Mobile Healthcare: Patient Data Delivery by Jim Bloedau

Mobile Healthcare:
Patient Data Delivery

July, 2008 Market Traction Brief

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Information Advantage Group prepared this report as a general guide and basis for further discussions and
diligence on the select area of healthcare—Mobil Healthcare: Patient Data Delivery.

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Table of Contents (linked)
Hover on section title and ctrl click

I. EXECUTIVE SUMMARY................................................................................................................4
II. PROLOGUE ..................................................................................................................................5
III. 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 ................................................................................7
IV. 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 ...............................................................................................................10
V. 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 .........................................................................13
VI. BUYERS & USERS ...................................................................................................................13
Buying: Decision By Committee - Top Clinical Influencers ........................................................13
VII. 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 ..........................................................................................16
VIII. 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 ....................................18
IX. VENDORS .................................................................................................................................19
X. INFLUENCE & OVERSIGHT ......................................................................................................21
Regulatory ..................................................................................................................................22
Associations ...............................................................................................................................22
Standards ...................................................................................................................................23
Bibliography.....................................................................................................................................24
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I. EXECUTIVE SUMMARY
In the hospital, a large part—50%--of many clinical worker’s time is spent moving from one
point-of-care (POC) to another capturing data and creating information for documentation
purposes. In response to this burden, clinicians are constantly looking for a better way and are
increasingly turning to wireless technology to get some relief. As a result, many wireless
devices are augmenting or taking the place of paper-based processes and changing the way
care is accessed, delivered and documented. The result is a developing technological menu
that is redefining “mobile” as the ability to use a small computing device backed by a wireless
network—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 deploying
an application that reaches into a hospital’s legacy systems and presents a comprehensive
patient 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 market
will 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 mobile
wireless devices, their use of these for access to clinical data is spotty and only now just
breaking into double-digit percentages. A brighter sign is a recent rash of reported orders by
vendors that coincide with their rapid development and release of value-adding modules may
be an indication that vendors are reaching the critical mass of utility and value needed to ignite
the market.

What is clear is that mobile and point of care computing is changing the way physicians and
nurses practice and hospitals deliver patient care. By enabling access to clinical information
quickly and securely from any location, at any time, the overall efficiency and quality of patient
care is improved. Because of this, hospitals will continue to actively deploy and upgrade
wireless 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.

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II. PROLOGUE
Since the concept of radiophones was first discussed Key Driver For Enterprise Mobility
by 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, 2007

comic book hero Dick Tracy's wristwatch radio of the
1930s, improved two-way communication via wireless B etter Mgmt.
technology has rapidly evolved—particularly for D iffuse 48%
Workforce
healthcare over the last decade. The first telephone
paging system of 1949--designed for doctors--started
Lower
caving in to pagers in 1974 and cell phones in the Operational 33%
1980s. 1 The recent launch of wireless e-mail devices Costs
has caused Motorola, which once controlled 85% of
the market, to discontinue its paging operations in More
Remote 32%
2002—a mere three years after introduction of the Workers
Blackberry. 2
New
Of all industries, healthcare is one of the most mobile Customer 18%
and documentation intensive. A large part—at least Competition

50% of many clinical worker’s time—is spent moving
Lower
from one point-of-care (POC) to another capturing data
Service 16%
and creating information in the clinical setting for Frequencies
documentation purposes. This documentation is
captured 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%
Computers

Healthcare 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 or
and adoption of first generation mobile computers. without wireless 15%
connect)
Because of the evolution of technology and need for
greater 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 is
accessed, delivered and documented—inside or
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outside the walls of a hospital.

Booming numbers of patients, who require care from multiple specialties and the financial
need to make their hospital stay as short as possible, are pressuring clinical staff to deliver
and document patient care more safely and efficiently. Add to this the persistent shortage of
clinical professionals across all specialties and you have a perfect storm that raises the
question: How are we going to deliver patient care going forward?

In 2008, enterprise mobility has emerged as a strategic initiative among leading health care
organizations. Wireless device designers offer a plethora of useful utilities that can be
configured to fit a growing number of general and task-specific compact devices. The
richness of this technological menu has redefined “mobile” as the ability to use mobile
computing devices backed by wireless video, voice and data networks--what was once purely
a telecom issue is an IT concern today.

This report will focus on mobile patient data delivery (MPDD) market and leading vendors that
offer a robust list of modules, integration utilities and portal technology that offers the clinician
access from anywhere, anytime.

