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Computers in Radiology |
1 All authors: Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215.
Received August 5, 2003;
accepted after revision January 14, 2004.
Address correspondence to J. M. Busch
(jmbusch{at}bidmc.harvard.edu).
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CONCLUSION. We have implemented and described a robust mobile solution that maintains a seamless connection with the departmental intranet. Resident feedback regarding the use of the mobile solution program has confirmed our belief that using this mobile technology is a feasible and clinically practical alternative for accessing time-sensitive and educational materials. Furthermore, our description can help others deploy such digital products and facilitate the transition to soft copy that is already occurring in radiology education.
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Personal digital assistants (PDAs) are attaining widespread use in the medical community. Flanders et al. [1] recently described some of the uses and software available for PDAs that are specific to radiology. However, few reports have described the actual integration of PDA technology with radiology training programs.
Our initial vision was to use technology to simplify the lives of radiology residents while offering clinical and educational value in a mobile setting. We thought that advances in technology had made PDAs portable and powerful enough to be useful to residents as everyday reference devices. In addition, our goal was to use this mobile platform to provide convenient and simple access to critical departmental information and educational materials in a unified PDA program.
Even though the number of desktop PCs with intranet and Internet access is increasing in the workplace, a PDA can provide an alternative and faster vehicle for retrieving departmental information and commercially available educational material. The computing power of an Internet-connected desktop computer can offer access to an almost limitless amount of information. Although this information is narrowed to departmentally pertinent material by an institutional intranet, capturing the most used departmental information in a single program on a mobile device can make access to that critical information much more efficient. Consequently, we have developed a package that enables easy synchronization of Web-based departmental and educational information to PDAs (Fig. 1). In this article, we detail the development of our solution and describe its impact on our department.
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Although earlier generations of handheld computers were designed as stand-alone devices, the current generation has become more popular and useful largely because of its ability to synchronize information with PCs. A program running on the user's PC provides a means for transfer and synchronization of information between the PC and the PDA. In this way, a user may conveniently enter large amounts of data on his or her PC, synchronize the information with the PDA, and then retrieve or edit this information from the hand-held device. Conversely, any changes made on the PDA will be reflected on the PC after another synchronization.
For our department, we decided that the PDA would initially function best as a readonly device. This decision was based on three considerations that were relevant at the time of inception. First, immediate access to numbers, schedules, and imaging protocols was desired with little need to alter these data in the mobile setting. Second, the limited input capabilities of the PDA made accurate data entry slow and cumbersome and therefore suboptimal. Finally, the ability to enter into and alter pertinent information in the PDA for synchronization to a server computer could be implemented in the future as demand for the feature is defined. With these considerations, a solution was formulated by compartmentalizing the project into three areas: Web information design, compilation of Web information to PDA format, and information display and synchronization on the mobile device. However, before developing the components of the system, a handheld device and a backbone program needed to be chosen.
Choosing a PDA
With the many types of PDAs available, compromises had to be made regarding
features such as device size, processor speed, screen size and resolution,
device memory and expansion capability, connectivity, and cost. Of these
features, the most important to us were expansion capability, screen
resolution, and a small, lightweight profile because regardless of what
information and features the device offers, if you do not have it with you, it
does you no good.
Another limiting factor was the choice of the handheld operating system (OS). The two primary choices were Pocket PC (Microsoft, based on Windows CE) and Palm OS (PalmSource). Traditionally, Pocket PC devices have been more powerful, featurerich, and expandable than their Palm OS counterparts. However, these advantages also brought with them several significant drawbacks: the devices had a more complicated user interface, used more power, and, most important, were heavier and more expensive.
Palm OS devices were developed earlier and are more memory-efficient and cost-effective than Pocket PC systems. Also, the Palm OS platform currently has both a greater user and a greater programmer base than Pocket PC, and, consequently, many medical programs that are available for Palm OS have not yet been ported for Pocket PC. The differences between the two platforms are now blurring as Pocket PC systems become lighter, easier to use, and gain a greater software developer network, and as the Palm OS systems become more expandable and feature-rich. For our needs, Palm OS was chosen as the initial platform because the latest units are lightweight, have expandable memory, and use a high-resolution color display. Additional factors we considered included supporting the existing base of Palm OS users already in the department and desiring that the same device use currently available and commercially developed radiologic reference software. Our chosen PDA is the Clié PEG-T665C (Sony), which has a 16-bit color 320 x 320 pixel thin-film transistor display, weighs 4.9 oz (138.9 g), measures half an inch thick (12.7 mm), and supports a 128-MB memory expansion card. The cost to provide both the PDA and a single 128-MB Memory Stick (Sony) was approximately $300 per resident. Minimal additional cost was incurred by purchasing extra cradles to enable synchronization within the department.
Choosing the Backbone Program
We then investigated how to make our departmental intranet available on the
PDA. Current Palm OS devices do not have the native capability to upload,
process, or display HTML–based Web pages. Although we initially
considered writing a custom application to run on the PDA, several robust
software solutions (commonly known as offline Web viewers) were available for
this task.
