................................................................................................19X. INFLUENCE & OVERSIGHT ......................................................................................................21 Regulatory ..................................................................................................................................22 Associations ...............................................................................................................................22 Standards ...................................................................................................................................23Bibliography.....................................................................................................................................24 Page 3 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  4. 4. I. EXECUTIVE SUMMARYIn the hospital, a large part—50%--of many clinical worker’s time is spent moving from onepoint-of-care (POC) to another capturing data and creating information for documentationpurposes. In response to this burden, clinicians are constantly looking for a better way and areincreasingly turning to wireless technology to get some relief. As a result, many wirelessdevices are augmenting or taking the place of paper-based processes and changing the waycare is accessed, delivered and documented. The result is a developing technological menuthat is redefining “mobile” as the ability to use a small computing device backed by a wirelessnetwork—what was once purely a telecom issue is an IT concern today.Mobile Patient Data Delivery (MPDD) systems are one of the more exciting mobile niches.These products provide the infrastructure for integrating, managing, developing and deployingan application that reaches into a hospital’s legacy systems and presents a comprehensivepatient view at the bedside on a wireless, handheld device. Although it is early in this market,the total market potential is currently estimated to exceed $443 million. Growth of this marketwill remain slow and lag the 27% CAGR of healthcare’s billions of dollars wireless market.This lagging market is partially explained by the fact that most physicians carry several mobilewireless devices, their use of these for access to clinical data is spotty and only now justbreaking into double-digit percentages. A brighter sign is a recent rash of reported orders byvendors that coincide with their rapid development and release of value-adding modules maybe an indication that vendors are reaching the critical mass of utility and value needed to ignitethe market.What is clear is that mobile and point of care computing is changing the way physicians andnurses practice and hospitals deliver patient care. By enabling access to clinical informationquickly and securely from any location, at any time, the overall efficiency and quality of patientcare is improved. Because of this, hospitals will continue to actively deploy and upgradewireless networks and buy systems that support delivery and management of care inside and,in a response to a strong remote healthcare trend, outside the walls of the hospital. Page 4 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  5. 5. II. PROLOGUESince the concept of radiophones was first discussed Key Driver For Enterprise Mobilityby AT&T in 1915 and introduced to our imagination by Ab e rd e e n S urv e y , N o v e mb e r, 2007comic book hero Dick Tracys wristwatch radio of the1930s, improved two-way communication via wireless B etter Mgmt.technology has rapidly evolved—particularly for D iffuse 48% Workforcehealthcare over the last decade. The first telephonepaging system of 1949--designed for doctors--started Lowercaving in to pagers in 1974 and cell phones in the Operational 33%1980s. 1 The recent launch of wireless e-mail devices Costshas caused Motorola, which once controlled 85% ofthe market, to discontinue its paging operations in More Remote 32%2002—a mere three years after introduction of the WorkersBlackberry. 2 NewOf all industries, healthcare is one of the most mobile Customer 18%and documentation intensive. A large part—at least Competition50% of many clinical worker’s time—is spent moving Lowerfrom one point-of-care (POC) to another capturing data Service 16%and creating information in the clinical setting for Frequenciesdocumentation purposes. This documentation iscaptured and presented in many forms, including: Speech (dictation) Free Text (care giver notes) Document Imaging (patient contact areas) Leading Mobile Devices Deployed Static and Dynamic Clinical Imaging (x-rays, MRI, PET Accross Work Force (June 08 Survey of CIOs) scans) Electronic Data I/O (bedside testing and monitoring, lab results, operational input) Cell Phones 49% Waveforms (EEG, ECG) Business &Clinical Encoding (XML tagging, ICD-10, Laptop/Notebook/ SNOMED, billing codes) T ablet 43% ComputersHealthcare is also one of the strongest adopters of Smart Phones (cell phones with 19%wireless communications, only lagging transportation office apps.)and retail, and includes a strong history of early trials PDA (with orand adoption of first generation mobile computers. without wireless 15% connect)Because of the evolution of technology and need forgreater clinical efficiencies, “mobile” healthcare is Pagers 5%beginning a second generation of computing. Today,wireless devices are augmenting or taking the place of Proprietary Mobile T erminals 4%early laptop charts and changing the way care isaccessed, delivered and documented—inside or Page 5 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  6. 