IPad EHR | EMR and EHR

“Fat Finger Syndrome” Not Just a Google Problem

In trying to keep things light this week, I’ve taken inspiration from two very different sources – NPR and Homer Simpson. A recent Morning Edition piece on “Fat Fingers Blamed for Mobile Ad Clicks” highlights the problem many smart phone users face - large fingers on a small screen usually result in the occasional misspelling, accidental click on a field or image, or unintended dial.

The story concentrated on “Google’s launch of a new type of mobile ad that aims to combat the ‘fat finger’ problem. As the smart phone market grows, mobile ads have become more important to the tech giant, which makes most of its revenue through advertising.”

Listening to the piece, which started off with a hilarious sound bite from the Simpsons, made me wonder if EMR developers face this same type of problem when developing their software for mobile devices. What sort of consequences do providers face as a result of unintended clicks or incorrect data entry?

I polled a few friends who work in healthcare IT user experience (coincidentally, a topic that I heard come up quite often during the fall conference season), and they brought up numerous cases – some with dire consequences – of mistaken medication administration because of very similar patient names.

I also came across the ubiquitous drawback of using tablets in healthcare: “The iPad is difficult to type on, [one provider] complains, and his “fat fingers” struggle to navigate the screen,” according to a Kaiser Health News story last year.

But, providers, as they so often do, are creating workarounds. One family practice in particular has “introduced a stylus since some people occasionally suffer from ‘fat finger syndrome’ (some people just have an innate ability to miss the buttons in the questionnaire when they use their fingers).”

How have you, your practice or your colleagues dealt with pleasantly plump pads of the finger? Please share your anecdotes in the comments section below.

drChrono EHR Featured on Apple’s iPad Website

Carl Bergman recently sent me a link to a video on the Apple iPad website that profiles an urgent care center in St. Louis using the DrChrono EHR software. Here’s the intro about the urgent care facility using the iPad:

iPad makes the rounds with physicians.
Trained to handle any medical condition that comes in the door, emergency room physician Dr. Sonny Saggar treats everything from life-threatening issues to small cuts that need a few stitches. Dr. Saggar is also the medical director at Downtown Urgent Care in St. Louis, MO — and its sister location, Eureka Urgent Care in West St. Louis County. He and his staff rely on iPad to help them deliver efficient, high-quality health care. “We can often get patients precisely the care they need in less than 20 minutes,” he says.

I think it’s brave for any doctor to put a time on how long it takes to give care. Does DrChrono have a module that tells you average patient times. Did Dr. Saggar get those times from the EHR? Plus, he says that they often can which I guess could mean that they often can not? Of course, the above copy was probably written by some intern at Apple.

The page also offers these benefits to using an iPad EHR:
-Health records go paperless
-Better communication at the point of care
-Smooth operation
-More personalized care

Are these the benefits you see of using an EHR with the iPad?

We’ve written a lot about ipad EMR software on EMR and EHR. In fact, we were writing about the iPad together with EMR well before the iPad even was officially released. While doctors love the iPad, I’m still not seeing very many doctors use the iPad for their daily documentation needs. The challenge has and still is that the iPad is a great consumption device, but has yet to be a great documentation tool. I’ll be interested to see if someone will be able to crack that second nut.

Epocrates EMR Killed Immediately After Launch

Back in 2010, Epocrates had its EMR ducks in a row. The company, known best for a very popular smartphone-based drug interaction database for physicians, announced plans to release a mobile SaaS EMR. While Epocrates was jumping into a market more crowded than a barrel full of monkeys, one could see where leaders might see an EMR as an extension of the relationship it already had with physicians.

Now, Epocrates leaders have said “oops” and announced that they were killing the product, telling investors and the public that building the darned thing was distracting it from its core business. It does seem that the company was struggling with the EMR rollout process: it didn’t roll out its first-phase product until August 2011 and didn’t get its Meaningful Use certification until February of this year. But this is the first time I’ve seen a company kill a product at this stage of development, particularly in such a high-profile manner.