We evaluated three popular packages: AvantGo (iAnywhere Solutions), iSilo (DC & Co.), and Plucker. Text-only solutions were not evaluated because they did not support either graphics or images. Our initial choice was AvantGo, the market leader in Internet mobile connectivity for PDAs. Although AvantGo does provide one-stop shopping as a server-based package, several major limitations were identified. The PDA browser was unable to use the 320 x 320 pixel resolution of newer Palm OS devices. Because it is a server-based package (i.e., information for the PDA is cached through an AvantGo-based server), we would become dependent on the hosting company for ongoing service. At the time, long-term stability and the cost of the services provided were not guaranteed. Last, because of the resolution restrictions, we would be unable to display radiologic images that had been planned for our "Case of the Week" feature.
The iSilo product supported high-resolution browsing with hyperlinks and included an HTML compiler that allowed the user to create Palm OS–compatible files from chosen HTML content (Web pages). These features are attractive; however, the user interface seems better suited for viewing large documents, such as textbooks, than for emulating the Web browsing experience. In addition, the compiler did not inherently support scheduled updates of the resultant Palm OS–compatible file.
The Plucker product offers an excellent and user-friendly offline viewer that provides a similar experience to a PC Web browser. The Plucker Viewer supports high-resolution browsing and image support. The package includes an HTML compiler, called the Parser/Distiller, which allows scheduled compilations of Web content, an important part of our overall mobile solution. As a part of the compilation process, Plucker offers the option of data compression, which significantly reduces the memory footprint of the application database. The Plucker product is free, open-source software and allows all components of our software package to operate on systems administered locally.
After a thorough evaluation, we chose the Plucker product as the backbone for our custom departmental package. The Plucker distribution includes both the PDA offline Web viewer application (Plucker Viewer) and a set of tools that run on Internet-connected PCs (Parser/Distiller) to copy and reformat Web sites for viewing on the PDA using the Plucker Viewer. However, use of this package (iSilo, as well) requires the retransfer and recompilation of unchanged departmental data. Therefore, every attempt was made to minimize the time or bandwidth inconvenience that resulted from this software limitation.
Developing the Components of the System
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Conversion of the Departmental Intranet to PDA-Friendly HTML
Relevant portions of the departmental intranet (e.g., schedules, contact
information) were selected for transfer to the PDA. Preparing the chosen
intranet data for PDA display required adaptation of the Web pages originally
tailored for PC Web browsers and relatively high-resolution monitors. This
conversion presented several challenges to our Web designer.
Internet pages often contain images, banners, tables, and formatting that are inappropriately sized for the PDA screen. When viewing unmodified Web pages on the PDA, the user must scroll from left to right to see the full content of the page. This operation is cumbersome and time-consuming, ultimately leading to loss of end users. Therefore, some customization is required for the hardware limitations of the PDA. Although certain aspects such as tables and large images have to be adapted for the PDA's 320 x 320 pixel screen, much of our information content is database-driven and requires only minor formatting modification for display on the PDA.
Dynamic HTML, routinely written for conventional Web browsers, contains style sheets and scripting languages that are not supported by the current version of the Plucker package. Furthermore, not all features of HTML are currently supported (e.g., tables). To avoid compatibility errors, specially limited HTML was easily used by our Web designer (the departmental intranet Web master) for the PDA-friendly Web pages. Ultimately, these simple adaptations allowed us to provide the same information on the mobile device as on departmental computers.
Additionally, the HTML-based data of the intranet contains embedded hyperlinks to other documents, Web pages, and e-mail addresses that present a challenge to a Web compiler. When copying a Web page, a Web compiler must follow all hyperlinks contained on that page. Sometimes a Web page contains unintentional embedded hyperlinks, each of which could be a Web page with multiple subsequent hyperlinks. This arrangement can result in the compiler trying to capture an enormous data set. Depending on the user-defined software settings for the compiler, this data set could be infinite in size and scope and therefore impossible to capture and load on a PDA. We call these unintentional links "hyperleaks." When creating Web pages, the designer must pay careful attention to all hyperlinks to prevent hyperleaks and subsequent failure of the compiler. However, modification of the existing intranet should require little time and expertise from a careful departmental Web master.
Getting the PDA-Friendly Intranet into a Palm OS Format
Once relevant portions of the departmental intranet were converted into
PDA-friendly HTML, attention was turned to compiling this information before
transfer to the PDA. Compiling is accomplished using the Plucker
Parser/Distiller. The compiler starts from a designated home page and copies
that Web page, with all of the text, formatting, and graphics on that page.
The program then identifies any Web pages to which this home page links and
subsequently goes to each of those pages to copy all the text, formatting, and
images. The compiler continues following and copying Web pages until a
user-defined depth of recursion is reached, a software and hardware limit is
reached, or all linked Web pages are copied. The information gathered by the
compiler is then converted into a file that is viewable with the corresponding
Palm OS application (the Plucker Viewer).
