Tuesday, April 6, 2010

The iPad goes live at BIDMC

The following is a guest post from Dr. Larry Nathanson MD, who leads BIDMC's Emergency Medicine Informatics efforts. (Note that the photo contains only fictitious patient names):

I had been anxiously awaiting the arrival of my iPad --This is the form factor I have been asking (begging) of all the vendors for years. I'm very happy to say that it appears to be living up to my high expectations.

The screen is gorgeous. It's very clear and bright, I had no trouble seeing the screen in bright outdoor light. The machine seems extremely responsive -- it reacts immediately to user input and the browser renders pages as fast as my laptop. In landscape mode, its surprisingly easy to type on the on screen keyboard. I wouldn't call it "touch typing" but the autocorrection fixes almost all of the typos that are introduced when I just let my fingers fly. It turns out to be much easier to enter data than I expected, and in fact this entire review was typed completely on my iPad.

I tested it today during my shift in the ER. Initial tests with our clinical applications went amazingly well. The ED dashboard, WebOMR and Provider Order Entry all appear to function well without modification. The popup blocker does try to get in the way of new windows, but it's a only a minor annoyance. The EKGs look better onscreen than on paper. It was great having all of the clinical information right at the bedside to discuss with the patient. The only problem was that the increase in efficiency was offset by the patients and family who wanted to gawk at it.

The battery life is one of the most astounding features. I don't know how they did it but the claimed 10 hour run time might actually be more accurate than the usual inflated claims that I'm used to for mobile devices. The device arrived at full charge and after testing all day and leaving it playing several full length movies the battery still had 40% left. This could easily make it through an entire ER shift on one charge, eliminating the need for hot swappable batteries.

I am a little concerned about how well it will hold up in a clinical environment, particularly the abuse it will get in the ER. The case is very smooth and the rounded bottom makes it easy for it to slide out of a hand or off a table. I don't get the feeling it will be as forgiving of drops as some better padded (albeit heavier) devices. I'm hoping someone will create a case that has a hand strap on the back (like the Panasonic MCA has).

One problem that plagues all tablets that I've used clinically is the difficulty entering strong passwords. The onscreen keyboards of mobile devices makes it much harder to quickly enter numbers, symbols and mixed case and is, in my opinion, one of the biggest barriers to medical tablet adoption. A biometric, or other creative way of addressing this will likely be needed.

From a consumer electronics point of view I'm also impressed. When just web surfing or watching video I do like that I can just lean back and hold the iPad as I would a book or magazine. My wife found that she preferred the iPad Kindle program to the actual Kindle device. (That bodes poorly for my plans to develop software on it!)

In summary, I'm very excited -- the form factor is close to perfect and it's robust enough to keep up with a busy ER. I think this is one of the most promising developments in medical mobile computing in a long time.

There is one major drawback however: Now my iPhone seems slow and inadequate!

Sent from my iPad


Ricky said...

I completely agree. I'm a second year Med-Peds resident at UNC in Chapel Hill, NC and wrote an iPhone application (UNC Housestaff in the App Store) for use by residents and faculty. I've been in communication with hospital IT and the director of telecommunications regarding adoption of iPhone and iPad for use by housestaff and have had a positive reception.

In addition to the advantages you detail above, there's already a version of Citrix Receiver (as well as LogMeIn) available for the iPad, making it possible to use the device as a full Windows PC if needed. Unfortunately, our hospital's version of Citrix is too old to support this functionality, but upgrades may happen this year. I hope to have an iPad shortly to use with our EMR.

Unknown said...
This comment has been removed by the author.
Michelle W said...

Glad to hear an actual user review of the iPad, and thanks for the picture. I wonder how you felt about the lack of multitasking? I've heard from some that this vice might actually be a viture, but I'm still not sold that everyone only wants one application open/available at a time. Personally I think the Norton Inc Adam looks like an even bigger win for HIT than the iPad, though the proof will be when actual doctors like you put these devices through their paces.

TweetMinistries said...

I can't wait for tablet technology to become mainstream, and I think the iPad is the major player to do that. I use the Motion Computing C5 at present, but at 5 times the price.

Any aficionados of tablet medical applications should take a look at www.consentcare.com - should be a perfect fit for consenting your patients!

Anonymous said...

I would like to play with one, but think that the first generation iPads might be like the first generation netbooks -- in that what follows is what matters. I was an early netbook adopter with an Acer Aspire One, which is still a great little device. But, the netbook iterations that followed are much better. They are more powerful, have better screens, longer battery life, and just better little machines. The first generation was good, but the next generations were much better.