It must have been more than a bit embarrassing to make the announcement during HIMSS12 when, of course, companies traditionally kick off products they’re planning to sell vigorously. As Epocrates was making plans to dump or sell their EMR, the company’s CMIO, Tom Giannulli, MD, was pitching the company’s new iPad EMR to editors.

As Epocrates itself pointed out, there aren’t too many dedicated iPad EMR offerings out there. So in theory, this should not have been a waste of the company’s time. On the other hand, with the iPad still a new frontier for EMRs, we still don’t know whether it will ultimately work as a platform of choice for physicians. As we’ve previously discussed on this blog, the iPad seems to be a pretty good medium for reading data but a very awkward one for entering data. Whether that’s a fatal flaw remains to be seen.

Truthfully, this looks like a failure of execution from start to finish, rather than a product that couldn’t possibly work. But these are tough times. Even the best execution may not work; and if so, Epocrates was probably wise to fold its cards before further damage was done.

Physicians Say iPad Not Ready For Clinical Computing

Doctors love them, but don’t think the iPad is ready to play a major role in clinical practice, as Apple hasn’t done enough to optimize it for healthcare, according to a new study by Spyglass Consulting Group.

According to a new report by Spyglass, doctors don’t feel the iPad is ready to have an impact on care delivery. While 80 percent of physicians responding predicted that the iPad will have a positive impact on future care, it’s just not ready today, they said. (Most doctors I’ve talked with agree, noting that while it’s great for reading data, it’s extremely difficult to use for data entry.)

We’re not at all surprised to hear this given some of the iPad horror stories traveling around. For example, when Seattle Children’s Hospital pilot-tested iPads for its doctors, the result was a complete flop. Doctors there complained that that it was just too awkward to enter data into the otherwise sexy device. Shortly thereafter, IT switched its plans and rolled out a zero-client set-up.

So, what will it take to make the iPad clinically useful? To be successful in healthcare, Apple and its partners need to rewrite and optimize clinical apps to include gesture-based computing, natural language speech recognition, unified communications and even video conferencing, Spyglass research concludes.

I’d add that EMR/EHR vendors need to create native front ends for the iPad; given its penetration among doctors, I’m baffled by vendors who demand that doctors use their system via Citrix or the Web.

Unfortunately, with the exception of Epic’s Canto, few vendors offer a fully-fledged iPad app as a front end to their system. (One of few examples of a native iPad app from a smaller EMR vendor comes from Dr. Chrono, which, perhaps not so coincidentally, just got $2.8 million in venture funding.)

What’s more, Apple will have to do something about iOS security. It’s little wonder that 75 percent of doctors said that hospital IT departments weren’t eager to support mobile devices on corporate networks. While any device exposes networks to additional threats, Apple seems to have some particularly difficult problems, especially where its Safari browser is concerned.

Like the doctors surveyed by Spyglass, I have little doubt that iPads will end up assuming an important role in healthcare. But given the snail’s pace at which native iPad apps are being launched, it may be a long time before that happens.

Obstacles To Using Tablets As EMR Front Ends

Not long ago, I recently posted an item on HospitalEMRandEHR.com discussing how one hospital dropped plans to distribute iPads as front-ends for its Cerner EMR. Doctors at hospital, Seattle Children’s, gave the iPad very bad reviews as an EMR-connected device, in part because they felt that Cerner’s system was too hard to use via a Safari browser.

Since then, a few readers have commented on the story, and interestingly, they’ve offered more nuanced feedback on what works (and doesn’t) in deploying a tablet as an EMR device for clinical use, including the following:

* Deploying the iPad initially offers a patient “wow factor” — in other words, it may make providers look hip and up-to-date technically — but that doesn’t last very long.

* Even a well-designed, tablet-native tablet app may still be frustrating for clinicians to use, given the high volume of information they need to enter. (Paging through a dozen screens is no fun.)

* When choosing a tablet, be aware that the physical performance of the tablet (especially the touch screen) can be a big issue. If clinicians “touch” and the screen doesn’t respond, it can throw them off their stride.