6. outside the walls of a hospital.Booming numbers of patients, who require care from multiple specialties and the financialneed to make their hospital stay as short as possible, are pressuring clinical staff to deliverand document patient care more safely and efficiently. Add to this the persistent shortage ofclinical professionals across all specialties and you have a perfect storm that raises thequestion: How are we going to deliver patient care going forward?In 2008, enterprise mobility has emerged as a strategic initiative among leading health careorganizations. Wireless device designers offer a plethora of useful utilities that can beconfigured to fit a growing number of general and task-specific compact devices. Therichness of this technological menu has redefined “mobile” as the ability to use mobilecomputing devices backed by wireless video, voice and data networks--what was once purelya telecom issue is an IT concern today.This report will focus on mobile patient data delivery (MPDD) market and leading vendors thatoffer a robust list of modules, integration utilities and portal technology that offers the clinicianaccess from anywhere, anytime.III. OVERALL DESCRIPTIONMPDD products provide the infrastructure for integrating to legacy systems and deploying anapplication that presents a comprehensive patient view at the bedside on a mobile device.Typically, the MPDD solution is presented as a platform that solves the inhouse and remoteaccess, security, administration, personalization and data synchronization issues of mobilecomputing while allowing access to inhouse patient data.Mobile Patient Data Delivery Systems – Multip le ApplicationsThese systems are generally an amalgamation of any number of modules and add-on utilitiesthat are not limited to: Clinical Portals – Allows the clinician secure access over the web to essential patient information. Point of Care (POC) Data Delivery – Essential patient information, as determined by the hospital or configured by the clinician is delivered at the bedside or accessed remotely. Software modules may include:  Patient List  Patient Information  History and Physical  SOAP Notes  Labs and Tests  Problem List  Medication List  To-Do List Charge Capture – Hospital procedure and diagnosis codes are captured more accurately, easily and alerts assure completeness of charges. Page 6 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  7. 7.  ePrescribing – Prescriptions can be sent and checked for drug interactions and other related patient safety issues. Dictation – Mobile device records clinician dictations and sends for transcription. Reference Library – Clinical knowledge from any number of reference libraries can be accessed remotely or loaded into the mobile device. Provider Directory – A listing of local providers by specialty with contact information. Personal Information Management – schedules, phone numbers and other personal-use data can be loaded for the clinician’s use.These applications have been developed to interface with most major hospital informationsystems (HIS) or “best of breed” configurations to offer unified access to patient data fromanywhere using a PDA, smartphones, tablet or PC running a Web browser.The Right Computing Device Is SituationDependent Wireless Devices Common toCurrently, there is no one-size-fits-all mobile solution Healthcarefor the clinician. In the hospital, computers on wheelsthat were taken from room to room were the first wave.  Desk & Lap ComputersThey remain common because they offer typing  Cart-based vs. Stationary Computing Devicescapability and large screen size for rapid viewing of  Tablets PCslarge amounts of data. These systems are hard to  PDAdisplace because of the high comfort level already  Smart Phonesestablished. 3  Bar Code and RFID Scanners  PagersFrom a hardware perspective, the current sentiment is  Wireless Patient Care Devicesthat tablet computers are the best way to facilitate use  VoIP Badgesof technology at the bedside. 4 Additionally, what is  Multimedia Playersseen clinically is a variety of handheld devices that  Physiologic Testing &have been selected because they were free or bought Monitoring Devicesby the clinician with other personal uses in mind.Knowing this, hospitals are seeking a variety of functions that can be accessed with off theshelf devices, like PDAs and smartphones, with portal-based Web access generally astandard offering.Costs – From Cow Paths to Country RoadsNoted deployment challenges are dominated by costs that can more than double vendor costsduring full roll-out and included: 5 Initial Mobile Hardware Costs – handhelds, tablets, browser capable devices, carts, displays, sync stations Integration/Software Costs – modules, add-on software, wireless network/upgrades, consulting fees. Security And Electrical Interference Concerns – security upgrades, wireless audits/upgrades/staffing Device/Infrastructure Management – additional IT and improved skill sets Maintenance, Training and Support – software upgrades and help desk Page 7 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  8. 8.  Professional Services – ongoing vendor supportVendor’s pricing is customized according to the number of physicians, modules and interfacesrequired by the hospital’s legacy system configuration--because of this, vendors are reluctantto publish estimates for full systems.For software, physician applications and services for stand-alone handhelds generally start at$40 and reportedly rise to at least $250,000 to install in a 500+ bed hospital. 6 Physiciansgenerally load additional software to their mobile devices that may include: Medical References for PDAs (numerous by specialty) - $40-$150 purchse price Electronic prescribing - $70/month Charge Capture $50/year Stanford Guide to Antimicrobial Therapy $30 MedCalc (80+ formulas with references and tips) – Free Immunization Guide – Free Coding – FreeMany of these utilities are included in the leading vendor’s offerings.IV. BENEFITS RETURNS - Quality of Care LeadsMobile and point of care computing is changing the Biggest Impact Better IT At POC Can Haveway physicians and nurses practice and deliver patientcare. By enabling access to clinical information quickly Improve Quality 76%and securely from any location at any time, the overall of Careefficiency and quality of patient care is improved whenclinicians have access to better information at the Improve Staff 16% Efficiencypoint-of-care. 7 8Financial Improve 4% Revenues In the U.S. alone, the cost of information capture and report generation was estimated to be $50 billion Increase Local 2% annually in 2002. 9 Competitiveness  An estimated $6.9 billion was saved across the entire U.S. health care industry, as measured by Other 1% productivity enhancements, by using wireless technology in the medical field. 