pervasive computing in hospitals - semantic scholar...chapter three: pervasive computing in...

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chapter three

Pervasive computing in hospitals

Jakob E. BardramUniversity of Aarhus, Aarhus, DenmarkHeribert BaldusPhilips Research Laboratories, Aachen, GermanyJesus FavelaCentro de Investigación Científica y de Educación Superior de Ensenada, Ensenada, Mexico

Contents

3.1 Introduction .................................................................................................. 503.2 Contemporary computer technology in hospitals ................................. 52

3.2.1 Patient monitoring .......................................................................... 523.2.2 Hospital information systems and

electronic patient records............................................................... 533.2.3 Picture archiving and communication systems (PACS)........... 54

3.3 Challenges for computer technology in hospitals.................................. 553.3.1 Nomadic work................................................................................. 553.3.2 Collaboration and coordination.................................................... 563.3.3 Mobility among heterogeneous devices...................................... 573.3.4 Rapid context switching ................................................................ 583.3.5 Integration of the digital and the physical world ..................... 59

3.4 Current trends in pervasive computing research for use in hospitals ...................................................................................... 593.4.1 Mobile and pervasive computing ................................................ 603.4.2 Wireless sensor networks for patient monitoring ..................... 643.4.3 New human–computer interaction technology ......................... 65

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50 Pervasive computing in healthcare

3.4.4 Hospital groupware and collaboration support ........................ 663.4.5 User authentication and security ................................................. 69

3.5 Discussions and conclusions...................................................................... 69References .............................................................................................................. 75

3.1 IntroductionPervasive computing offers a compelling vision of unobtrusive, proactiveaids to our daily life that vary with and are appropriate to our locationand activities. In many respects, pervasive computing aims at movingbeyond the desktop computer to weave itself into the very fabric of oursurroundings, being available for use when needed. Taking the workingconditions for clinicians in a hospital into account, this vision is particularlyappealing. Hospital clinicians work in a setting that is fundamentally dif-ferent from the office—they are extremely mobile and often do not evenown desks or personal computers; they work collaboratively and seldomon personal tasks on personal computers; their jobs are intrinsically tiedto the physical domain of the patient and not to digital material in computersystems; and they constantly alternate between different working contextsboth in terms of physical location and the task at hand. Mobility, collabo-ration, interruptions, ad hoc problem solving, and physical work arefundamental aspects that characterize the work of nurses, physicians,surgeons, radiologists, and so on.

In such settings, pervasive computing concepts and technology seem tooffer attractive solutions. One can easily extrapolate Weiser’s original ubiq-uitous computing vision into a hospital setting where pads (equivalent toPDAs), tabs (equivalent to tablet PCs), and liveboards (equivalent to inter-active Smart Boards) would be available in large numbers everywhere.29

These devices would all be seamlessly connected in a wired and wirelessnetwork to provide location and context awareness, available for all to useanywhere, anytime. For example, a nurse would pick up a pad in a patient’sroom and use it for small, quick jobs like documenting medicine handout;a physician would pick up a tab when arriving at the ward, be automaticallyidentified, and then use this pad during the ward round; a radiologist wouldbe able to access and present radiology images in medical-grade quality onan arbitrary liveboard in any of the conference and meeting rooms in thehospital; collaborative software systems for colocated and distributed coop-eration regarding patients and their treatments would be available on allthree devices. Location and context awareness would ensure that the properinformation would be available for easy access in all places and wouldreduce the chances of relevant medical information being overlooked.

However, for historical reasons, pervasive computing research hasfocused almost exclusively on the well-known office and home environ-ments. Taking pervasive computing into the hospital could substantiallyimprove the understanding of requirements for nonoffice environments and


Chapter three: Pervasive computing in hospitals 51

would benefit hospital procedures and thus patients and clinicians. Hence,by moving pervasive computing into the hospital, we would improve theworking conditions of clinicians and thereby help them do what they aregood at—treating and caring patients.

Moving pervasive computing into hospitals, however, puts forth a rangeof challenges. The idea of publicly available devices originally pursued inthe visions of ubiquitous computing would need to be supplemented withproper security and privacy-enabling technologies. A hospital is a ruggedenvironment that has little resemblance to office and meeting settings nor-mally studied in pervasive computing research. A hospital environmentwould put hardware and software under an extraordinary degree of wear,especially physically but also in usability—there is little room for unrespon-sive systems or complicated user interfaces in life-critical situations.

This chapter introduces some of the main computer-based systems usedin hospitals today, discusses some of the key challenges for the use ofcomputing and networking technology in today’s hospitals, and examineshow current software and hardware technology is evolving to meet some ofthese challenges.

Section 3.2 describes current computer technology used in hospitals,including hospital information systems (HIS), picture archiving and com-munication systems (PACS), and intensive care monitoring systems. Thesethree types of systems work to a different extent as the computational back-bone in all hospitals and, hence, these systems are candidates for change.

Section 3.3 discusses the core challenges to computer technology asdeployed in a hospital setting. The central argument is that contemporarycomputer technology has evolved during the last forty years to primarilysupport personal office work at a desk. Because clinical work in a hospitalis so fundamentally different from office work, many of the modern softwareand hardware components fit poorly into a hospital environment. The dis-cussion of these fundamental challenges is based on ethnographic researchon the issues faced by the hospital users of modern computers.

Pointing into the future, Section 3.4 introduces examples of currentresearch aimed at applying pervasive computing technology in hospitals.There are numerous efforts that attempt to address the challenges. Theseefforts include research on mobile computing in hospitals, location- andcontext-aware computing, wireless communication, software infrastruc-tures, support for cooperation and social awareness, and multimodal inter-action with computers (e.g., during a surgical operation).

Based on these research examples, we discuss some key considerationsto take into account when designing, developing, and deploying pervasivecomputer technology in hospitals. These considerations range from securityissues, such as user authentication, to fundamental software infrastructureand operating systems concerns, to the integration of digital systems asrepresentations of the physical world, a vital consideration for the successof digital-based pervasive technology in physical-based clinical work.



The chapter concludes with a summary of the key points that werepresented and contemplates the future direction of pervasive computing inhospitals.

3.2 Contemporary computer technology in hospitalsComputer technology is continuously evolving in hospitals. Incorporatingstand-alone solutions for monitoring and diagnosis, such as ECG monitorsand x-rays, communication technology allows distributed hospital informa-tion systems (HIS); connected picture archiving and communication systems(PACS); electronic patient records (EPR); and networked intensive care mon-itoring systems. Such types of systems are very common in all modernhospitals today.

Hospital communication is moving toward wireless solutions, which areincreasingly important for both administrative and clinical applications.Wireless and portable technologies help increase efficiency by allowing theequipment to be brought to the patients and not vice versa. Wirelessnessenables the complete mobility of devices and persons, a new degree offlexibility of caregiving, and seamless access to all different types of patientdata wherever and whenever needed, resulting in an increased quality ofcare, operational efficiency, and convenience. Wireless patient monitoring,for example, allows recovering patients to be mobile instead of being con-fined to a hospital bed close to a stationary monitor. Wireless access to patientdata and real-time vital signs allows a clinician to quickly and efficientlyassess the patient situation, without the need for immediate physical pres-ence in noncritical situations.