It’s hard to argue that hospitals (and medical practices) should take mobile access to EMRs seriously. And anyone here would know, most organizations are. After all, now that health IT industry is looking hard at mHealth, smart new ways to use mobile devices in care seem to be springing up daily.

But before you dig too deeply into your mobile strategy, you may want to hear more clinicians on how their mobile EMR usage is playing out. Call me a curmudgeon, but it seems to me that it may still be too early to invest big bucks in a tablet for mobilizing your EMR just yet.

Don’t get me wrong: I’m convinced that someday, every doctor will enter and access patient data via some sort of mobile device. But it seems that there’s some fairly important technical issues that still need to work themselves out before we can say “this is how we should do it.”

Reasons to Not Use Virtual Desktop Access to Your EMR on an Ipad

I found this great article which highlights a number of the reasons I’ve been saying that the iPad needs its own native EMR interface and not just some Virtual Desktop solution to access your EMR.

First it offers two reasons why the Virtual Desktop solution is a good option:
-Security
-Cost

The first benefit of security is a good once since as long as your virtual desktop and access to your virtual desktop are secured, then you don’t have to worry about healthcare related data on the iPad. The second benefit is mostly a benefit to the EMR software vendor. Sure, they could make the argument that the price to develop a native iPad app is passed on to the end user. However, most doctors won’t feel that cost. In most cases it just means that other features on the EMR development roadmap will just get pushed back. Although, even this can be a bad strategy if your developers are good at developing EMR software on your current platform, but aren’t familiar with developing a native iPad app. Then, it’s worth spending some money on an iOS developer who knows which features of the iPad they can really leverage.

Now on to the reasons the article suggests that you develop a native iPad app and not just do the virtual desktop solution:
-Doesn’t Make Use of Native iPad Functionality
-Requires Constant Connectivity
-Virtualized Apps are Not Optimized for the iPad

The first and third in the list are very much related and are the biggest reasons why a native iPad EMR app makes so much sense if you’re going to do something on the iPad. The second item actually doesn’t apply very well to an iPad EMR app which even when created as a native app will likely need to have internet connectivity to have any value. An EMR iPad app could be made that didn’t need connectivity, but I have yet to see one that’s done that.

Black Friday Sales Boost mHealth App Predictions

The holiday season is officially upon us, or so said both of my daughters after they saw Santa Claus conclude the Macy’s Thanksgiving Day parade. Black Friday and Cyber Monday have come and gone – not unnoticed by the average American consumer if recently released retail figures are any indication. The economy seems on the verge of a slight upswing, if our holiday spending this early in the season is any indication.

How does healthcare fit into all this? Two holiday headlines recently caught my eye. The first, “Apple Breaks Black Friday Record,” notes that iPad sales “surged 68%” that particular day, breaking the company’s own purported predictions that it would achieve Black Friday sales four times higher than normal. The second, “Mobile Healthcare and Medical App Downloads to Reach 44 Million Next Year, Rising to 142 Million in 2016,” makes the prediction that “[a]cceptance of new healthcare practices like remote patient monitoring will come directly from consumers becoming engaged in mHealth through the smartphone.”

Forty-four million medical app downloads next year might not be such a high number to reach when you take Apple’s record one-day iPad sales into consideration. Physicians and healthcare consumers alike seem to not only be jumping onto the tablet bandwagon, but gearing up to race it to the finish line as well.

So now that we’ve established the healthcare connection, what’s all this got to do with EMRs? Will these predictions and likely outcomes coincide with an upswing in mobile EMR app development? As of yesterday, 60 apps popped up when I searched for “EMR” apps for the iPad in the iTunes store. Forty-seven results came up for “EHR,” many of them the same. I’ll be interested to see what this number is six months and then a year from now.

As this blog has well documented for some time now, healthcare’s love affair with the iPad was a slow burn at first, but has now become fast and furious. I can only imagine that EMR developers will take their relationships with the iPad to the next level in record time just to meet customer demand. While I won’t necessarily be waiting with baited breath for Practice Fusion’s launch next year of its iPad app, I will definitely check it out while at HIMSS, where I assume they’ll give it a Vegas-style launch.