10  Additionally, $900 million in savings was realized by reducing inventory loss through wireless tagging of devices and instruments. 11 Early results for physicians found that every dollar spent on a mobile charge capture system returned $5 to $7 in billed charges. 12Operational 31% of health care providers claim to recover at least 50 minutes per day by using enterprise- wide mobility solutions. 13 Page 8 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  9. 9.  Surveyed physicians stated they access handheld devices 5.4 times per day. 14  The time saved using mobile devices allowed them to see an extra 3.8 patients per day. 15 Direct input of patient data via a wireless handheld reduces callbacks and follow-ups caused by illegible notes and prescriptions—particularly beneficial in documenting for reimbursement.  A clinical trial of a mobile tablet-like device in 2007 produced a 42% improvement in point-of- care documentation. 16Clinical Effectiveness Nursing Tasks Better IT At POC Can Improve An American Academy of Nurses (AAN) study itemized nearly 300 workflow issues that proper Care Delivery 26% & Coordination application of technology could improve.  There was no clear consensus with regard to a Documentation 23% single area in which technology could have the most positive impact on workflow. Medical 22% Administration  25% of respondents identified each of the following broad areas—care delivery and Communication 18% coordination, documentation and medication administration. Dont 5% Know/Other Use of a mobile patient data system’s clinical alerts Patient Care 5% Devices detect potential problems improved patient outcomes over the 2005-07 including: 17 Suplies & 2% Equipment  15.6% reduction in mortality/1,000 inpatient discharges.  13% decrease of cardiac and respiratory arrests for all inpatients.  22% decrease in cardiac/respiratory arrests in non-critical care areas.  38% fewer ICU deaths for medical/surgical patients transferred there with a diagnosis of sepsis.  35% increase in interventions for congestive heart failure, as encouraged by the Centers for Medicare & Medicaid Services.  115% increase in responses for critical care support and assessments. Leading Application For Patient Safety H IMS S Oc to b e r, 2007 Physicians think digital images and video captured at point of care by handheld devices could enhance CPOE 33% clinical documentation stored in the electronic medical eMar (Electron records. 18 Medication 29% Admin.Patent Safety Bar Coding 17% Bar code technologies are well established as beside technology that improves not only patient safety, but Nursing 6% D ocumentation operational efficiency.  The current market shows that bar coding Other 6% technology is most frequently used in laboratories, followed closely by radiology, pharmacy and Physician 6% materials management. 19 D ocumentation RFID 3% Page 9 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  10. 10.  Surveyed physicians thought point of care computing devices pose significant infection control risks. 20  Poor physician hand washing, multi-tasking at the bedside and ignorance of the potential risk were viewed as the major causes. 21Workforce ImprovementA clinical trial of a mobile tablet-like device in 2007 resulted in: 22 62% increase in nurse satisfaction with the hardware and related clinical workflow changes.Patient PerceptionDespite surveyed physicians, thinking computing devices used at point of care could interferewith the physician/patient relationship, when patients saw them using hand-helds: 23 71% felt there was better interaction among their doctors and nurses. 24 60% felt the potential for medical errors was reduced. 25Community Perception A noted secondary reward was the cascade of cooperation that one mobile implementation catalyzed: 26  Competitive hospitals joined forces and adopted the same mobility solution at the community level.  80% of the physicians wanted the practice management component after mobile implementation.V. IMPLEMENTED, USED, SERVICEDThe mobile IT infrastructure between acute and ambulatory “Were doing the chargearenas continues to coalesce with VPNs and WLAN the leading capture portion first astechnologies. Physicians are carrying up to three to four mobile we see that as the meatdevices—smartphones are quickly becoming the most popular-- and potatoes, while themostly for personal use and reference. Advanced computing, clinical side will follow,like e-prescribing or patient data access, from these devices is like desert.very sparse with the exception of younger physicians or those Allistair Erskinemandated to do so by their employer. VCUHS Chief Medical Healthcare Use Of Wireless TechnologyBecause of the enterprise impact and need to generate CAG R 2005-2010 % Share 2010clinician buy in, a demonstration pilot is the path mostoften taken when deploying a mobile patient data system. WLAN 28.3% 26%Equipment and staffing costs and slow adoption by 19.8%clinicians lead the list of deployment and maintenance Bluetooth 20%challenges. 17.5% WWAN 45% 16.6%Virtual Private Networks Are the Leading RFID 48%Method of Access – WLAN & Bluetooth t he Zigbee 11.2% 75%Leading Wireless Tech 3.7% UWB2008 studies showed: 27 40% WMAN 2.9% 29% Page 10 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  11. 11.  Network access was provided by: 28  73% - VPN access.  43% - Citrix Remote desktops.  35% - offer portal access 41% of respondents use roaming desktops.  85% of healthcare respondents stated that they are looking to use tablets or mobile devices.Physician Adoption of Mobile Devices Are Mostly For Personal Use A survey of 1,200 physicians showed that use of handhelds more than doubled between 2001 and 2006—about 50%. 29  The most common uses were: 30  Drug Reference Database  Prescription Dosage Calculators  Continuing Medical Education  Product Updates A recent survey of physicians revealed that the choice of a computing device at point of care was most importantly dependant on: 31  Physician’s Personal Preferences  Location  Urgency Of The Situation  Tasks To Be Performed  Complexity Of The Applications To Be UsedSmartphones Are the Leading Devices Used By PhysiciansA November 2007 survey of physicians revealed the most Leading Mobile Device Usagecommon clinical patient data computing devices and their In Healthcareoverall acceptance: 32 Doct ors Nurses Smart 63% Smartphones: 75% of physicians are using them. Phones 59%  Mostly for personal tasks—very few are using them for back office access to patient data. 33 53%  Less than14% of physicians were using smartphones Pager 81% to access single function clinical applications to manage patient data, prescribe medications or charge 41% capture in 2007. 