Here are some of the things that I see that could go into the next iPad:

1. Flash support.
2. Multitasking.
3. Webcam.

One question I have with any of these consumer devices is how they hold up to attempts to sterilize them. Mobile phones are reportedly veritable petri dishes for pathogens. How does one realistically keep clean a piece of somewhat delicate electronics?

Medical Quack said...

This is great and exactly what I was wanting to see, an enterprise healthcare test on the IPad! I was not aware of the LogMeIn application so that solves remote support and using a Windows based PC. I wonder too how long it will be before we see a full on virtual machine application developed, maybe not too far away?

If it works with Citrix VPNs, log ons to the network are covered.

I have been a long time Tablet PC user myself and have touch screen on the unit I use and have had it for a couple years now, but the price of an IPad versus the unit I have is huge, mine being a lot more expensive. Good kudos there.

I can also appreciate the durability comments too, where the unit might be good in an office set up, but the durability in the ER is something of a different color and the "sealed" units made by some tablet companies certainly have an advantage there, but who knows where we go from here, maybe a rugged IPad someday?

I tried using an onscreen keyboard on my unit a ways back and for me it was not what I preferred but good to know that for some it is ok, but that's all personal preferences too.

Great information here in this post and will look forward to reading more as everyone contributes! Thanks much!

Anonymous said...

The ipad is amazing for clinical and academic work. Does anyone out there know a way to get Epic running on it via Citrix, perhaps?

Unknown said...

I agree. One of the challanges with this device in clinical settings will be for those physicians going ePrescribing of controlled substances that may need to meet the recently released proposed requirements. This may be tough to do without the biometric reader and/or a USB port. Lots of potential though!!

Jared Houck said...

I still think there is a large gap between what many HOPE the iPad will do and what it actually CAN do. Tablet PCs have been on the market for many years and promised many of the same things. The limiting factor has been (and most likely will continue to be) software. I've listed another 10 reasons the current iPad will not be significantly deployed in healthcare if you have the time.

Robert Hurst said...

Nice appraisals and opposing views from both sides (Larry and Jared) -- I suspect the reality is somewhere in between.

I'll be watching cautiously to see how the early hype transforms hopefully into meaningful application. The smart phone and netbook are just not cutting it for me -- so I'll stick for now with lugging the Lenovo Thinkpad and remain faithful to "classic mobile computing" ...

Unknown said...

Can you print with it? I would love to trial this in our Urgent Care Center; I can get to our EHR online, and we have wireless access, but need to be able to print out patient discharge information and prescriptions. Is there an app for that?

Christine A Robb, MD

John Halamka said...

Two approaches to printing

1. Many EHRs handle printing on the server side, so that works fine.

2. For local printing, you'll need an app like Print Central (from the app store) which works fine on the iPad.

Unknown said...

Sounds like the iPad is very workable for,"Content Viewing." What about actually producing a SOAP chart note, exam findings, HPI? Not going to happen on an IPad.

webhill said...

Larry, I agree with S about the kindle app :) tho &ye ipad version is buggy & crashes when I return from a book to the app home screen about 66% of the time. Have you looked at radiographs on this ipad yet? I'm just loving how they look on mine! I can't wait til more developers create ipad optimized apps. The 2x thing is, IMO, lame. Though th DIA app (veterinary teaching images - great for tableside client education) images actually look great at 2x, just the text doesn't look so hot.

I'm a fan :)

Anonymous said...

For entering strong passwords quickly, take a look at 1Password in the Apple App Store.

Sean said...

Good post. I've been looking for any and all articles/videos/blogs that are giving the early reviews of the iPad in a clinical setting. I have a feeling many doctors are doing the same.

Does anyone know of a webinar or webcast coming up that might give a visual walkthrough of how this new device could be implemented into healthcare professionals' workflow? If not, would anyone here be interested in helping to collaborate to set this up? John -- I'd be very excited to have you show us the highlights if you'd be willing to do so...

Anonymous said...

They need to be capable of disinfection. Charts are the most likely culprits of disease transmission within a medical setting. The iPad is no different but better because you alone handle it.

I had a unique experience. I passed through airport security with a certified "cold" computer traveling to a hospital. I reviewed charts on a "clean" library table in vascular surgery. The nurses used it for lunch and always cleaned the table, including the day I was working. I left the hospital and was stopped at the airport for having an explosive contaminated computer, nitro. Security swabbed the computer so that the patterns of use, like holding it with two hands with the cover closed, were obvious. The contamination came from the "dirty books", the charts. The iPad needs Voice over iPad and will be a good replacement for charts using wifi. It may cut down on infection rates.