3.2.1 Patient monitoring

Patient monitoring systems can provide real-time, continuous, or intermit-tent assessments of critical physiological parameters. This availability of awide range of vital-sign parameters plays an important role in the clinicalbenefits that patient monitoring can provide. An unfortunate side effect isthe required cables, which tether patients to stationary monitors, compro-mise patients’ movements, and hinder access by the caregiving staff.

Traditional monitoring systems track different types of biological mea-surements (like ECG, arterial oxygen saturation (SpO2), and blood pressure)using dedicated sensors that are cabled to a measurement server (like a bedsidemonitor); via backbone connectivity these sensors can be linked to centralsurveillance systems. Building on this technology, today’s telemetry solutions(i.e., devices used to measure and transmit data) provide a certain degree ofpatient mobility by connecting cabled sensors to a body-worn telemetry-relaysystem that forwards the data to bedside monitors and surveillance systems.Enabled by a hospitalwide wireless infrastructure, the coverage of telemetrysystems is being extended from isolated, departmental solutions to hospital-wide systems. Usually, the computational infrastructure for the monitoring



and communication of clinical data is separated from that used for hospitalinformation and administration to ensure reliability and security.

Along with wireless monitoring, location-based solutions are receivingincreased attention. Patient-centric monitoring can be combined with a loca-tion estimation service, which can reliably calculate the room where a useror device is located. This could be achieved by automatically deployingwireless communication signal information from an existing telemetry infra-structure. This would make it possible to locate any patient using telemetryimmediately in the event of an alarm. By using the same technology forcaregivers, the system could also help to locate and alert the closest emer-gency responder to the patient.

3.2.2 Hospital information systems and electronic patient records

Hospital information systems encompass all the software and applicationsused in the administrative and business settings, as well as clinical environ-ments in integrated delivery networks, acute hospitals, secondary hospitals,primary care centers, free-standing medical centers, diagnostic centers, andgroup practices. Today, approximately 40 percent of HIS data is administra-tive data, while clinical data have a share of approximately 60 percent.15

Examples of administrative functions include:

• Materials and supply chain management• Assets management • Equipment maintenance• Financial management• Human resource management

Clinical systems cover:

• EPRs and patient clinical management systems• Medicine management systems• Referral and booking systems• PACS information management systems• Laboratory and pharmacy information systems• Patient management, such as order tracking, reporting, physician

access, and charting• Care management, such as care protocols and care schemes

Historically, different types of systems have been represented by separatecomputer systems and this is still the general picture. Therefore, considerableeffort is spent trying to create an integration standard that would enabledifferent types of systems from different vendors to integrate and cooperate.However, different standards exist and so far there is no generally acceptedstandard. HL7 is the U.S.-based industrial standard that is used worldwide.However, there is a European standard (HISA), and the ISO 18308 is astandard set for electronic health record (EHR) reference architectures.Hence, system interfaces to modalities and legacy systems (e.g., diagnostic

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devices or monitoring devices, either for networked access or for completeinformation system integration) are an ongoing challenge.

Nonetheless, wired and wireless networks are increasingly allowingseamless access to individual systems, providing point-of-care informationaccess, and order and clinical data entry. System access can be performedremotely from fixed terminals or mobile devices, such as tablet PCs or PDAs.Increasingly, access to specific information systems is also being integratedinto other hospital functions, such as into monitoring systems. In the future,we expect to see an increase in the integration of differing data sets fromvarious sources, particularly in clinical decision support systems. Mobileaccess to these services will allow efficient, high-quality caregiving.

3.2.3 Picture archiving and communication systems (PACS)

PACS started as the computerized replacement of conventional radiologicalfilms, opening the path toward a filmless clinical environment, wherehospital users can acquire, store, transmit, and display images digitally.Today's installations are typically small and link the intensive care unit withthe radiology department and a few workstations.

However, advances in medical digital imaging technology are makingx-rays, computer tomography (CT) scans, ultrasound (US) scans, magneticresonance imaging (MRI) scans, and other radiological data increasinglyeffective. Also, technology for PACS has significantly evolved over the lastfifteen years. PACS were mainly developed to archive, manage, and savediagnostic images obtained with different modalities. Evolving fromstand-alone radiology systems, PACS are being integrated into the health-care information system environment and cover the following areas:

• Image acquisition—interfacing with digital acquisition devices (CT,MRI, US, etc.)

• Image processing—either at the acquisition phase or post acquisition(e.g., to enhance image quality or analyze images for diagnostics)

• Image viewing—at diagnostic, reporting, consulting, and remoteworkstations

• Archiving—on short- or long-term storage devices• Communication—primarily via hospital local area networks but also

via wide area networks or public communication services• Integration—offering one integrated system to the user that includes

modality interfaces and gateways to healthcare facilities and depart-mental information systems

Driven by technology advances and medical needs requiringhigh-resolution digital images for diagnoses, increasing image resolutionand quality result in an extremely high amount of data to be processed,transported, and archived. To fulfill these requirements, there is an increas-ing trend to merge proprietary medical systems with industry-standard datastorage and network equipment. New storage solutions currently allow



hospitals to manage more than a terabyte of digital images. High-speednetworks, such as transmission via a fiber channel, are used to transport data.

New caregiving procedures increasingly require that all relevant medicaldata be available at the point of care, namely by moving devices and datato the patients rather than by moving patients to different sets of stationaryequipment. This implies a broad coverage of a reliable, fixed PACS infra-structure throughout the hospital. In addition, mobile and handheld devicesare being used more frequently by clinicians, imposing new challengesto efficient data management, such as the ability to display images onsmall screens and the need for reliable, secure, and efficient wirelesscommunication.

3.3 Challenges for computer technology in hospitalsComputers first appeared in hospital environments more than forty yearsago, mostly in support of administrative and accounting tasks. These infor-mation systems still constitute the computational backbone of many hospi-tals. However, with the adoption of EPRs, clinical decision support systems(CDSS), and computerized physician order entry (CPOE) systems, the focusof computers in hospitals is increasingly moving away from assisting inadministrative tasks to supporting health workers in patient care, wherecomputers are expected to reduce medical errors, improve quality, andreduce costs.

Work in a hospital, however, is very different from work in an office,for which traditional desktop computers were developed. Hospital workdemands close coordination and collaboration among specialists distributedin space (i.e., different locations within the hospital) or time (i.e., workingdifferent shifts). Hospital workers are constantly moving to locate colleagues,evaluate and care for patients, access information, and obtain otherresources. Thus, mobility is a characteristic element of hospital work.In addition, physicians and nurses experience frequent interruptions andoften need to change the context of their work based on their locations, thepatients they are currently attending, the notification of new lab results, orsudden changes in the states of patients. These working conditions call fora new computing paradigm that is designed for hospital work: one thatsupports collaboration and coordination, mobility, seamless interaction withheterogeneous devices, and frequent task switching.

In the remainder of this section, we describe results from field studiesthat characterize hospital work and discuss how current computer technologyfails to support it, thus introducing the need for nontraditional forms ofcomputer support.