34 VoIP 19% Tablet Computers: Too big and heavy; too short of a PDA Use In Healthcare battery life for a full shift in the acute care setting. (Healthcare Informatics Survey, Summer, 2006)  The ambulatory care setting is enthusiastic for them Patient because it is a different workflow environment than acute Treatment 42% care.  Physicians can control the environment; short distance to docking stations; physicians financially invested in the technology.  Most felt that handwriting recognition not ready for Diagnostic Other Admin. prime time. 14% Tests 23% 21% Page 11 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  12. 12.  Mobile Computing Carts: Mostly used by nursing, but as stationary units in the hall rather that room to room.  76% of acute care nurses interviewed using mobile clinical carts reported the carts remain abandoned in the hallway where they are being used as a fixed location terminal. 35  In 2007, physicians preferred to use a full size terminal and keyboard to access clinical information systems at point of care. 36  Business class computers are not well suited to meet the heavy demands of a healthcare environment. 37 Wall-Mounted PC (flat panel displays): With multiple large screens-most favored by physicians in intensive care areas.  Large screen area fostered efficient review of large amounts of patient data.  Video and image capture at the bedside is promising.Extra Work and Age-Dependent Preference Lead Physician AdoptionChallengesClear demarcation of mobile use exists between generations of physicians. While there aresome older physicians who never learned to type: At least 80% of the younger physicians who are members of the American College of Cardiology (ACC) are using advanced mobile devices. 38 35% of medical schools are now requiring the use of at least a PDA in the third and fourth year. 39 85% of physicians are independent and only affiliated with a hospitals—they could take their business elsewhere if mandated to use technology—despite this position, the trend is for mandated use. 40 Mobile technology has physicians taking too many extra steps—reverting to old ways: 41  Electronic charge capture reverting to the old super bill—a paper based checklist.  To much electronic communication has physicians developing blocking and workarounds to lessen the pressure—like answering services and office staff screening email. 42Mobile Nursing Offers Greater ChallengesGreater challenge and complexity is found in nursing’s Leading Application of Mobile Devices Inexperience with mobile computing. A December 2007 Healthcaresurvey of nurses showed: 43 64% believed their wireless infrastructure not reliable Medication 14% enough to support point of care computing solutions. Administration Nurses reported logging in/out of systems upwards of Records/Document 80 times per day. 11% Management Nurses are concerned about the usability and portability of computing devices deployed at point of care. Patient Admit & 11%  Mobile carts are large and bulky making them Discharge difficult to maneuver within the confines of a patient’s Drug Delivery room. 10% Systems  Provisioning enough PCs across the enterprise to provide sufficient access to the systems was a Laboratory 8% problem—space and expense were the key limiting Management factors. Asset Mgmt. & 6% Page 12 of 28 Tracking© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  13. 13.  Clinical information systems are being used, but not always in real-time or at point of care.  Often double-documentation is the practice--documenting first on paper at point of care and then re-entering into the electronic medical record. Surveyed nurses believe their hospitals lack the appropriate technical infrastructure to support point of care computing including: 44  reliable networks  systems interoperability across the continuum of care  security requirements that do not impede nursing productivitySecurity Concerns – Same as Other IndustriesSecurity concerns are universally shared across allindustries. End Users Perception Of Threats - General Ge ne ra l S urv e y A p ril, 2008 41% of non-healthcare CIOs surveyed June 2008 survey recognized that security is a top challenge in Internal developing and executing mobile strategies. 45 Users 33% Theft A May, 2008 study derived from research conducted by the Computing Technology Industry Association Mobile Devices 31% (CompTIA), noted theft and other security concerns External 24% Breaches are rising for use of hand-held devices and lap computers by remote and mobile workers: 46 Internal 21%  60% stated that security issues related to the use of Data Theft hand-held devices for data access and transfer Virus 18% have significantly increased over the past 12 Protection months.  55% of those surveyed said that security issues Phishing 18% have significantly increased for wireless networks Theft over the last year. Portable 17%  33% have developed security awareness training Media for employees  90% of organizations that have implemented this training for remote and mobile workers believe security breaches have been reduced.VI. BUYERS & USERSPan-mobility solutions for patient care cross all clinical departments and are often daunting inscope. Leading clinical stakeholders must champion these projects—particularly the ChiefNursing Officers (CNO) and Chief Medical Information Officer (CMIO)--typically a physician.The final decision rests with the capital equipment/services buying committee.Buying: Decision By Committee - Top Clinical Influ encers Clinicians remain hesitant to adopt mobile solutions unless they can clearly see a way to (in order): save time, make money or raise the quality of care. Funding for mobile computing finds strong competition from:  Electronic Medical Records (EMR)  Computerized Physician Order Entry (CPOE)  Picture Archiving and Radiology Information Systems (PAC/RIS) Page 13 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  14. 