III. OVERALL DESCRIPTION
MPDD products provide the infrastructure for integrating to legacy systems and deploying an
application 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 remote
access, security, administration, personalization and data synchronization issues of mobile
computing while allowing access to inhouse patient data.
Mobile Patient Data Delivery Systems – Multip le Applications
These systems are generally an amalgamation of any number of modules and add-on utilities
that 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.
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 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 information
systems (HIS) or “best of breed” configurations to offer unified access to patient data from
anywhere using a PDA, smartphones, tablet or PC running a Web browser.
The Right Computing Device Is Situation
Dependent Wireless Devices Common to
Currently, there is no one-size-fits-all mobile solution Healthcare
for the clinician. In the hospital, computers on wheels
that were taken from room to room were the first wave.  Desk & Lap Computers
They remain common because they offer typing  Cart-based vs. Stationary
Computing Devices
capability and large screen size for rapid viewing of
 Tablets PCs
large amounts of data. These systems are hard to
 PDA
displace because of the high comfort level already  Smart Phones
established. 3  Bar Code and RFID Scanners
 Pagers
From a hardware perspective, the current sentiment is  Wireless Patient Care Devices
that tablet computers are the best way to facilitate use  VoIP Badges
of technology at the bedside. 4 Additionally, what is  Multimedia Players
seen clinically is a variety of handheld devices that  Physiologic Testing &
have been selected because they were free or bought Monitoring Devices
by the clinician with other personal uses in mind.

Knowing this, hospitals are seeking a variety of functions that can be accessed with off the
shelf devices, like PDAs and smartphones, with portal-based Web access generally a
standard offering.
Costs – From Cow Paths to Country Roads
Noted deployment challenges are dominated by costs that can more than double vendor costs
during 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
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 Professional Services – ongoing vendor support

Vendor’s pricing is customized according to the number of physicians, modules and interfaces
required by the hospital’s legacy system configuration--because of this, vendors are reluctant
to 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 Physicians
generally 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 – Free

Many of these utilities are included in the leading vendor’s offerings.

IV. BENEFITS RETURNS - Quality of Care Leads
Mobile and point of care computing is changing the Biggest Impact Better IT At POC Can Have

way physicians and nurses practice and deliver patient
care. By enabling access to clinical information quickly Improve Quality
76%
and securely from any location at any time, the overall of Care
efficiency and quality of patient care is improved when
clinicians have access to better information at the Improve Staff
16%
Efficiency
point-of-care. 7 8
Financial 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. 12
Operational
 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


 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. 16
Clinical 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. Don't
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


 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. 21
Workforce Improvement
A 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 Perception
Despite surveyed physicians, thinking computing devices used at point of care could interfere
with 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. 25
Community 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, SERVICED
The mobile IT infrastructure between acute and ambulatory “We're doing the charge
arenas continues to coalesce with VPNs and WLAN the leading capture portion first as
technologies. Physicians are carrying up to three to four mobile we see that as the meat
devices—smartphones are quickly becoming the most popular-- and potatoes, while the
mostly 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 Erskine
mandated to do so by their employer. VCUHS Chief Medical

Healthcare Use Of Wireless Technology
Because of the enterprise impact and need to generate
CAG R 2005-2010 % Share 2010
clinician buy in, a demonstration pilot is the path most
often 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%
UWB
2008 studies showed: 27 40%

WMAN
2.9%
29%
Page 10 of 28


 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 Used
Smartphones Are the Leading Devices Used By Physicians
A November 2007 survey of physicians revealed the most
Leading Mobile Device Usage
common clinical patient data computing devices and their In Healthcare
overall 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


 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 Adoption
Challenges
Clear demarcation of mobile use exists between generations of physicians. While there are
some 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. 42
Mobile Nursing Offers Greater Challenges
Greater challenge and complexity is found in nursing’s
Leading Application of Mobile Devices In
experience with mobile computing. A December 2007 Healthcare
survey 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


 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 productivity
Security Concerns – Same as Other Industries
Security concerns are universally shared across all
industries. End User's 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 & USERS
Pan-mobility solutions for patient care cross all clinical departments and are often daunting in
scope. Leading clinical stakeholders must champion these projects—particularly the Chief
Nursing 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


 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 nurses

VII. MARKET
Overall - Mobility Technology Continues Strong Growth
With many people having both private and work related Millions of U.S. Wireless Subscribers
wireless accounts, the number of U.S. wireless subscribers 450

should eclipse the total number of people (307 million) in 400

the 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 2007

An 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


N otebooks Dominates Mobile Computing
The largest share of the $88.9 billion global mobile computing market belongs to notebook
computers. 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.
Converged
Converged Mobile Devices (CMD) – Leading Handheld Device Market
CMDs are the result of mobile technologies coalescing Projected CMD Market
with 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
325.0
dynamic). The first version, Handspring, was 24.7% CAGR
2007-2012
introduced in 2000 and the iPhone is the latest popular Million 275.0
Units
example. This trend has caused HP and Palm to see Shipped
225.0
annual double-digit declines in their traditional
handheld lines while Nokia and Research In Motions 175.0