Bethany said...

I'm curious how you carried the iPad around at the hospital? I know of physicians who would pass on this device because it won't fit in a lab coat pocket and would be too cumbersome to carry around while making rounds.

Chris said...

Great review Jared. You raise some very valid points and I'm encouraged by the excitement the iPad is creating in this space (as evident by this thread). I wanted to address one point you made about "the limiting factor [of tablets] has been (and most likely will continue to be) software". Check out www.logicalink.com to see how we've embraced the pen and tablet for physician and patient documentation. We've been helping EMR vendors address adoption rates and usability with the tablet. The recent legislation on meaningful use has helped bring the industry to us. The big vendors have historically ignored making their apps friendly for the tablet (or user friendly in general) - it takes careful thought and they just want to build the next database to capture charges.

Those of us that have been developing tablet friendly applications for years have been begging manufacturers like Motion, Intel, Fujitsu, Lenovo and Tablet Kiosk to build a device with the iPad specs. We, along with some of our major hospital system clients, discussed the ideal device and it was met with silence. Every change they've proposed has been in tiny increments. Apple will prove them wrong and I'm excited that it will shake up the industry.

Although the world is moving away from pen/paper and to texting, I still think the stylus has an important role in instructured data. Physicians like our solution because adoption is a non-issue, they can easily annotate diagrams and enter unstrutured notes. I wish the iPad had support for a stylus and ink. And I can't believe they didn't include a camera or USB ports. But the price point, battery life, form factor for documents, and bright screen are enough of a game changer that we're investing in this space for both hospitals and clinical trials.

Sean said...

@Bethany -

That's an excellent point, but there are already companies who are quick to capitalize on the opportunity to create clothing with pockets big enough to accommodate the iPad. Check this out:


I guarantee there are some lab coat vests to come...

TweetMinistries said...

Sean, I have been involved for several years in developing a web-based consent system that produces a pdf document that is then annotated into the clinical record.

From this point of view the advent of the iPad is perfect, because it puts that ability within reach of any doctor who can be bothered about informing his patients properly and ethically.

www.consentcare.com is our site that gives the info.

Any doctor with an iPad could sign up for free while we are in BETA and take advantage of this system!!

Martin Young

Unknown said...

How delicate is the screen? I understand from Apple employees(off the record)cracking the delicate glass(?)screen would be an issue. The Kindle is some sort of polymer that is more durable. Anyone know the specs on the iPad screen?

John Halamka said...

I do know that the iPad screen has problems when you put it in a blender - see this You Tube Video for details!

smeidu said...

Despite the App craziness I strongly believe in the ‘Browser’ as the killer feature for the future of mobile devices and in special the iPad. I made an Interface Design Concept for Google Chrome on an iPad and wrote down my thoughts on alternative Webbrower for iPad OS. http://www.smeidu.com/chrome-for-ipad/

Would love to hear your feedback!

shadowfax said...

What EDIS are you running on the iPad? Just curious.

John Halamka said...

We wrote the BIDMC Emergency Department information system ourselves. It has been commercialized by Forerun Systems. I have no financial relationship to the company.

Anonymous said...

Does anyone have to use MEDITECH in their ED? Can the iPad be made compatible with this system?


Unknown said...

There is so much potential for the iPhone and iPad in the provider/hospital environment that it hard to decide what to work on first!

We're currently developing a rounds, surgical and Nephrology capitation program for the iPhone. With each new os version release from Apple, there are so many new, great sink you teeth into API's that it's hard to stop smiling!

We also sell Sage Intergy EHR on the provider side and can't wait to start developing iPad apps to interface. Steve Job's is a genius. He's certainly helping to make this fun.

Alfred Harding
CL Medical Consulting
Lubbock, TX
Sage Intergy EHR

Lucien Engelen said...

Has anybody already has some protocols or reviews on the hygienic front. We want to start using the iPad in our Hospital and looking for experiences.

Lucien Engelen
Radboud University Nijmegen Medical Center

@zorg20 on twitter

Bobby Bautista said...

We are in the testing phase using the IPADS. We are using citrix receiver to get published applications. We are hoping to use Virtual Desktops so doctors can just have the same experience of their desktop use no matter which devices they use Desktops/IPADS/IPODS etc.

DanM said...

The iPad has been tested with MEDITECH using a secrue Citrix connection. I read an article on their website about its use at Fauguier Health System (Warrenton, VA) used in physician rounding.