14.  Because most are soft dollar returns, the argument for mobile devices weakens under the weight of ROI and total cost of ownership analysis. Building out wireless networks that support a wide range of enterprise-class solutions like wireless data, VOIP and RFID and integrating departmental systems is proving difficult. Although physicians and nursing are the primary users of mobile patient data devices, the technology will effect most departments and require committee approval that may consist of:  CEO  CIO  CFO  CMIO  CNO  Nurse Informaticist  Pharmacy Chief  Laboratory Chief  Radiology Chief  Risk Manager  Compliance Staff  IT network/mobility experts Primary users of Mobile Solutions are:  Staff and affiliated practice physicians who make rounds at hospitals  Hospital pharmacists  Hospital nursesVII. MARKETOverall - Mobility Technology Continues Strong GrowthWith many people having both private and work related Millions of U.S. Wireless Subscriberswireless accounts, the number of U.S. wireless subscribers 450should eclipse the total number of people (307 million) in 400the US over the next several years. 350 255M 300 9.98% CAGR 250 2002-2007 Just released 2008 Mobility Survey of CIOs uncovers 200 significant penetration of mobile devices in the workplace: 150 47 100  Nearly 50% of employees are equipped with cell phones 50 and nearly 20% with smart phones. 0 1985 through 2007An early 2008 survey showed ample room for unified Global Mobil Computing Market (Billion)communications and devices: 48 $92.0 8% of frequently traveling business people rely solely on $87.0 $88.9 their mobile number. $82.0  Carrying multiple and often redundant devices is their $77.0 $55.6 $72.0 first choice over a unified communication/computing $67.0 7.0% CAGR device. $62.0 $57.0 $52.0 Page 14 of 28 2005 2006 2007 2008 2009 2010 2011© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  15. 15. N otebooks Dominates Mobile ComputingThe largest share of the $88.9 billion global mobile computing market belongs to notebookcomputers. 49 In 2006, notebook computers held 84% of the total global market.  They are expected to reach more than 96%, worth $69.2 billion by the end of 2011. 50 Virtually all the mobile computing device vendors reported good rewards from the total sale of 342 million devices that produced $1.15 billion in 2007: a 15.8% increase over 2006. 51  The 2008 projections for handset market growth have been reduced from 13.5% to 12%. 52 The global PDA market continues its market slide with a 53% decline between Q4’06 to Q4’07.ConvergedConverged Mobile Devices (CMD) – Leading Handheld Device MarketCMDs are the result of mobile technologies coalescing Projected CMD Marketwith handheld personal information managers (PIM) of (Units Shipped)the past to produce a synergistic marriage of voice 375.0 376M(telephony), data (wireless) and video (static and 325.0dynamic). The first version, Handspring, was 24.7% CAGR 2007-2012introduced in 2000 and the iPhone is the latest popular Million 275.0 Unitsexample. This trend has caused HP and Palm to see Shipped 225.0annual double-digit declines in their traditionalhandheld lines while Nokia and Research In Motions 175.0(Blackberry) have enjoyed CAGRs in the hundreds of 125M 125.0percent. 2007 2008 2009 2010 2011 2012 Where Healthcare Is Planning Increased ITIn the general market, mobile carriers, content Spendingcreators, device makers, software developers and new (Survey M arc h 2008 =- IDC)media players, like Google, see the increasing demand Softwarefor a variety of business applications integrated into 70%handheld devices as critical to their mobile aspirations. Hardware Services 60% 30% Converged mobile devices continue strong product Healthcare Wireless Market growth in the wireless industry. (May, 2008: Blueto o th, RFID, Zigbee UW B W W AN, W M AN, W LAN & Others )  Smart phones’ CAGR of 15.7% promises the $10.0 $10.0 highest growth with project revenues of around $17.8 billion. 53 $8.0  Competitive pressures have driven the price of a Billions $7.0 smart phone down to $200, making smart phones $6.0 more affordable to a broader base of users—clear evidence that vendors are focused on providing $4.0 greater utility to differentiate their products. $2.7 27.8% CAGR $2.0 2005-2012  Worldwide smartphone sales in the first quarter $1.8 of 2008 totaled 32.2 million units, a 29.3 percent $0.0 increase from the previous year. 54 2005 2006 2007 2008 2009 2010 2011 2012 Page 15 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  16. 16. HEALTHCAREHospitals are actively deploying wireless networks and buying systems that call for activephysician usage. The problems is that despite most physicians carrying a mobile device,utilization of hospital mobile patient data applications for access, either wirelessly or throughsynching stations, to clinical data is only just now breaking into double-digit percentages.Strong Growth for Healthcare Wireless Deployment In 2003, 25% of US hospitals had deployed wireless technology—current projections see this level to be 90% by 2010. 55  As of Spring 2008, the market has shown a 23% CAGR that will increase to make it a $10 billion market by 2012. 56  $300,000 is the average to be spent on wireless technology by healthcare organizations over the next two years according to a 2007 survey of healthcare IT professionals. 57Mobile Patient Data Delivery MarketClaims that healthcare is nearing a tipping point in the deployment of mobile patient datadelivery technology is premature for a number of reasons including: Although consensus points to the market just now entering double-digit market penetration, there are few indications that the systems being deployed are much past information databases or charge capture. Leading vendors have been around for about ten years and are just now entering the double digit millions of dollars revenue stream. Revenues for the two leading vendors:  Hoover’s reports $7.6 million in 2007 revenues serving 14,000 physicians ($543 per physician) for PatientKeeper; which also claims 10% of the market and to have quadrupled revenues.  