3.3.1 Nomadic work

Most hospital workers need to move continuously to perform their dailywork to access people, knowledge, and resources.7 In addition to moving



between patients’ beds, physicians and nurses need to change locations tofind artifacts (e.g., patient records, x-ray images, and medications) or locatespecialists. Indeed, most hospital workers do not even have desks.

A recent study, conducted in the internal medicine area of a midsizeteaching hospital, estimated that hospital staff walk more than one kilometerduring each work shift.23 Physicians in particular spend about 50 percent oftheir time in “base locations,” 35 percent of their time in bed wards, and therest of their time in other areas such as hallways. Physicians move constantlyfrom one area to another spending, on average, fewer than ten minutes ina given place before changing location.

In contrast with other working environments, information in hospitalsis generally not concentrated in a single place but is distributed among acollection of artifacts in different locations. Patients’ records are maintainedand used in coordination with data on whiteboards, computers, or bindersthat are located in rooms, labs, common areas, and offices. The entire hospitalcan be seen as an information space that is "navigated" by hospital staff toget the information required to perform their work effectively.11

Physicians and nurses frequently need to locate colleagues. A physicianmight require the opinion of a specialist to confirm a diagnosis; a nursemight need to contact the doctor in charge of a patient who is showingdiscomfort or pain; a resident physician might need a couple of free handsto help with an intervention. This does not necessarily require people tomove within the hospital, but it very often does.

Hospital workers make decisions and act in ways that are highly influ-enced by their locations, the locations of others with whom they collaborate,and the locations of relevant artifacts, such as patient records or specializedequipment, required to perform their daily work.24 All of these locations areessential in determining the type of information staff might require.

In almost all situations, instant information access is required. The adop-tion of desktop-based computer technology under these circumstances intro-duces important challenges. Currently, the most common solution is placingPCs throughout the hospital. However, the process of moving to the nearestcomputer, logging into the system, locating relevant information, and log-ging out is a rather cumbersome process in many instances if only one recordneeds to be consulted or one item entered into the system. A more recenttrend is the widespread adoption of handheld computers, which increasinglyprovide access to hospital information such as EPRs through wireless net-works. It has been estimated that 40 percent of practicing physicians in theUnited States used PDAs in 2004; this is more than four times the overallconsumer adoption rate.12

3.3.2 Collaboration and coordination

Work in a hospital setting is characterized by a high degree of collaborationamong specialists, such as physicians, nurses, and pharmacists.26 A studyconducted in a public hospital reported that 70 percent of the medical staff



consulted clinical records with other doctors and nurses at least once a day,and all of those who participated in the study reported sharing this infor-mation at least once a week.14 It would be difficult to conceive of a hospitalwhere physicians and nurses do not communicate and coordinate theiractions. Nurses need doctors’ medical notes to plan and conduct their activ-ities, while doctors’ diagnoses and clinical decisions are based on the analysisof patient information obtained and captured by nursing staff. Exchanges ofinformation are intense, occurring face to face, over telephones, or asynchro-nously using different kinds of messaging systems. The patient is the centerof work activity in the hospital and his or her care is the responsibility ofseveral specialists throughout the day.

Care cannot be interrupted, nor should it be affected, by shift changes.Hospital workers make use of shared information artifacts that are flexibleenough to convey information across group boundaries and to coordinatework.26 These artifacts serve as containers of relevant patient data, as wellas a channel of communication with other individuals. The most notableexample of this is the patient record, which is used by physicians, nurses,and other hospital staff to record the work done on a patient, to extractinformation relevant to clinical work, and to support clinical decisions. Arti-facts used in a hospital to convey information should support diverse needswhile still conveying information common to all users.

The coordination of work in a hospital ward utilizes a wide range ofdifferent artifacts (whiteboards, notes, patient records, Post-its, etc.), whichare highly interdependent and supplement each other in providing an appro-priate view on the current status of work.8 Artifacts such as whiteboardshung on walls communicate information regarding patients’ conditions andlocations.28 Mobile artifacts, such as clipboards with an individual patient’srecords, provided greater detailed patient records including information onmedication administered to him or her.

The effectiveness of information artifacts depends on their location butalso on their ability to provide adequate information to the user. Due to theirdifferent professional backgrounds, hospital personnel are likely to experi-ence problems when defining and agreeing on the most useful way to rep-resent information.26 Therefore, in order to be effective, an information arti-fact has to be versatile and able to present large amounts of information ina way that is meaningful to the diverse needs of all the artifact’s users.

3.3.3 Mobility among heterogeneous devices

Clinicians are highly mobile and use many different computers and devicesas part of their daily work. Often it is difficult to keep track of where a userwas in an interrupted task or to transfer a user’s session between differentcomputers. As a result, the computational support for clinical tasks must bemanually reestablished continuously during a working day. For instance, anurse might access a desktop computer to record the medications she hasgiven to a patient. She gets interrupted to attend an urgent call and when



she returns to her previous task, she might need to log in on a differentcomputer to resume her interrupted task. The nurse might have to retraceseveral steps to get to the point she was at before the interruption took place.

The problem with current desktop computer technology is that applica-tions run in isolation on homogeneous devices. Computer interaction isdesigned with the assumption that there is only one user for each computer,which is clearly not the case in hospitals. It is difficult to move a set ofapplications or services from one computer to another, and it is even moredifficult to move them between different kinds of devices, such as from adesktop computer to a PDA. Even though portable devices like PDAs andtablet PCs are increasingly used in hospitals, there is still a need to usedifferent computers during a working day. The use of thin client technologyis attempting to address this challenge; however, current solutions still sufferfrom some of the same limitations. Most clinical applications do not run asWeb-based solutions accessible from browsers, because they often requirethe responsiveness that only a native platform application can currentlyprovide. The use of technology such as Citrix, which provides remote accessto desktop computers, does not help to resolve the limitations found indesktop-based computing because although Citrix executes remotely, it stillprovides the user with a standard desktop PC functionality.

3.3.4 Rapid context switching

Hospital workers are involved in many concurrent activities and they con-stantly alternate between these activities. Interruptions are a frequent partof hospital work as physicians and nurses need to take care of severalpatients and attend to different chores.

Constant interruptions and task switching is not exclusive of hospitalwork. Almost all workers interleave their attention across different areas ofconcern.17 As people switch from one task to another they need to integrateresources associated to the new task. A daily clinical round, for instance,involves the evaluation of several patients. To do this, the physician in chargeand a group of residents move from bed to bed, gathering information frommedical records and direct patient examinations to discuss and decide onthe plan of care for the day. The context and resources associated to eachcase are specific to each patient and often patients are treated more or lessin parallel.

Modern computer operating systems are application, rather than task,oriented. They do not integrate well the different information resources thatare associated to the care of a patient; even if one is able to display severaldocuments on the screen, switching to a new patient involves manuallyclosing each file that is currently displayed and then opening the files relatedto the new case in each application of interest. This additional work can bequite time-consuming, creates the potential for errors (e.g., if informationfrom two different patients is accidentally open in different applications),and breaks up the seamless transition desired for task switching.