The compiled PDA-friendly Web pages function without a problem. Unfortunately, we discovered that the compiling process, using a standard PC, requires almost 10 min to complete. This delay was partially the result of including such image- and memory-intensive features as "Case of the Week," recompiling unchanged data, and our desire to use processor-intensive data compression. However, the use of compression allows a smaller memory footprint on the mobile device and requires less transfer time during synchronization. The decision was then made to run the Plucker Parser/Distiller on a designated departmental server that hid this time-consuming process from the end user, preserving simplicity and ease-of-use to maintain user compliance.
Currently, the Parser/Distiller is scheduled to compile the PDA-friendly intranet twice daily: once in the early morning to accommodate users before the start of the workday and again at the end of the workday to ensure that updates made during the day have been compiled. The resulting file produced by the Parser/Distiller (residing on a departmental computer) is sent via file transfer protocol to an intranet Web server (an institutional computer) and hosted at a specific Web address. This work flow design effectively removes the burden of the regular compiling process from the user while maintaining an up-to-date representation of the departmental intranet.
Synchronization to the Mobile Platform
With the intranet data now compiled into a single file (Plucker data file)
compatible with the Plucker Viewer, the final component of our solution could
be developed. Although the Plucker distribution package includes a conduit to
compile a Web site and then handle the transfer of the compiled Plucker data
files to the PDA from the user's computer, our use of a central Web server to
distribute an up-to-date Plucker data file presented a unique challenge and
required a custom solution.
The Palm OS uses a method called HotSync to synchronize the data between PCs and Palm OS PDAs. After a user initiates synchronization between the PC and the PDA, the HotSync Manager program running on the PC is activated. The HotSync Manager then sequentially runs several program modules called conduits, each of which handles the data transfer between the Palm OS device and the PC for one PDA application.
We needed a conduit that would download the precompiled Plucker data file from an Internet Web site and transfer it to the PDA. A sample Java conduit (Sun Microsystems) provided in the Palm OS Conduit Development Kit was customized and compiled to download the specified Plucker data file at regular intervals. The time that this data file was last updated is stored in the preferences of the PDA, and the user has some flexibility in configuring the frequency (each synchronization, daily, or weekly) that the conduit synchronizes the Plucker data file. File transfer time is minimized (< 30 sec on a broad-band connection) because of compression used during the compiling process. The average file size is 600 kB, which varies mainly because of the contents of "Case of the Week."
A simple Palm OS launcher program was also written using the C programming language to provide a custom icon with our institutional logo on the "Application Manager" menu of the Palm OS device. Although the custom Web design for this product needs to be maintained in conjunction with the departmental intranet, the custom software programming could likely be completed by a skilled Palm OS programmer within 1–2 weeks. This customized program accomplished two goals. It provided a unique program for our conduit to associate with during the HotSync process and a custom application icon, which, when selected, starts the Plucker Viewer and loads our mobile content.
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In addition, resident response suggests that the most useful departmental information on the PDA is the call schedule (Fig. 3A). By tapping on the day in question, located on the calendar, the user is hyperlinked to a page containing all of the radiology staff, fellows, residents, and technologists on call for that day (Fig. 3B). These individual listings are then hyperlinked to their contact information (i.e., pager and office telephone), and users merely have to tap the name to access that information. Because this information is generated by the departmental database, the information reflected on the PDA is identical to that displayed on a departmental computer. Personal contact information and other departmental telephone numbers are also accessible under the "Yellow Pages" tab.
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Of the educational features, the most enjoyable has been the "Case of the Week." This feature has traditionally been a hardcopy film centrally located in the department for all to view. With the advent of PACS (picture archiving and communication system), this time-honored teaching tool has been transformed to soft copy (Fig. 4). By placing it in their hands, we have given every resident the opportunity to formulate his or her own opinion before hearing the group consensus (the "Case of the Week" Web site is also available for viewing on a traditional browser).
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We have encountered few problems since the initial version was released to our 32 residents. Specifically, no complaint regarding transfer time of the Plucker data file has been filed. The modularity of the project allows components of the system to be upgraded or debugged without disrupting other components of the system. The simple data flow has been an asset for maintaining functionality in both the mobile and desktop settings. Queuing from the same departmental databases also allows easy and simultaneous content update of both the static and mobile platforms. This efficient design combination keeps user and system administrator efforts to a minimum.
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The next step in this digital medical revolution is to bring the power and functionality of the PC to the mobile device. Some have anticipated that by 2005, 50% of physicians will be using the PDA as a medical informatics tool [2]. Robust mobile platforms, such as the one deployed in our department, expand the use of the PDA by offering medical professionals efficient and reliable educational and departmental information in the palms of their hands. Our experience suggests that implementation of a mobile platform to facilitate distribution of time-sensitive information is a viable solution for other institutions with a departmental intranet.
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