Case Study: Women's Cancer Center

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The physicians of the Women's Cancer Center in Palo Alto, California, are innovators in their field, pioneering the use of laparoscopic surgery as a cancer treatment. They are also breaking new ground in the application of wireless technology, pioneering the use of wireless handheld devices in the medical field. These devices don't play a part in surgery, but PDAs coupled with wireless modems and Java software do help the center manage patient data, insurance claims, and schedules. In the past year the Women's Cancer Center has gone from a method of filing claims based on paper and fax to one that is 100% electronic, and the results are impressive.

More than 30 physicians work at the Women's Cancer Center, each treating hundreds of patients each year. Up until mid-2001, the physicians filled out paper forms for each diagnosis or procedure they performed, and staff faxed these to the insurance companies for payment. The doctors documented their procedures using the insurance companies' standard codes (44950 for an appendectomy, for example). Even though a billing representative at the center audited each claim, errors and delays were inevitable.

To cite only a few of the problems:

• Doctors often filled out a month's worth of reports at a time, and often filed them more than 30 days after they performed the procedures, with an entirely predictable result of inaccurate and incomplete data.



• Paper forms weren't convenient. Doctors typically didn't carry these forms around with them, and needed to be in their offices to work on them.



• Faxes inherently introduce “information loss,” and human factors on both sides widen the margin for error.



• Incorrect code numbers could beentered all too easily.

Some kind of digital solution was in order - but what kind? Director of Operations Paul Seeley started to talk with software vendors about possible solutions. The original idea was to replace fax with email, but once Seeley started talking with Jim White of Fourth Generation, Inc. it became clear that they could actually create a much more elegant system.

The initial thought was that a simple email form or checklist sent via PDA would suffice, but as the design progressed this email-based solution evolved into a full-blown application with client and server components. “We wanted something that was truly mobile, not just wireless,” says Seeley. “Our doctors travel to many different hospitals and we needed something they could use even when out of range of the network.” Jim White and his partner had been experimenting with Java 2 Platform, Micro Edition (J2ME) since late 1999, and felt the platform was robust enough to support the requirements of the application's client side.

The ability to store some information on the device was a big feature not available to a strictly web-based application that used WAP and WML, or to an email client. The desire to maintain some data locally, combined with the need to use the application even when not connected to the network, led first to the concept of intelligence local to the device, and from there to Java technology. “We had to be able to move to different platforms, “ says White, “and Java allowed us to run on several different PDA platforms easily. C & C++ market share was dwindling while Java's share was growing, so we decided on Java”

Many of the doctors already had Palm devices, and when coupled with a wireless modem the Palm was a viable platform. White's choice as the JVM was esmertec's Jbed Micro Edition CLDC, one of the few J2ME implementations available for Palm in early 2000.

The system has a three-tier architecture:

• PDA-based (and web-based) client applications

• Servlet-based middleware that communicates with the wireless clients

• The practice management system that was already in place

White's team at Fourth Generation developed the first two tiers and integrated them with the existing practice management and billing software. Figure 1 illustrates how the system works.

Figure 1: How it Works

The hardware and software infrastructure of the system consists of:

• PDAs: Mostly Palm V handhelds

• Wireless Modems: Novatel Wireless Minstrel V

• Wireless Service: Omnisky/Earthlink

• Web Server: Apache & Tomcat

• Database: MySQL

The client software running on the Palms is actually four separate applications:

• ClinicLine is the main application, used for code capture and scheduling.

• FlashRpt allows the doctor to enter an appointment that wasn't scheduled previously by office staff.

• SwitchRg allows the doctor to switch regions when working at different hospitals (San Diego, Las Vegas, etc.)

• SyncRpt accesses the main clinic system to upload schedule information and send coded appointment and patient data back to the main clinic system.

Doctors receive schedule updates by running SyncRpt, usually several times daily. This application is much more convenient than a typical Palm sync, which requires bringing the PDA to a cradle attached to a desktop. It simply synchronizes the ClinicLine data on PDA and server over the air. It can sync records for several patients in less than 30 seconds, wirelessly. If there is no wireless service available (the device is out of range, the network is busy, etc) the device retries automatically, several times. If it still cannot synchronize, the application alerts the user to try again later. To ensure security, data is encrypted using the Bouncy Castle cryptography APIs. White would have liked to use XML for client-server messaging, but XML was “too bulky” for the low bandwidth of the wireless connections. The addition of XML parsing libraries on the client also made the memory footprint larger and program execution slower, so Fourth Generation chose a comma-delimited format instead.