3.3.5 Integration of the digital and the physical world

Clinical work is inherently tied to the physical world. In contrast tooffice-style work, which uses text documents, technical drawings, spread-sheets, and bank accounts, the main object of clinical work—the patient—ishard to represent digitally and even harder to treat and care for by usingcomputers. Even though many aspects of clinical work can be representeddigitally, such as medical records, radiology images, and basic patient infor-mation, manipulating these digital documents does not cure the patient. Asmany doctors say, “No patient has ever been cured by writing in the record.”Core clinical work inevitably lies outside of the computer and in the realmof the physical world. In this case, the physical world includes the patientand all his or her physical parts, as well as items such as medications, testsamples (e.g., blood and urine samples), and surgical instruments.

Most contemporary computer systems and clinical computer applica-tions ignore this physical dimension of clinical work and are used merelyfor retrospective record keeping. In a clinical setting, computer systemsmay provide a greater benefit to the healthcare profession if they are moreclosely tied to the physical world by being able to sense it, affect it, andaugment it. Technologies for sensing and adapting to the physical world canbe used to create a link between a (physical) patient and his or her medicalrecord or between (physical) medication and relevant online information.Technologies for affecting the physical world could include actuators formoving samples around and for adjusting surgical tables and lighting in anoperating room. Technologies could, for example, project digitally analyzedthree-dimensional images onto the body of the patient before and during anoperation to guide the surgeon.

3.4 Current trends in pervasive computing research for use in hospitals

So far, we have read how a hospital is saturated with computing technologyyet there are fundamental challenges for contemporary technology in sup-porting the nomadic, collaborative, interrupted work of clinicians. The basicideas, concepts, and principles of pervasive and ubiquitous computing offera new kind of technology that moves beyond the limitations of the personal,desktop computer and into the users’ surroundings. Going back to the orig-inal work on ubiquitous computing at Xerox PARC, support for mobile andcollaborative computing was at the core of the hardware and software devel-oped there.29 The mobile Tab and Pad and the LiveBoard worked seamlesslytogether as a common infrastructure. Location- and context-aware systemshelped users to locate each other and provided relevant information tailoredto the users’ work contexts. Different applications were able to supportremote and colocated collaborations. These original ideas seem to be veryrelevant for a hospital environment and thus several academic and industrial



research groups have worked to design reliable and effective pervasivecomputing for a hospital or clinical environment. In this section we givesome examples from this research to provide an overview of this effort andto illustrate the core challenges that this research tries to address.

3.4.1 Mobile and pervasive computing

As discussed in Section 3.3, one of the core challenges to hospital work isthe mobility of clinicians, patients, and clinical devices. This need for mobil-ity must be supported by computer technology if it is to be used in clinicalwork. The current strategy for supporting mobile work in a hospital is touse mobile computer technology (PDAs, tablet PCs, and laptops) with awireless local area network. Many hospitals now have WiFi (IEEE compat-ibility standards for wireless local area networks) and many clinicians, espe-cially physicians, use PDAs as an information repository that provides accessto handbooks on topics such as medicine, departmental procedures, clinicalguidelines, and referral forms. In many hospitals laptops are used duringward rounds to access medical information in the EPRs.

However, there are still many challenges in the current use of mobilecomputers in hospitals. These challenges relate to the following aspects:

Hardware—Mobile hardware designed for office use, such as laptops,tablet PCs, and PDAs, perform poorly in a rugged environment likea hospital. These devices break if you drop them on the floor, aredifficult to sterilize or keep sterile, cannot be cleaned with alcoholand are fragile regarding liquids in general, and are still rather heavyto carry around. As a consequence, it is not uncommon to see laptopsmounted on wheeled tables around the hospital.

Information overload—The amount of information that clinicians han-dle is enormous. They treat hundreds of patients and each patientcan have voluminous medical records. Hence, navigating this infor-mation on the small screen of a mobile device while working in ahigh-paced environment presents a core challenge to the use of mo-bile equipment in hospitals.

Heterogeneous devices—As mentioned in previous sections, cliniciansdo not use a single device. They constantly switch to different com-puters, depending on the purpose of their current tasks and locations.There is a need to move users between devices. With current mobiletechnology, the user must reestablish their user session each timethey move to another device.

Isolated devices—Clinicians often meet and engage in ad hoc, colocatedcooperation while discussing information, such as when a nurse anda physician discuss a patient’s medical treatment. Because currentmobile devices are inherently isolated, there is no technological sup-port for a colocated exchange of medical information, such as usingtwo tablet PCs together to share views and work together.



Wireless communication—The application domain demands medi-cal-grade quality of communication. However, today’s systems stillstruggle with problems like interference between wireless technolo-gies, limited bandwidth capabilities, and no network roaming withinor between wireless technologies.

Several research initiatives address these challenges. The use of con-text-aware technology is a way to mitigate information overload. In general,medical context-awareness systems characterize situations by identifying“who, where, and what.” Context-aware systems will help locate and presentrelevant information to users by taking into account contextual information,such as a user’s identity, role, location, device used, time, and status of aninformation artifact (e.g., the availability of lab results). Based on the com-bination of this information, applications could adapt to different situationsand behave optimally according to the specific situation, thus improvingcaregiving procedures. For example, when a physician carrying a PDAlinked to a context-aware system is near one of his patients, the system wouldbe able to automatically display a clinical record for that specific patient.4,24

Or—as illustrated in Figure 3.1—medical images that are relevant to anongoing operation may be shown on large displays in the operating room.By making a context-aware PACS client for the operating room, the systemcan more or less automatically provide access to relevant images based onthe knowledge of the patient, the type of operation, the surgeon, and theprogression of the operation.

Figure 3.1 A context-aware PACS displays relevant medical images during anoperation.



Context awareness can also be used for communication, enabling hos-pital staff to send different types of messages depending on environmentalconditions. For example, a physician could send a message to the doctorresponsible for a patient in the next shift when he evaluates the patient andthe laboratory results are ready. In this case, the time of day (next shift),the location of the physician (near the patient), and the availability of theresults are the conditions that trigger the delivery of the message. Contextawareness is also essential for wireless patient monitoring. One applicationof this is an emergency alarm that is transmitted to the central informationcenter if an at-risk patient is ambulating alone. In the case of patient trans-port, the alarm would first be sent to the attending clinician. Realizing suchan application requires not only information on patient mobility, but alsoon the current situation in which the patient is mobile.

Application roaming10 addresses the challenge of having multiple het-erogeneous devices in a hospital environment, some of which are mobile.Application roaming supports the transfer of a user session from one deviceto another, such as from a desktop PC to a PDA. Application roamingrequires that the session be adapted to the devices during the transfer (e.g.,the smaller screen on a PDA and its limited network access is taken intoconsideration). It is important to realize that mobile devices in a hospitalare not isolated but need to blend into the existing technological infrastruc-ture beyond mere network access. Mobile devices need to work seamlesslywith EPRs by not only providing access to clinical data, but also by coop-erating with any applications running on different computers in the hos-pital.

