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SMD Technology Manual

Made possible with the generous support of the Community Telecommunications Network Grant

TECHNOLOGY
MANUAL
Community Telecommunications Network Grant
Street Medicine Detroit
Michael Oom

SMD Intro/Background
Street Medicine Detroit (SMD) is a student-run organization that provides primary and
preventative health care to the unreached, service-resistant homeless of Detroit. What stands
us apart from other free clinic systems is that we provide care directly on the streets and in
shelters, extending the medical system to those most disconnected from it. Street teams
engage with patients during street runs and conduct a standard history and any relevant parts of
a complete physical examination. Once the exam is complete, the street teams present their
findings to the healthcare professional. An assessment is formed, and a plan is conducted. The
patient encounter ends with a debriefing with the patient and any applicable counseling. This
process is completed for each patient. When all patient exams are complete, the street run
ends, and the entire outreach team is transported back to the base of operations (Tumaini
Center) where post-run documentation is carried out.
There are over 20,000 homeless individuals living in Detroit, an alarming number with dire
consequences. It has affected our own emergency rooms and public health services, and it has
major biopsychosocial implications on those who bear homeless status. A state of
homelessness exacerbates the health problems of an individual: homeless are four to nine
times more likely to die prematurely than the general population. The Detroit Homeless Death
Prevention study demonstrated that the homeless in Detroit have a higher mortality than the
homeless of other major cities, showing their profound vulnerability. Furthermore, because of
complicated mental health issues and complex socioeconomic backgrounds, these individuals
often lack adequate health care to address their needs. This creates healthcare disparities
between the homeless and those with housing. Thus, not only have they been excluded from
the population economically and socially, they have also been excluded from our healthcare
system. We want to act as a bridge to the homeless to help them access quality health care
they have lacked for so long.
As a medical student-led organization based at WSUSOM, we established SMD to alleviate the
health and healthcare disparities prevalent among the homeless and provide training in
compassionate, patient-centered medicine in the medical education curriculum. Thus, we now
are developing our program to meet these two overarching goals.
Purpose
With SMD’s initiative for wireless broadband capabilities and tablet technology, many barriers to
quality care in the mobile clinic setting have been alleviated and are constantly being improved
upon. The purpose of this manual is to provide other groups with some of the process and
struggles we went through along the way and serve as a primer for some of the information to
be familiar with for other mobile medical clinics looking to expand their technological
capabilities.

Body
Technology has recently thrust itself into the medical field in an unprecedented way. With the
recent introductions of the HITECH Act as part of the HIPAA regulations as well as other laws
governing and rewarding the use of technology in the medical field, its use is becoming the
norm. At SMD, this was our motivation for getting up to date with our technological abilities such
that we could leverage the benefits of electronic records and utilize the internet in ways that
would allow us to deliver better care.
Our needs are far more unique in that we are a mobile clinic and any technology we use must
be mobile and accessible in the field, whether that be on the street or in a shelter. We need
solutions that allow us to safely store patient data, easily access it in the field, and fully compare
statistical metrics for research and quality improvement.
Contextual Considerations
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) has laid out strict safety
protocols with regards to the storage of Protected Health Information (PHI). The Health
Information Technology for Economic and Clinical (HITECH) Act has further specified the
precautions necessary when accessing and storing PHI electronically. We will discuss such
precautionary measures here strictly as an overview. First, someone in the group should read
up on HIPAA and the HITECH Act. It is necessary to be conscientious of the working boundary
a group must maintain in order to maintain HIPAA compliance, especially when changes to
protocol are to be made. Next, the physical storage location of the data must remain HIPAA
compliant. This dictates a certain amount of backup of the physical data, protection from
disaster, and limitations on access to the data. After doing research, we determined that as a
student organization, these were protections that we could not adequately maintain. Therefore,
the best option for us was to pay for HIPAA compliant storage via the cloud. This also helped us
meet some of our other requirements in that the data would be always accessible from
anywhere, whether we were at home or in the field. The data remains safe in that it is never
stored on the local computers/tablets (were they to be stolen). The last major HIPAA
consideration is that access to the data has to be restricted to specified users that are HIPAA
trained and given permission to access PHI. Each person using the system needs to have a
unique login when accessing data so that people’s access of PHI can be tracked should misuse
of PHI be at hand. In order to meet this requirement, we realized that our options should be
limited to pre-made EMR systems that have these functions built into them. It would not be
feasible for us to have designed a system that we could track access to PHI on our own.
EMR
In making the decision to go with an electronic medical records (EMR) system, it is important to
understand the options available as well as the implications of those systems. From the
beginning we have been using a proprietary system that is jointly used by our main partner. We
have been actively seeking to switch to our own EMR system so that we can have better control