Thompson Reuters (MercuryMD) reported $10 million in 2005 revenues at time of acquisition in 2006.Given the above, the following extrapolations are based on published case studies, vendorrevenue and vendor claims of market share. 1 Based on market performance, the total market potential is currently estimated to exceed $443 million. Growth of this market will remain slow and lag the 27% CAGR for overall wireless growth in healthcare.  Recent rapid module development by the leading contenders and their claimed increases in revenues may be an indication that vendors are reaching the critical mass of utility value needed to ignite the market.1 A $250,000, 534 bed installation ($468/bed) Approximately 800,000 practicing physicians Approximately 802,000 community hospital beds Page 16 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  17. 17. V III. TRENDS – Outside the WallsIn healthcare, we can expect numerous wireless Remote Access In Healthcareapplications crossing every specialty and locality (Healthcare Informatics Survey, Summer, 2006)where care is delivered. Many of the future Practionersapplications will be mobility-intensive, in that they will 58%be focused on delivery and management of careoutside the walls of the hospital. This trend will drive Otheradditional applications with many being purpose- 2%specific at first then another round of deviceconsolidation. As the number of utilities that can beconsolidated into a single device increases, it is Admin.expected that the general adoption curves will also 25% Patientsincrease. This will also precipitate and even higher 15%growth in cost for deploying and managing wireless technology.ePrescribing 40% of physicians use systems that range from Computerized Physician Order Entry (CPOE) to mobile devices to prescribe medication: 58  Although they may be using technology, often prescriptions are printed out rather than sent electronically.  Physicians feel that there are still too many steps involved for ePrescribing.  A July 2006 Institute of Medicine (IOM) report attributed 1.5 million patient injuries each year to medication errors and asked physicians to adopt e-prescribing by 2010.Mobile Nursing 86% of acute-care nurses are using devices to access reference materials—including drug databases, manuals and medical calculators—and make informed patient decisions. 59 Nurses spend almost 50% their time documenting their treatments.  78% of nurses use IT at the patients bedside to cut down on first writing the information on paper and then transferring it to electronic reports. 60  36% of nurses adopting this practice are using products to capture vital signs data that is automatically upload it to the patient’s electronic record. 61  53% of nurses use devices (mostly bar coding) to ensure positive patient identification required for medications, blood transfusions and specimen collection. 62Home Health Mobility: “We need to be A growing number of clinicians are traveling to patients’ homes, which requires remote connectivity to improve communication and paying attention to to keep patient records up to date. this movement  7.6 million U.S. patients require home care in some form— because spending on this is projected to double by 2013. 63 healthcare will be  Expect growth in round the clock quality monitoring and moving instant data access from complex devices like monitors for increasingly into cardiac, respiratory and neurological parameters. the home….” 94% of home health nurses use computerized mobile devices in patient’s homes. 64 Page 17 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  18. 18. Mobile Testing The POC testing device market will continue to expand outside the acute care arena due to the need to test for: 65  1000+ infectious diseases  Drug consumption  Toxins in food and agricultural products  Genetically modified organisms  Cancer markers  Biothreat agents  Allergens and immune response levels  Human recognition Much of this testing with be done by nonprofessional personnel using handheld devices or in a lab on bench instruments.  This trend is driving the need for easy to use platforms that can readily transfer to the acute care setting.Mobile Learning Continued strong growth in mobile learning products and services is fostering the movement of knowledge building events, content, tools, and applications from the desktop to handheld devices.  The overall market is showing a 27.3% CAGR which is expected to produce $1.5 billion by 2011. 66  The US healthcare sector mobile learning market is $96 million (May 2006) and showing a 23.5% CAGR that will produce $276.5 million by 2011. 67RFID & Bar Coding The overall RFID market is estimated to reach $9.7 billion by 2013 and show a 15% CAGR for the 2008-2013 period. 68  RFID in the healthcare industry is getting good traction during its early stage  The healthcare market for RFID would reach more than $1 billion by 2010 and $3.1 billion by 2012. 69  Growth in the healthcare market will occur as issues of network infrastructure scalability, interoperability, and the relatively high costs of implementation are resolved. 70 The adoption of mobility applications has been helped by increasing usage of bar-code technology for medication administration, charge capture and patient identification . 71Unified Communications – Not Yet Prime Time Despite the buzz about and availability of Unified Communications (UC) systems, clinicians are cobbling together a variety of mobile devices to suit their needs.  67% of clinicians interviewed carry two or more mobile communications devices (mobile phones, pagers, etc.), allowing them to communicate with specific networks of people or perform certain job functions. 72 Wireless Skills To Be #1 In Five Years – Healthcare To Lead Demand Page 18 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  19. 19.  A global survey of IT decision makers concluded the Mix Wired/Wireless Networks need for mobile and wireless skills is expected to show Across All Healthcare Enterprises the highest growth rate and become #1 over the next (Healthcare Informatics Survey, Summer, 2006) five years. 