Device composition tries to address the challenge of isolated mobiledevices. A composite device is simply a logical device that is made ad hocfrom several distinct physical devices.25 For example, if the nurse and phy-sician, each carrying a tablet PC, met in the ward, they can put these twotablet PCs next to each other and the PCs could merge as one tablet PCwith an extended display surface. The nurse and physician can now dragand drop files, objects, and applications between the two displays andinteract with them directly. A related technique is to support informationtransfer between heterogeneous devices, such as the transfer of medicalinformation from a computer with multiple users to a personal PDA.14 Ora PDA could be used as a remote access point to a display, like an interactivewall-size display, as illustrated in Figure 3.2. Here two physicians collabo-rate by using one device each. More PDAs can be connected to the largedisplay to support a medical conference.

Looking further ahead, a parallel strategy for supporting mobilecomputing in hospitals is to embed computers everywhere in the hospital,thereby enabling clinicians to gain access to whatever information they need,regardless of location. This strategy seeks to move away from personal com-puters to publicly available computers by allowing all clinical personnel togo to an arbitrary computer and start using it as if it were a personal computer.Examples of such computers in the hospital of the future would include large



wall-based displays for conferences, displays build into the tables and wallsall over the hospital (especially in bed wards), displays built into patient beds,and mobile displays the size of today’s PDAs and tablet PCs. The mobiledisplays would still be publicly available; such devices would not be personalbut could be handed over from one user to another.

Because all contemporary operating systems—namely Windows, Linux,Mac OS—are designed for personal computers, the ability to have seamlesscontext-aware systems requires a new infrastructure layer or some funda-mental new operating systems technologies. There are needs for smoothuser identification and authentication, for migrating the user’s sessionsbetween devices, for adapting to the heterogeneous devices used, and forsupporting collaboration while moving around. Several research projectswork with these challenges, which are not isolated to a hospital environ-ment. Some projects look specifically at operating systems support for smartspaces, like the Interactive Room project at Stanford21 and the Gaia projectat the University of Illinois at Urbana-Champaign.27 Projects like Aura atCarnegie Mellon16 and Activity-Based Computing (ABC) at the Centrefor Pervasive Healthcare in Denmark6,13 research how computers may sup-port human activities and tasks on a higher conceptual level than on thelevel of files and applications, which is the case in present operating sys-tems. The ABC project specifically focuses on the challenges of the hospitalenvironment.

Figure 3.2 Device composition between a PDA and a large interactive display thatis supporting a medical conference.



3.4.2 Wireless sensor networks for patient monitoring

Cables connecting a patient to related equipment can be bulky, intrusive,inconvenient, and can even hamper access to the patient by clinicians. Toget rid of the various cables at the patient body, the next phase goes beyondtelemetry through the introduction of wireless sensors and wireless sensornetworks, to provide nonobtrusive monitoring and unlimited mobile mon-itoring. Medical body area sensor networks consist of intelligent, wirelesssensors; transducers; and devices that communicate with one another orwithin the immediate vicinity of the patient’s body. A simple example wouldbe an ID tag, three ECG electrodes, and a bedside monitor with a measure-ment module to receive the sensor signals. The electrodes would transmittheir data at regular intervals, along with an identifying code received fromthe ID tag, by sending low-power radio signals to the monitor for display.If it became necessary to monitor the patient’s blood pressure, for example,the nurse could just add a self-contained blood plethysmometer that com-bined its data with ECG data to calculate and transmit the blood pressureto the corresponding module.

As this example illustrates, rather than delivering specific, single wire-less solutions for different, individual measurements, the core concept ofmedical body sensor networking is a peer-to-peer, self-configuring platform.Peer-to-peer operation makes the network failure tolerant, as it is not depen-dent on any particular component. Self-configuration makes it possible tointegrate components into the network simply by placing them on or nearthe patient. Apart from sensors, this type of network could include datarecorders or illness-specific processing components. For example, a diabeticprocessor could combine data from glucose and ECG sensors to provide abetter and more immediate clinical picture.

In practice, the medical sensor network will mean more than just gettingrid of the cables. The ability of the sensors to communicate with nearbydevices means that if the patient needs to be moved, the caregiver could justclip a transport monitor to the head of the bed and wheel the patient off,without having to disconnect, reconnect, or reconfigure cables or sensors.As a patient’s condition improves, a caregiver would only need a singletelemetry unit to cover the whole range of parameters, as even telemetrywould become cableless, with a seamless transition between systems as thepatient physically leaves and enters the range of their bedside monitor.

There is, however, a new and interesting challenge associated with wire-less monitoring systems. If there are no physical wires connecting the patientto external devices, then how do you know which device is associated to acertain person and which signal comes from which patient?1 This problemcalls for secure and robust automatic identification solutions that operateanytime and anywhere, regardless of the devices or sensors that are attachedto patients. This capability is of vital necessity, otherwise the patients’ datacould get mixed up, causing treatment problems and, quite possibly,life-threatening situations.



Finally, medical sensor networks not only enable flexible hospital mon-itoring, but also enable the seamless transition toward “care everywhere.”Relaying the sensor network to a mobile phone can transform the phoneinto a new personal healthcare device that not only provides local displayand storage, but also can automatically forward alarm messages in criticalconditions to emergency centers.

Along with the advances of research in smart sensor technology, externalsensors (e.g., located in places such as the patient’s bed) will be increasinglyavailable and can be flexibly integrated to a patient sensor network, thusallowing completely unobtrusive monitoring. The absence of wires in asensory system means the systems could also be built into items of clothing,while advanced low-power wireless technology and intelligent power man-agement systems would ensure that they operated for months or years onsmall batteries. As a result, patients will be able to go freely about theirnormal daily lives while being well looked after.

3.4.3 New human–computer interaction technology

Looking at computer use in hospitals, some fundamental human–computerinteraction challenges become evident. The use of a keyboard and mouserequires a desk, and even using a laptop requires the user to place the laptopon a horizontal surface. In hospitals, it is not uncommon to see a laptopbeing placed on the patient’s bed as the clinician has no other flat surfaceto use. Moreover, in clinical situations there is little time and room for tediousclicking and typing. Moving to more acute and intense clinical situations,like those found in operating rooms, it is difficult, if not impossible, for thesurgeon to use a keyboard and a mouse. In many ways, new human–com-puter interfaces are needed in hospitals.

One promising technology for hands-free interaction is speech recogni-tion, which is already in use in several hospital settings. Speech recognitionis often used for transcribing continuous speech and is most notably usedfor dictating to the medical record. The use of a specialized language in thedifferent medical specialties helps to train a speech recognition engine, whichcan achieve very accurate recognition rates. Speech recognition is also usedfor executing commands. For example, in the Stryker Endosuite system(www.stryker.com) for endoscopic surgery most of the instruments and toolscan be controlled by voice commands from the surgeon. However, voicecommands are used less for clinical applications such as EPRs.