over data. With our choice to use cloud storage and EMR, we looked to evaluate the options for
web-based EMR systems. We tested out a variety of popular services that were free for use,
including Practice Fusion, Kareo, and Charm EHR. Each system serves similar purposes and
are very effective. The details of each system are too complex for the scope of a manual like
this, but we can share what sort of questions and concerns we had in testing each system. One
requirement was that the system was accessible via Google Chrome on both Android and
Windows tablets. This was a problem for Practice Fusion as currently it uses Adobe Flash,
which however is not supported by current mobile versions of Google Chrome on Android. At
the time of this writing, Practice Fusion is actively working on a solution that is geared for the
iPad using a remote desktop style solution. Another requirement for us was to have a system to
put in custom note templates. Furthermore, this template had to be simple enough for
volunteers to easily use without much oversight. Practice Fusion did seem to best support this,
although the other systems did have some sort of templates which seemed a little too
complicated. Lastly, the most important requirement for us was to be able to export our deidentified data into a system that we could easily track the metrics for research purposes. This
proved to be the big stumbling block for all of the systems we tested as none of them had a way
to consistently export encounters for our metric tracking. This is due to the business models of
these companies with an effort to control how easily you can remove your information from the
systems. Some of the systems allow for a one time export of your data if you were to shift your
business to another provider but none of them had a system that would allow us to do this after
every encounter. With that, we are still actively searching for the system that will best serve our
needs. It was determined that some of these solutions like Practice Fusion would be great for
other groups who did not have the requirement of easily integrating into our research workflow,
provided they tackled the Adobe Flash problem. Thus, currently we are looking into developing
our own system in collaboration with another street medicine group in Santa Barbara, CA
through tools provided by Microsoft Office 365 and Microsoft Access.
Specific Technology Considerstions
Wireless Access
Wireless cellular internet access has been paramount to any of our technological endeavours to
improve patient care. We use a mobile WiFi hotspot with service through AT&T. This allows us
to connect our various tablets and computers to the internet at the same time and access all of
our patient data during patient encounters. Thus far, we have not run into many issues with
regards to wireless coverage, save for the instances in the basements of some of the shelters in
which we work. We would recommend that when choosing a wireless provider, other groups
should test out coverage in the areas in which they work before choosing a service.
Mobile Operating System Comparison
One of the biggest differences amongst our equipment is that half of our devices run Android
and half run Windows 8. These are very different operating systems in use, capabilities, and
style. In order to better understand the systems, a summary of each style may be useful before
discussing strengths and weaknesses. Windows 8 is designed for both desktop computers and
mobile tablets. In an effort to combine the interfaces in one operating system, Windows 8 may