73 Wireless &  Those needing wireless skills the most were: 74 Hard Wired  63% - healthcare 72%  63% - education With skill shortages and escalating costs, it is expected that a large portion of future wireless No Fully hardware sales will be bundled into managed services Wireless Wireless agreements. 75 23% 5%  When compared to wireline, the costs to manage wireless services and devices is nearly 10 times more. 76  Enterprises outside of healthcare face two major challenges in supporting wireless mobility: 77  64% - struggle with escalating costs for services  57% - think supporting devices as a close second priority.IX. VENDORSMost of the vendors offering mobile application only offer one or two applications and typicallyare small informational providers (e.g. drug formularies) or application specific (e.g. chargecapture/personal schedule for physicians,). There are only a handful of vendors offering areasonably robust listing of applications that incorporate integration and workflow engineeringto present a comprehensive picture of patient data at POC. Of these, consensus and analysispoint to PatientKeeper and Thompson Reuters Healthcare (acquired MercuryMD).PatientKeeper is clearly the more aggressive vendor in the market and may be the leader byrevenues due to recently reported deals closing and new product releases. ThompsonReuters is a leader in information applications for healthcare and acquired MercuryMD in2006—little is published about their success with this acquisition, however, they have been theleading favorite of KLAS survey respondents for the last six years.Of special note is the HIS developers response to the demand for mobile capabilities. Hereagain, PatientKeeper has integrated with most of these systems, partnered with the leaders(Cerner, GE, Sage) and leading electronic medical record vendors while others HISdevelopers (McKesson, Siemens, Dairyland) have developed their own limited mobilecapabilities. Most of the remaining vendors below have been in business less than ten years,are venture funded and present some interesting options.Other than Thompson’s acquisitions of MercuryMD, there are no signs of consolidationreported. Page 19 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  20. 20. Market Distribution of Vendors Based on Annual Revenue When Available 2 Vendor Annual Revenue When Available [in millions] PatientKeeper  $7.6M (for 2007, Hoover’s current report)  physician portal  Claims about 10% of  essential clinical results market  ePrescription  Highly rated in Gartner’s  ambulatory order entry Magic Quadrant for being able to execute a strong  monitoring vision  patient ID  KLAS market leader  Microsoft Healthcare User Group award (2006)  Extensive Partners List includes the largest hospital and physician software vendors:  Cerner  GE  Sage (formerly Medical Manager) Thompson Reuters Healthcare (formerly MercuryMD)  $10M (2005) –Xpert Navigator  2007: sixth year in a row as Top KLAS Mobile Data Delivers information direct from the hospitals various  Health Data Managements third annual Nursing HIS system components – including: Information Technology  demographics Innovation Award in  laboratory results recognition of its  medication lists groundbreaking early  radiology results detection efforts—used  pathology reports Thompson system.  consults and other transcribed reports  KLAS market leader IQMax – Enterprise platform offering: Founded 1999; privately held.  Charge capture  Clinical results2 Source: Publicly available records Page 20 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  21. 21. Market Distribution of Vendors Based on Annual Revenue When Available 2 Vendor Annual Revenue When Available [in millions]  Dictation  Prescription  Formulary  Collaborative Media MedAptus – leading charge capture vendor 70% growth in 2007, founded 2003? Add on modules include:  Anesthesia  Communication  Rounding List  Dictation  Clinical Results  Clinical Content  Electronic Prescribing  BI Analytics Cogon Systems  U.S. Army selects Cogon MPI Systems to develop Portal advanced clinical decision support tools for hand held Medication computers Consolidated medical records New Age Systems Founded 1986: system integrator with mobile applications;privately held.X. INFLUENCE & OVERSIGHTNumerous regulatory and standards authorities are increasingly putting pressure on ITleadership to ensure patient and business data is securely maintained. Clearly, the need tomonitor for compliance to these regulations is changing the way healthcare operates: 78 60% healthcare organizations now employ a Chief Compliance Officer (CCO) 40% of IT decision-maker are spending 11-40% of their time on compliance 91% acknowledge HIPAA regulations influence or strongly influence IT purchasing decisions Page 21 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  22. 22. RegulatoryThe more relevant regulatory considerations for mobile patient data delivery are focused onprivacy and security including:HIPAA Regulations: Regulations covering electronic security and transmission of patientinformation require documented and tested business continuity and security plans. 45 CFR 164.512 9(f): This rule states that the legal process in obtaining a court orders and the secrecy of the grand jury process must protect the individual’s private information. 45 CFR 164.502(f): The final HIPAA rule changed the protections afforded to the deceased, obligating covered entities to guard the health information of a deceased individual in the same manner as a living one.Joint Commission on Accreditation of Healthcare Organizations (JCAHO): They have thepower to suspend accreditation if security and disaster management programs are not inplace.National Institute of Standards and Technology (NIST) SP800-30: Sets statutoryresponsibilities under the Computer Security Act of 1987 and the Information TechnologyManagement Reform Act of 1996 (specifically 15 United States Code (U.S.C.) 278 g-3 (a)(5).The May 2007 IRS memorandum clarified that hospitals may donate up to 85% of the cost ofelectronic health records (EHR) software to physicians, as permitted by legislative exceptionsto the anti-kickback statute and Stark Federal Physician Self Referral law. It further stated,that the EHR items or services