A promising technology being explored for data entry in clinical settingsis the use of a digital pen that records the user writings on special paperforms. The information can then be transmitted to a computer wirelessly byusing the pen’s Bluetooth transmitter or by placing the device in its cradle.The special paper allows the pen to register the location where the user writes,and through predesigned paper widgets it can be determined whether, forinstance, a box was checked, indicating that a medicine was administered tothe patient. The technology, developed by Anoto (www.anoto.com), allows



for a seamless transition between the physical and digital domains. This dualrepresentation facilitates data capture while allowing the information to beshared and processed.

An interesting research topic within the field of pervasive computingsupport for hospitals is the development of multimodal interaction technol-ogies for medical applications. A multimodal interaction is the idea of usingmore than one way of interacting with a system. For example, allowing auser to point to an object and say “copy this.” Multimodal interaction tech-niques are being researched in an operating room context.18,19 Today it isvery difficult for a surgeon to access medical information while operatingon a patient. If she needs to take a closer look at an x-ray, she needs tosuspend the operation and walk to a PC, which is typically located in thecorner of the operating room. Because the surgeon cannot touch the com-puter for fear of contamination, she must ask the nonsterile operation nurseto find and display the image. If context awareness was combined withmultimodal interaction techniques, the surgeon could access patient data,such as x-rays, directly perhaps by using hand movements and voice com-mands to manipulate the data. This research is still at a very preliminaryand challenging stage. There is, however, no doubt that helping cliniciansto access clinical data while their hands are busy is of central importance inhospitals.

3.4.4 Hospital groupware and collaboration support

As discussed in previous sections, collaboration is a crucial part of patientcare. However, little computer support for intra-hospital collaboration existstoday, as most forms of support are designed to assist coordination. Forexample, most HIS incorporate basic support for interdepartmental referraland requisitions, like requesting a blood test for a patient. Similarly, work-flow types of systems, like computer support for clinical guidelines, havebeen developed and implemented in hospitals, supporting the distributionof work tasks among a set of cooperating nurses and doctors.

Sharing information is central to cooperation and collaboration. Thissharing of information can occur silently without explicit communication,such as when different care professionals examine a patient’s medical records.Because the patient is usually the focus of collaborative care efforts, the patientrecord is a powerful and central tool for implicit communication and coor-dination among care professionals. Research into cooperation via commoninformation spaces reveals that additional computer support should beembedded into electronic medical records. For example, it should be possiblefor a clinician to subscribe to events and be notified when they occur (e.g.,available lab results). It should also be possible to add meta-comments to therecord for each user and to reflect an individual’s needs for seeing data inspecific ways, while not causing the data to be inaccessible to others.

Furthermore, due to the many medical conferences taking place inhospitals, groupware technology that enables online, real-time conferencing,



including video and shared access to medical records, could become quitebeneficial. For example, a physician and a radiologist may want to discussan x-ray image using a conferencing system. Currently, collaborative group-ware support exists outside the EPR and is not integrated with medicalapplications. As a consequence, clinicians need to go to special teleconferencerooms and launch special teleconferencing applications. This means that acollaborative session must somehow be arranged beforehand so that thecollaborators can reserve and physically go to a specific conference location.Furthermore, in current groupware technologies you start a session betweenspecific computers, not users. Hence, a potential collaborator must knowwhich computer his colleague is in front of so that he can contact thatcomputer and start a collaborative session.

Some research projects have looked at these challenges. In the IntelligentHospital project,22 multimedia conferences were established between users,not machines. The infrastructure routed the conference session between thecomputers used by collaborators or the ones closest to them. If the user wasmoving while engaged in a teleconference, the session would roam to followhim or her around. In the ABC project,6 support for collaboration wasdesigned to be inherent to the runtime environment—basically all sessionscan be collaborative and can have a range of participants. In an EPR imple-mented on top of the ABC environment, activities regarding the treatmentof a patient can be shared among a set of participants. If, for example, aphysician is engaged in prescribing medicine for a patient and a nursecompleted this activity as well, the physician and nurse would be given theoption to choose to communicate and cooperate directly or to continueworking individually. In the latter case, however, ABC allows them to main-tain a peripheral awareness of the actions of one another.

Supporting social awareness among collaborating colleagues in a hos-pital is another central research area within pervasive healthcare. Field stud-ies have shown that clinicians maintain a peripheral and social awarenessof one another in order to keep up to date with the flow of work and toalign their own actions to those of others.3,7,9 For example, people involvedin an operation monitor the status and progress of the operation in order tobe ready when needed.28 The AWARE architecture9 is designed to helpdevelop clinical applications that support these kinds of social awareness.Building on top of a context-aware infrastructure that collects informationabout clinicians’ locations, statuses, and current activities, the AWARE archi-tecture supports the development of different client applications that canhelp clinicians maintain a mutual social awareness. For example, the Aware-Phone has been built on top of the architecture and enables clinicians to usetheir mobile phones to look up the statuses, calendar information, and loca-tions of colleagues before calling them. By gaining access to this basic infor-mation about a colleague’s current working context, the clinician is able toreduce the number of interruptive calls. Hence, she can decide whether itwould be more appropriate to call another, less busy, colleague or to post-pone the call to a more suitable time. Similarly, the AwareMedia application



supports social awareness within an operating ward. AwareMedia runs onlarge interactive displays and shows the location, status, and current activityof all surgical personnel; the operating schedule for each operating room;the people located inside the operating room, including the patient; and avideo feed from inside the room. Figure 3.3 shows the use of the AwarePhoneand AwareMedia in an operating ward.

It has been estimated that hospital workers spend up to 5 percent oftheir work shift time tracking the locations of colleagues and hospital assets.23

This has motivated the development of location estimation solutions forhospitals. Versus Technology offers hospital tracking systems that use activeRFID in badges worn by clinicians and tags attached to artifacts. An alter-native solution is the one commercialized by Ekahau, which estimates loca-tion based on the intensity of the RF signals emitted by WiFi access pointsand that are registered in laptops or PDAs. Although less accurate, thistechnology has the advantage of not requiring additional infrastructure ifthe hospital already has a wireless network and hospital staff carry mobilecomputing devices. When integrated with context-aware mapping applica-tions, location estimation can help hospital workers find nearby colleaguesto consult a clinical decision or assist in a procedure.24 Vocera Communica-tions offers WiFi-based badges that estimate location and support two-wayvoice communication between users. These solutions foster collaboration inhighly mobile working environments and are increasingly being adopted inhospitals.

Figure 3.3 The AwarePhone and AwareMedia in use at a surgical ward.



3.4.5 User authentication and security

Studies of hospital work have revealed that frequent user log in and log outis the source of many usability problems.5 First, users log in often; sometimesa nurse will log in thirty to fifty times during a day shift. This is caused bythe combination of the nomadic nature of hospital work and the use ofdesktop PCs that force the nurse to log in every time she returns from a task.Second, conventional user authentication mechanisms do not support thecooperative nature of medical work. Often clinicians will sit together andwork on the same patient. However, because there is no such thing as a“shared log in” only one of them can be logged into the medical record ata time. Hence, they often need to take turns, logging on and off one at atime. This is often time-consuming and annoying, because they are collab-orating about the same patient. Finally, combining many log-in and log-outevents with the typical user authentication mechanisms of typing usernamesand passwords makes logging in in a hospital setting really frustrating. It isnot surprising that studies have shown that user authentication is circum-vented to a large degree at many hospitals.