(Blackberry) have enjoyed CAGRs in the hundreds of 125M
125.0
percent. 2007 2008 2009 2010 2011 2012

Where Healthcare Is Planning Increased IT
In the general market, mobile carriers, content Spending
creators, device makers, software developers and new (Survey M arc h 2008 =- IDC)

media players, like Google, see the increasing demand Software
for 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


HEALTHCARE
Hospitals are actively deploying wireless networks and buying systems that call for active
physician usage. The problems is that despite most physicians carrying a mobile device,
utilization of hospital mobile patient data applications for access, either wirelessly or through
synching 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. 57

Mobile Patient Data Delivery Market
Claims that healthcare is nearing a tipping point in the deployment of mobile patient data
delivery 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, vendor
revenue 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


V III. TRENDS – Outside the Walls
In healthcare, we can expect numerous wireless Remote Access In Healthcare
applications crossing every specialty and locality (Healthcare Informatics Survey, Summer, 2006)

where care is delivered. Many of the future
Practioners
applications will be mobility-intensive, in that they will
58%
be focused on delivery and management of care
outside the walls of the hospital. This trend will drive Other
additional applications with many being purpose- 2%
specific at first then another round of device
consolidation. As the number of utilities that can be
consolidated into a single device increases, it is Admin.
expected that the general adoption curves will also 25% Patients
increase. 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 patient's 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. 62
Home 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


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. 67
RFID & 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 . 71
Unified 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


 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. VENDORS
Most of the vendors offering mobile application only offer one or two applications and typically
are small informational providers (e.g. drug formularies) or application specific (e.g. charge
capture/personal schedule for physicians,). There are only a handful of vendors offering a
reasonably robust listing of applications that incorporate integration and workflow engineering
to present a comprehensive picture of patient data at POC. Of these, consensus and analysis
point to PatientKeeper and Thompson Reuters Healthcare (acquired MercuryMD).
PatientKeeper is clearly the more aggressive vendor in the market and may be the leader by
revenues due to recently reported deals closing and new product releases. Thompson
Reuters is a leader in information applications for healthcare and acquired MercuryMD in
2006—little is published about their success with this acquisition, however, they have been the
leading favorite of KLAS survey respondents for the last six years.

Of special note is the HIS developers response to the demand for mobile capabilities. Here
again, PatientKeeper has integrated with most of these systems, partnered with the leaders
(Cerner, GE, Sage) and leading electronic medical record vendors while others HIS
developers (McKesson, Siemens, Dairyland) have developed their own limited mobile
capabilities. 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 consolidation
reported.

Page 19 of 28


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 hospital's various  Health Data Management's
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 results
2
Source: Publicly available records
Page 20 of 28


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 & OVERSIGHT
Numerous regulatory and standards authorities are increasingly putting pressure on IT
leadership to ensure patient and business data is securely maintained. Clearly, the need to
monitor 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


Regulatory
The more relevant regulatory considerations for mobile patient data delivery are focused on
privacy and security including:

HIPAA Regulations: Regulations covering electronic security and transmission of patient
information 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 the
power to suspend accreditation if security and disaster management programs are not in
place.

National Institute of Standards and Technology (NIST) SP800-30: Sets statutory
responsibilities under the Computer Security Act of 1987 and the Information Technology
Management 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 of
electronic health records (EHR) software to physicians, as permitted by legislative exceptions
to 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 training
services necessary to create, maintain, transmit, or receive electronic health records, and
must be used “predominantly” for this purpose. Those hospitals that do not assure
compliance with this ruling risk losing their 501c3 nonprofit status.
Associations
American Telemedicine Association is the leading resource and advocate promoting access to
medical care for consumers and health professionals via telecommunications technology.

Continua Health Alliance is comprised of over 135 technology, medical device and health
care industry leaders dedicated to making personal telehealth a reality. Continua is working to
establish a system of interoperable personal telehealth solutions that empower people and
organizations 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 to
expand the wireless frontier and advocate on behalf of their membership before the Executive
Branch, the Federal Communications Commission, Congress and state regulatory and
legislative bodies.

Page 22 of 28


Standards
The Certification Commission for Healthcare Information Technology (CCHIT) provides
certification that vendors products are HIPAA compliant out of the box

PCI Security Standards Council is a newly formed as an enforcement arm of the credit card
companies 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 provider
whenever a patient is referred. This promises to bring an end to physicians having incomplete
information by providing the necessary information to support continuity of care with the hope
of reducing medical errors.

Page 23 of 28


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