must be software, information technology and/or trainingservices necessary to create, maintain, transmit, or receive electronic health records, andmust be used “predominantly” for this purpose. Those hospitals that do not assurecompliance with this ruling risk losing their 501c3 nonprofit status.AssociationsAmerican Telemedicine Association is the leading resource and advocate promoting access tomedical care for consumers and health professionals via telecommunications technology.Continua Health Alliance is comprised of over 135 technology, medical device and healthcare industry leaders dedicated to making personal telehealth a reality. Continua is working toestablish a system of interoperable personal telehealth solutions that empower people andorganizations to better manage health and wellness.CTIA-The Wireless Association represents all sectors of wireless communications – cellular,personal communication services and enhanced specialized mobile radio. Its mission is toexpand the wireless frontier and advocate on behalf of their membership before the ExecutiveBranch, the Federal Communications Commission, Congress and state regulatory andlegislative bodies. Page 22 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
  23. 23. StandardsThe Certification Commission for Healthcare Information Technology (CCHIT) providescertification that vendors products are HIPAA compliant out of the boxPCI Security Standards Council is a newly formed as an enforcement arm of the credit cardcompanies to help healthcare do a better job protecting cardholder information.ASTM Continuity of Care Record is a core dataset to be sent to the next healthcare providerwhenever a patient is referred. This promises to bring an end to physicians having incompleteinformation by providing the necessary information to support continuity of care with the hopeof reducing medical errors. Page 23 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.
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  26. 26. 36 (2007, October 8). 65% Of Physicians Fear Infection Risk By Using Mobile Computing Devices At PointOf Care — 160% Increase From 2005. Spyglass Consulting. Retrieved 6/9/08 from: http://www.spyglass-consulting.com/press_releases/SpyglassPR_POC_for_Physicians.v1.4.pdf37 (2008, December 17). 64% Nurses Believe Wireless Infrastructure NotReliable To Support Point Of Care Computing Solutions. Spyglass Consulting. Retrieved 6/9/08 from:http://www.spyglass-consulting.com/press_releases/SpyglassPR_POC_for_Nursing_v1.2.pdf38 Raths, D. (2007, February). Handhelds Get a Grip. Healthcare Informatics. Retrieved 6/09/8from:http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=6529D6C30B054CC0B08979DC71A8B67739 Raths, D. (2007, February). Handhelds Get a Grip. Healthcare Informatics. Retrieved 6/09/8from:http://www.healthcare-informatics.com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id=6529D6C30B054CC0B08979DC71A8B67740 (2008, June 25). Point of Care Computing: How Mobile Computing is Poised to Revolutionize PatientCare. Vendome. Retrieved 6/25/07 from:http://209.196.57.219/ME2/dirmod.asp?sid=7D6DBF0E417542D1BD2B73CAE9E1218A&type=gen&mod=Core+Pages&gid=E99F54C9E28F45859AA8FFA56BFE7BC941 (2008, June 25). Point of Care Computing: How Mobile Computing is Poised to Revolutionize PatientCare. Vendome. Retrieved 6/25/07 from:http://209.196.57.219/ME2/dirmod.asp?sid=7D6DBF0E417542D1BD2B73CAE9E1218A&type=gen&mod=Core+Pages&gid=E99F54C9E28F45859AA8FFA56BFE7BC942 (2008, June 25). Point of Care Computing: How Mobile Computing is Poised to Revolutionize PatientCare. Vendome. Retrieved 6/25/07 from:http://209.196.57.219/ME2/dirmod.asp?sid=7D6DBF0E417542D1BD2B73CAE9E1218A&type=gen&mod=Core+Pages&gid=E99F54C9E28F45859AA8FFA56BFE7BC943 (2008, December 17). 64% Nurses Believe Wireless Infrastructure NotReliable To Support Point Of Care Computing Solutions. Spyglass Consulting. Retrieved 6/9/08 from:http://www.spyglass-consulting.com/press_releases/SpyglassPR_POC_for_Nursing_v1.2.pdf44 Malkary, G. (2007, November). Point of Care Computing for Nursing. Spyglass Consulting. Retrieved6/9/08 from: http://www.spyglass-consulting.com/spyglass_whitepaper_POC_nursing.html45 Currier, G. (2008, June 12). Mobility Boosts Worker Productivity, Customer Service. CIOInsight.Retrieved 6/19/08 from: http://www.cioinsight.com/c/a/Research/Affirmative-Action/?kc=EWWHNEMNL061908STR346 (2008, May). Hand-held Device Security Concerns Rise. Health Data Mangement. Retrieved 6/9/08from: http://www.healthmgttech.com/enews/2008_may/feature-1.aspx47 Currier, G. (2008, June 12). Mobility Boosts Worker Productivity, Customer Service. CIOInsight.Retrieved 6/19/08 from: http://www.cioinsight.com/c/a/Research/Affirmative-Action/?kc=EWWHNEMNL061908STR348 Leo. (2008, February 20). Converged Mobil Devices Still Not In for Business People. The MobileWeblog. Retrieved 6/10/08 from: http://www.mobile-weblog.com/50226711/converged_mobile_devices_still_not_in_for_business_people.php49 (2007, April 9). Mobile computing market to reach $88.9 billion by 2011. BCC Research. Retrieved6/10/08 from: http://www.computerproducts.globalsources.com/gsol/I/Laptop/a/9000000085777.htm50 (2007, April 9). Mobile computing market to reach $88.9 billion by 2011. BCC Research. Retrieved6/10/08 from: http://www.computerproducts.globalsources.com/gsol/I/Laptop/a/9000000085777.htm51 (2008, January 25). Handset Sales Strong in Q4 07. Mobile Enterprise. Retrieved 6/11/08 from:http://mobileenterprisemag.com/ME2/dirmod.asp?sid=&nm=&type=news&mod=News&mid=9A02E3B96F2A415ABC72CB5F516B4C10&tier=3&nid=29C4ADE430D842CDB6BEF6447546BADC52 (2008, January 25). Handset Sales Strong in Q4 07. Mobile Enterprise. Retrieved 6/11/08 from:http://mobileenterprisemag.com/ME2/dirmod.asp?sid=&nm=&type=news&mod=News&mid=9A02E3B96F2A415ABC72CB5F516B4C10&tier=3&nid=29C4ADE430D842CDB6BEF6447546BADC Page 26 of 28© 2011 IAG LLC Inc. Non-disclosure: IAG LLC retains all rights to the use and distribution of this document. This confidential andproprietary information must be held in strict confidence and not disclosed to any other parties without the express writtenpermission of IAG LLC, San Francisco, CA 415-346-3860.

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