Because computer security and access control to personal medical datais of the highest importance in medical computer applications, studiesregarding the trouble of logging in should be taken very seriously in thedesign of clinical applications. It is important to create secure user authen-tication mechanisms that support frequent log in and log out at a fast pacewith minimal manual and cognitive overhead. Hence, technologies likesmartcards2 and biometric systems that use methods such as fingerprintrecognition or iris scanning20 seem like appealing alternatives for this setting,and indeed, they have been deployed in several hospitals around the world.These technologies, however, also have their limitations. For security rea-sons, a user on a smartcard system still has to type in a PIN code, makingthis technology only marginally better than the username and passwordmechanism. Fingerprint recognition is ill suited in a hospital environmentwhere the staff often use latex gloves, and iris scanning is still a ratherinvasive and expensive technology. Furthermore, these user authenticationmechanisms merely address the identification and verification of a singleuser. Log-in and log-out mechanisms that acknowledge the collaborativeand mobile work environment of a hospital ward are still needed.

3.5 Discussions and conclusionsIn this chapter we discussed some of the more fundamental challenges withrespect to hospital work and we presented current trends in research intopervasive computing technology that address these challenges. Most of thetopics covered in this chapter are summarized in Table 3.1.



Tab

le 3

.1A

Su

mm

ary

of C

halle

nges

and

Tec

hnol

ogie

s

Cha

lleng

eD

escr

ipti

onT

echn

olog

y Su

ppor

tIs

sues

Sect

ion

Mob

ile a

nd n

omad

ic

wor

kH

ospi

tal w

ork

is h

ighl

y m

obile

and

mos

t us

ers

do

not

have

des

ks t

o pl

ace

com

pute

rs o

n.

Mob

ile d

evic

esPo

rtab

le a

nd s

mal

lR

obus

t ha

rdw

are

Wir

eles

s co

mm

uni

cati

onSm

all d

ispl

ays

Lim

ited

res

ourc

esIs

olat

ed d

evic

esR

equi

res

easy

acc

ess

3.3.

1, 3

.4.1

Shar

ed e

mbe

dd

ed

dev

ices

Stat

iona

ry a

nd la

rge

Pow

erfu

l d

evic

esL

arge

dis

play

sN

etw

orke

dR

equi

res

easy

acc

ess

Req

uire

s ap

plic

atio

n ro

amin

gC

olla

bora

tion

and

co

ord

inat

ion

Mos

t w

ork

in h

ospi

tals

is

high

ly c

olla

bora

tive

and

re

quir

es m

uch

coor

din

atio

n ac

ross

tim

e,

spac

e, a

nd o

rgan

izat

ion.

Coo

rdin

atio

n, b

ooki

ng,

sche

dul

ing,

wor

kflo

wE

xplic

it c

oord

inat

ion

Wor

k sc

hed

ulin

g an

d b

ooki

ng

(e.g

., op

erat

ion

plan

s)Su

ppor

t fo

r w

orkf

low

(e.

g.,

trea

tmen

t of

cer

tain

dis

ease

s)

3.3.

2, 3

.4.4

Tel

econ

fere

ncin

gR

eal-

tim

e vi

deo

conf

eren

cing

ac

ross

dis

tanc

eO

ften

req

uire

s sp

ecia

l set

up a

nd

equi

pmen

tSh

ared

med

ical

rec

ord

sU

sing

dat

a en

try

for

coor

din

atio

nSu

bscr

ibin

g fo

r ch

ange

eve

nts

Lea

ving

tra

ces



Soci

al a

war

enes

sM

utua

l aw

aren

ess

of t

he s

tatu

s of

co

mm

on w

ork

(e.g

., an

ope

rati

ng

sche

du

le)

Ren

der

ing

visi

ble

issu

es in

wor

k th

at m

ay b

e re

leva

nt t

o ot

hers

Mon

itor

ing

the

surr

ound

ings

for

cu

es o

n st

atus

3.4.

4

Dev

ice

com

posi

tion

Mer

ging

sep

arat

e d

evic

es f

or

shar

ed u

se in

an

ad h

oc m

anne

rE

asy

shar

ing

of r

esou

rces

, lik

e sc

reen

, mem

ory,

file

s, e

tc.

3.4.

1

Het

erog

eneo

us

dev

ice

roam

ing

No

dev

ice

fits

all

task

s in

a

hosp

ital

and

the

refo

re

user

s ne

ed t

o m

ove

betw

een

hete

roge

neou

s d

evic

es o

ften

.

Web

-bas

ed a

pplic

atio

nsE

asy

dep

loym

ent

Stan

dar

d t

echn

olog

yL

imit

ed f

unct

iona

lity

and

re

spon

sivi

ty

3.3.

3

App

licat

ion

roam

ing

Ad

apta

tion

to

hete

roge

neou

s d

evic

esR

equi

res

elab

orat

e m

idd

lew

are

Exp

loit

s lo

cal r

esou

rces

3.4.

1

Pati

ent

mon

itor

ing

Mon

itor

ing

of v

ital

bod

y si

gns

are

incr

easi

ngly

d

one

wir

eles

sly

whi

le

bein

g in

tegr

ated

wit

h ot

her

syst

ems.

Wir

eles

s m

onit

ors

Ad

hoc

med

ical

sen

sor

netw

orks

Mob

ile p

atie

nts

Pati

ent

iden

tifi

cati

onW

irel

ess

com

mu

nica

tion

Sens

or f

usio

nPa

tien

t lo

cati

onW

irel

ess

dev

ice

asso

ciat

ion

Con

text

-sen

siti

ve m

onit

orin

gR

esou

rce-

effi

cien

t se

curi

ty f

or

wir

eles

s se

nsor

net

wor

ks

3.2.

1, 3

.4.2

(Con

tinu

ed)



Tab

le 3

.1(C

onti

nued

)

Cha

lleng

eD

escr

ipti

onT

echn

olog

y Su

ppor

tIs

sues

Sect

ion

Rap

id c

onte

xt s

wit

chin

gC

onte

xt-a

war

e sy

stem

sSe

nsor

s to

sen

se t

he c

onte

xt (

e.g.

, lo

cati

on)

Dev

ice

adap

tati

on b

ased

on

cont

ext

Info

rmat

ion

retr

ieva

l bas

ed o

n co

ntex

tR

emin

der

s ba

sed

on

cont

ext

Tag

ging

dat

a en

try

wit

h co

ntex

t in

form

atio

n

3.3.

4, 3

.4

Inte

grat

ion

of t

he d

igit

al

and

the

phy

sica

lP

hysi

cal l

inki

ng a

nd

book

mar

king

Mak

ing

links

bet

wee

n d

igit

al

mat

eria

l and

the

phy

sica

l wor

ldT

aggi

ng u

sing

bar

cod

es o

r R

FID

3.3.