seem disjointed and confusing. There are actually two user interface (UI) paradigms in Windows
8: Metro (or Windows 8 Style) and Desktop. The desktop mode resembles the familiar windows
from from computers using Windows 7 and earlier. The Metro UI is a more modern take on a
mobile UI. It is simple and clean. Microsoft has tried to implement a gesture based system
consisting of swipes from the edges of the screen into the Metro UI. This may become familiar
with extended use, but can be confusing to many users who are not familiar with the system.
Some apps are made for the Metro UI and some are made for the Desktop UI. Clearly, this can
lead to a good deal of confusion and it has for us. It is a common complaint about Windows 8
both amongst our users and the general population as a whole. As adoption of the newer
system becomes more common, we imagine that these systems will become more familiar and
less of a hassle. It is something that Microsoft is looking to fix on the next version of the OS.
However, even within the new Metro UI, Microsoft may have tried to oversimplify things which
actually ends up complicating things. For example, to access a search from within an app,
rather than a search bar or icon being easily accessed, one must know to swipe in from the right
side of the screen to access the search button. This is definitely not intuitive unless you have
used the system before. Another consideration is that Windows Metro UI and the Windows
Store (which contains the app for Metro UI) is still relatively young, so the app selection is far
more limited than the likes of either Android or iOS. Windows does, however, have access to all
the apps that were made for the old Windows OS’s (which run in the Desktop UI). Therefore, in
terms of software access, Windows is too young for the newer mobile Metro UI ecosystem, but
has access to thousands of older windows titles which are not necessarily designed for tablet
(and finger) use. Of note, Windows 8 (not Windows 8 RT) does support Adobe Flash within the
web browser, unlike both Android and iOS.
Android, on the other hand, is a very mature mobile operating system. It lacks some of the
legacy access that Windows has but more than makes up for that in its app selection and
usability. It uses a more standard mobile layout with a home screen and widgets, as well as an
app drawer. As an open source operating system, the Android code is available for
manufacturers to tweak and modify to their liking. Thus one company’s Android UI may look
very different than another manufacturer’s Android i.e. Samsung’s Touchwiz UI vs. Google’s
Stock Android experience. No matter the customized version, however, all the apps should work
on any Android system as each customization usually only adds additional features on to the
stock Android. Our users tended to feel more familiar with the Android devices as it has an
operating system that mimics most of their personal smartphones. Some of the strengths of
Android include that it is very extensible and easily customized to your liking and that there is a
huge app ecosystem available for it. At the same time, despite the numerous apps available, in
the medical ecosystem it seems that both Android and Windows take a back seat to Apple’s
iOS. This is simply due to the focus of app developers on iOS first. The iPad seems to be the de
Facto standard for mobile use in the medical field and thus the most innovation happens on
iOS. This is unfortunate because iOS and iPads are very limited to the capabilities provided by
Apple and aren’t at all customizable to meet the needs of a custom setup/workflow. Also, in
contrast to Windows, both Android and iOS do not have Adobe Flash capabilities within the web
browser which can severely limit the use of certain services that choose to use a Flash
implementation. We recommend that any group looking to purchase new equipment look