One of the biggest challenges for the client application was the user interface. The insurance companies use thousands of standardized diagnosis and procedure codes, and making them all available could well use up all the memory on a device. Fortunately, the vast majority of the center's claims fall into a small subset of those codes. Only the few hundred most-used codes were included in the application, making it easy for doctors to select routine codes. The scheduling screen and the coding screen for the ClinicLine application appear in Figures 2 and 3.

Figures 2 & 3: ClinicLine Scheduling and Coding Screens

According to White, the key to creating a good user interface for small devices is to enable users to enter data simply by tapping with the stylus or clicking buttons, rather than laboriously entering text strings by hand. The ClinicLine application achieves what White terms “pokeability” by offering most data in lists, and by providing a number of buttons for access to key functions. When text entry is unavoidable, when adding a schedule entry for example, the user can poke at a virtual keyboard or use Graffiti if available.

Clinic administration staff use a similar application for scheduling, but through a browser on the desktop rather than a PDA application. As a desktop application, it can offer an enhanced user interface, and can present more information at one time. Figures 4 and 5 show views of the web-based scheduling application.

Figures 4 & 5: Console Scheduling Views

The desktop application and the PDA clients share the same interface to the server. They rely on the same servlets to send and retrieve data, and functionality is identical. Some of the doctors don't like to carry a Palm and use the web-based interface exclusively, but the majority prefer the wireless version.

Much of the software is open source, chosen because it was free and the budget was small. The deployment was relatively small, so scalability wasn't a major issue. The database didn't need to support millions, or even thousands of transactions a day because there would be only a handful of users, hitting the database only when synchronizing. “Going forward we would like to move to a database that supports real transactions (Oracle, Sybase, etc.), but for now MySQL has been working fine,” says White. “We've worked very hard to make our SQL code very generic so that it can be ported to nearly any database easily.”

The Java server applications are even more portable than the client, and can run on a variety of server hardware. Even though the client is Java too, a port would require changes to the user interface -- to work properly on a smaller screen for example. The server code should run in any J2EE environment with little more than a change to the database connect string.

Initially, the clinic hosted the web server and database on site but eventually the center decided to have Fourth Generation maintain the servers in St. Paul, Minnesota. The server environment has been tested on a number of platforms including Linux, Solaris, AIX, SCO, and Windows, and can easily be deployed on a variety of configurations for other customers. Small practices might find it easier and more economical to use a hosted ASP environment, while larger clinics could choose to host everything in house, on hardware of their choice.

Seeley estimates that more efficient handling of insurance claims saves over $20,000 per month. Claims go in faster and contain fewer errors, so fewer are rejected by the insurance companies. An all-electronic system makes it easy for the administration to track claims, a significant benefit where more than a thousand are submitted each month. In the past, claims often went unpaid for months and many were never paid because they were lost or errors couldn't be corrected.

Even more impressive are the savings in time and staff. A typical practice might employ one biller for every three doctors. With over 30 doctors, the Women's Cancer Center would be expected to have 10 billers on staff – yet it has only one. Reducing the need for billing staff saves over $250,000 a year.

Most important perhaps is the time saved by the doctors. The system has reduced the doctor's time to file a claim from over 45 days to less than eight, and with better accuracy. Instead of spending time filling out paperwork they can concentrate more on what they do best: saving people's lives. No one will argue that a doctor's time is better spent with a patient than with paperwork.

With the success of the Women's Cancer Center implementation, Jim White and Fourth Generation hope to market their system to other clinics and practices.

White hopes to incorporate the following features into future versions of the system:

• Better error checking: Making sure the diagnosis codes and procedure codes match up should reduce the number of claims the insurance companies deny because, for example, a procedure code refers to open-heart surgery and the corresponding diagnosis code refers to an ingrown toenail.

• MIDP implementation: Most doctors already have mobile phones or pagers, so one less device to carry would be a boon.

• OTA downloads of application updates: Currently updates must be uploaded by traditional synching methods.

• Reporting: Although limited reporting is available now, White plans to add better tools for generating administrative reports. The ability to pinpoint problems should lead to even more savings.

In this case the benefits of wireless access are clear: Doctors can enter patient info immediately after surgery or consultation, no matter where they are. Administrators can get nearly instantaneous, accurate information about patient billing. The biller's workload and the amount of errors are significantly reduced.

“One question we hear often is: 'Is J2ME ready for prime time?”, says White, “and my answer is absolutely yes!” White hopes to see more companies using wireless technology, and encourages anyone thinking about it to jump right in and “get rolling.” The project, now in its second year, has been a great success in terms of money, time, and ease of use. Even though these doctors are very mobile, however you probably won't see them making house calls any time soon.