5

Aug

men

ted

rea

lity

Ove

rlay

ing

or d

ispl

ayin

g d

igit

al

mat

eria

l on

the

phys

ical

wor

ldM

ergi

ng t

he d

igit

al a

nd t

he

phys

ical

in o

ne v

iew

Use

r au

then

tica

tion

Smar

tcar

ds

Eas

y ac

cess

Req

uire

s m

anua

l int

erac

tion

, oft

en

PIN

3.4.

5

Bio

met

rics

Eas

y ac

cess

Mix

ed u

sage

in

a ho

spit

al

envi

ronm

ent

(e.g

., fi

nger

prin

t re

adin

g is

har

d w

hen

wea

ring

gl

oves

)

3.4.

5



The recurrent theme in this chapter has been the inadequacy of usingcomputer technology designed and developed for office use in a nonofficesetting like a hospital. Two of the most obvious differences are the highlymobile—or nomadic—nature of medical work in a hospital and the degreeof intense cooperation taking place. Therefore, computer support for hospitalwork must consider the fact that most hospital workers are highly mobileand require information throughout the hospital premises. Appropriate tech-nological solutions demand mobile computing and wireless networkingsolutions, through which physicians and nurses can remotely access andupdate clinical information. Coverage by a wireless network should enableaccess from multiple and diverse locations where information is required(e.g., bedside, ward, meeting rooms, etc.) while guaranteeing security.

Although it is the current state-of-the-art solution, consulting informa-tion on mobile devices can be unfeasible at times for several reasons: theuser might not have two free hands to hold the device and type or scribbleon it; there might not be an appropriate surface on which to place the device;the screen size might not be suitable for consulting images or lab results; orit might just not seem socially acceptable to consult a handheld device infront of a patient. These and related issues call for augmentation with otherforms of computer devices within the hospital, including traditional desktopcomputers as well as large displays. The locations of these devices shouldbe such that they are easily accessible to potential users while offeringguarantees for privacy. More generally, most computing technology inhospitals should be designed to be publicly available with easy access foreverybody while providing the proper mechanisms for maintaining privacy,access control, and security.

No one single device will address all requirements for informationaccess. Indeed, there is a strong demand for the seamless transfer of dataand applications from one device to another. With the implementation ofdata transfer over heterogeneous devices, a physician might receive a noti-fication indicating the availability of a patient’s x-ray images on his or herPDA or SmartPhone, move to a large display, and easily access the imagesto visualize, analyze, and possibly discuss them with a colleague. Futureinfrastructures should allow the user to log in only once and then transferinformation from one device to another quickly and effortlessly. This callsfor environments that have built-in support for application roaming anddevice composition, as discussed in Section 3.3.2.

Collaboration is absolutely vital in getting work done in a hospital and,while there is still room for improvement, functional teleconferencing tech-nologies to support collaboration are already deployed and used in manyhospitals. Workflow systems for coordinating work according to clinicalguidelines are also being implemented. While these applications are useful,in this chapter we wanted to also draw attention to other kinds of supportfor clinical cooperation, namely support for cooperation within clinicalapplications and for social awareness and implicit coordination in hospi-tals. When designing computer applications for clinical use, it is important



to consider how these applications could support these more indirect typesof cooperation.

Much coordination in hospitals is done ad hoc and implicitly. For exam-ple, even though an overall plan for the flow of operations during a dayexists, this plan is constantly adapted and adjusted to the changing circum-stances in workflow.3 Hence, methods for ad hoc adjustment must be avail-able and mechanisms for implicitly conveying the updated plan to all per-sonnel involved must be devised. Large whiteboards hanging on walls inall hospitals are extensively used for ad hoc rescheduling, for displaying theupdated schedule to all involved, and for maintaining status information ina prominent way that allows everyone to be aware of the current status ofthe plan with a glance. This is an example of implicit coordination that doesnot require explicit communication regarding the adjusted plan and its sta-tus. Because of the large number and diverse backgrounds of people on amedical team, implicit mechanisms for coordination and cooperation thatrepresent data of interest to many people are evident in many aspects ofhospital work life. Computer systems designed to support hospital workneed to take the necessity for diverse collaboration into account. Computa-tional support for implicit coordination could also help distribute and updateplans more effectively than whiteboards, making plans visible to interestedusers anytime and anyplace.

Turning to the physical context, we find that clinicians engage in manyparallel work tasks while moving physically in the hospital and using anumber of different devices. Technologies for hospital work need to takeinto account that a user’s location and task, and thus computational needs,are constantly changing. Building context-aware technologies into clinicalapplications can provide a considerable benefit by helping the users locateeach other and patients, by retrieving medical data that is relevant to thecurrent work situation, by adapting a device to the situation, and by taggingmedical entries with contextual information.

Although the discussion in this chapter mostly focused on software,there are also substantial challenges regarding the hardware to be used inhospitals. The hardware in hospitals needs to be resistant to shocks andliquids, must have limited ventilation in sterile areas, and must preferablybe embedded in cabinets or housing in the wall or in separate rooms, therebycontaining them as much as possible and making the visible parts easy toclean. Large displays, which are often needed for overviews and for lookingat large amounts of medical data, should be developed so that they can beinstalled discreetly all over the hospital. The unique demands of the hospitalenvironment is driving the development of more appropriate technologiesthan the standard desktop and laptop PCs.

In this chapter we discussed challenges and research involved with newtechnology for use in hospitals. Although many technologies are being devel-oped to support work in a hospital environment, they would be beneficialin other settings. It is not difficult to imagine how successful technologiesthat support the presentation of context-aware information, move user



sessions across heterogeneous devices, and provide device compositionwould have huge ramifications in both general businesses and the home.Hence, we argue that the challenging environment presented by a hospitalresults in technological solutions that will possess many properties that arerelevant in other settings as well.

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Body-Sensor Networks. In Lecture Notes in Computer Science, vol. 2920, Spring-er-Verlag, 2004.

2. Baentsch, M., Buhler, P., Eirich, T., Höring, F., and Oestreicher, M. Javac-ard—From Hype to Reality. IEEE Concurrency, Oct.–Dec. 1999: 36–43.

3. Bardram, J.E. Temporal Coordination—On Time and Coordination of Collab-orative Activities at a Surgical Department. Computer Supported CooperativeWork. An International Journal, 9 (2) 2000: 157–187.

4. Bardram, J.E. Applications of Context-Aware Computing in HospitalWork—Examples and Design Principles. In Proceedings of the 2004 ACM Sym-posium on Applied Computing, ACM Press, 2004, pp. 1574–1579.

5. Bardram, J.E. The Trouble with Login—On Usability and Computer Securityin Ubiquitous Computing. Personal and Ubiquitous Computing, 9 (6) 2005:357–367.

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7. Bardram, J.E. and Bossen, C. Moving to Get Ahead: Local Mobilityand Collaborative Work. In Proceedings of the Eighth European Conference onComputer Supported Cooperative Work (ECSCW 2003), Netherlands, KlüwerAcademic, 2003, pp. 355–474.

8. Bardram, J.E. and Bossen, C.A. Web of Coordinative Artifacts: CollaborativeWork at a Hospital Ward. In Proceedings of the International ACM SIGGROUPConference on Supporting Group Work (GROUP 2005), ACM Press, 2005, pp.168–176.

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