heavily at the capabilities of the operating system that they are looking to purchase. The apps
available for each system should be explored to fully understand the opportunity cost in
choosing one system over another.
Form Factors
We have used a variety of different tablet and computer form factors including a Microsoft
Surface Pro, Lenovo Yoga 13”, Google Nexus 10, and Samsung Galaxy Note 10.1. Each of
these has given us a feel for the advantages and disadvantages of each form factor as two of
these are slate tablet style, one is a foldable hybrid, and one has a folding keyboard cover. In
general, our users seemed to prefer using a tablet style device during the encounter but wanted
to use one with an attached keyboard for typing up notes after the encounter. Mobility has been
a very important consideration for during the encounters. The hybrid form factor of the Lenovo
Yoga seems to provide a good balance of portability and usability. The only thing going against
it is that at 13” it has a little more heft than our other options. We also have a couple of different
bluetooth keyboards to use with our android tablets which should give the dual form factor that
seems to work well. We run into some issues while trying to navigate and select text as mobile
bluetooth keyboards lack arrow keys and a mouse. Another form factor of note is that the
Microsoft Surface Pro and Samsung Galaxy Note 10.1 come with an active digitizer pen. This
allows for very accurate selection and handwriting on the device. Initially we thought this could
be very useful during patient encounters, but the more we used the devices the less so that
proved to be. In using the programs or services we use, there is simply no places for freehand
input and we haven’t found a way to fit that into our workflow. In evaluating future options or if a
group is looking to purchase devices for similar use, we think that some of the newer detachable
hybrid tablet form factors would seem to be a good option, especially around 10-12 inches in
size.
Accessories
With our use of tablets on the run, accessories like cases have been necessary in order to
protect the devices. We purchased cases for each device. Some of the tablets had 1st party
cases made that perfectly fit the form of the tablet as in the case of the Samsung Galaxy Note
10.1. Other tablets that didn’t have any 1st party cases often had relatively few choices that
were often significantly heavier and bulkier than 1st party cases tended to be. When a case is
heavier and bulkier, it can hugely impact the portability of your device, especially if it is on the
heavier side to begin with. As mentioned before, we also have bluetooth keyboards for some of
our tablets that have had varied success in their use. The lack of a mouse and arrow keys have
significantly reduced their utility when working with large amounts of text (especially if copying
and pasting). For these reasons, we highly recommend getting cases that are slim and formfitting in order to maintain the portability and we don’t fully recommend using a bluetooth
keyboard without a mouse and arrow keys. Of note, the functions and interface for using
bluetooth keyboard and pointing devices may vary from operating system to operating system.

Safety
With the use of new advanced equipment, especially in the mobile setting, safety of the devices
is a large concern due the cost of the equipment. During our street runs/ clinics, we have had
some of our medical equipment stolen. We simply do not have a way to watch over all of our
equipment at once. This has forced us to temper our use of the tablets and computers that we
have while on street runs in order to gradually incorporate them into our workflow. Our original
plan was to have each volunteer group using a tablet during the patient encounters. However,
many of our volunteers are with us for the first time which is cause for concern in adequately
protecting our equipment. We first started by only allowing our board members to use the
tablets during the runs. As we got more used to using them, we have allowed the volunteers to
use them more and more. Recently, we added a second street leader to oversee the teams on
every street run. This has allowed us to keep a better eye over things and more safely distribute
the tablets and equipment amongst our volunteers. This seems to work well provided that we
can afford to have 2 leaders on every run. Another consideration that we have looked into is
some sort of safety tether or bluetooth tether to either keep the tablets with us or alert us should
they get out of bluetooth range. Thus far, we have not invested in either of these as we haven’t
found one that we believe will work well yet. But it is worth consideration should other groups be
looking at methods to keep their equipment safe.
Accessible Resources
Another great benefit of having the power of the internet accessible is that we have found it
rather useful to us in looking up updated reference and referral guides. We use an online United
Way Resource Guide for services that are available to our patient population. The guides are
constantly updated and thus we have access to the latest information on every resource that is
available for a particular patient’s needs. Furthermore, the internet has a host of teaching
resources that we can leverage both for our patients and students. We are able to look up
current recommended treatments, drug information, current PCP information, physical exam
techniques, exercises, and student teaching materials. This has proved to be very beneficial
both for the providing care and for teaching students.
Future Possibilities
Touching on a similar topic, one of the future uses we have looked into for our technological
setup is a mobile printer system. Many of the EMR systems come with resources for patient
educational material for their particular medical conditions. With the lack of medical knowledge,
especially in our patient population, we find that this could be really useful for patients. Of
course, we do not know if our patient population would be amenable to printed patient education
material and the lower rates of literacy amongst the population would be reason for concern.
Regardless, a system could be developed to bypass these concerns given enough effort. We
see that there are many possible uses for this sort of technology setup especially as new
resources become available, particularly in the mobile medical app ecosystem. As to this and
other possible uses, we recommend that groups hold brainstorming sessions to think of novel
ideas and uses for whatever technology they invest in.

References
http://www.hhs.gov/ocr/privacy/
http://www.hhs.gov/ocr/privacy/hipaa/administrative/combined/hipaa-simplification-201303.pdf