I’d love to hear from physicians as to how inundated the market is likely to become with these types of technologies. And aside from EMR/EHR apps, will mobile health downloads really take off as predicted? Share your own predictions in the comments below.

Full Disclosure: Practice Fusion is an advertiser on this site, but they didn’t pay Jennifer to mention their iPad app. In fact, I’m not even sure if Jennifer knows they’re an advertiser.

The Must Have EMR Feature – An iPad Interface

I’ve written many times about the amazing phenomenon that we call the iPad and particularly how EMR vendors are reacting to the widespread adoption of iPads in healthcare. As I’ve written these dozens of articles, talked to hundreds of doctors, and far too many EHR vendors it’s become clear to me that an iPad interface is basically a Must Have feature for an EMR.

No, I’m not talking about some remote desktop type connection from the iPad to an EMR. Yes, every EMR is available on the iPad using a remote desktop type application. While that’s neat that it can do that, EMR vendors whose whole iPad strategy revolves around remotely accessing your PC which can run their EMR software are missing out on the real benefits of the iPad. The love affair that so many people have with their iPad is much more than just remote connectivity and a small touchscreen device. If that was all that mattered, tablets would have gone mainstream in healthcare long ago.

If an EMR vendor wants to leverage what’s made the iPad so popular, they need to create a native iPad app that can interact with their EHR software.

I’m not talking about replicating your entire EHR software on the iPad. That would be a mistake as well. Does your biller really need to do the billing on the iPad? Do you really want to do all your documentation on the iPad? Probably not, but with some thoughtful discussions with your existing EHR users, I think vendors will find some real value in leveraging the iPad technology connected to their EHR software.

I can imagine EHR vendors that create beautifully done iPad EMR apps will do very well in the market. Why? Because the doctors that love their iPad EMR app will start showing it off to their doctor friends.

My biggest fear with this commentary is that far too many EHR vendors are busy coding for meaningful use and EHR certification that they’re not looking for smart ways to leverage technologies like the iPad. Time will tell how this plays out, but I’ll be surprised if the iPad doesn’t play a part.

Could the iPad app of an EMR vendor become a real differentiator between the 300+ EHR vendors out there today? I’ve long believed that the biggest problem with EHR software today was their interface. The iPad is all about a new interface.

iPad EHR Concerns

Tripp Weeks, President of XLEMR, sent over an interesting list of concerns he and the people at XLEMR are going over when it comes to the iPad. As most readers know, we’ve talked about the various iPad EHR options many times before. However, I think Tripp’s analysis of the challenges and concerns of EHR on the iPad are worth a much larger discussion. So, here’s Tripp’s comments (with some minor revisions by me).

1) Readability – The ipad only has so much glass, our clients constantly ask us to display more details at a larger font on our larger piece of glass. Our strength is that we can easily scale Excel as needed to satisfy this request.
2) Speed – My personal observations of ipad users are that:
a) Data Entry – They only seem to look at the iPad, not actually use them for any real data entry other than a Web Search. Your point about a stylus is excellent, but I am just not convinced it will be any faster than using a stylus on our convertible based tablet solutions. Doctors frequently don’t use the stylus and prefer the keyboard and mouse.
b) Navigation – When they want to do something simple like calculate some numbers, it takes iPad users longer than it takes me to do it in my head. There seems to be a lot of “drill down” to get to where you want to be. While our application presents nearly all the data on a sliding window which is very fast navigation.
c) Comfort – Learning an iPad Application with as many data entry points as an EMR has is going to take training. This is a deal killer for most applications that are considered “too complicated to use” because it takes the physician too long to get the job done.
3) Cost – Our product will not be “free” it will cost approximately $400/month because it delivers this much value. I am concerned that the iPad market will not support this cost.

After reading our previous iPad EHR posts Tripp also offered this summary of our previous discussions and the missing discussion about speed on an iPad.
1) Buzz – It’s what’s cool.
2) Tool or Toy – Seems to be more toy than tool.
3) RDP – Quick and Easy and cumbersome.
4) Speed – I was fascinated to NOT hear SPEED discussed anywhere in the blogging. Our EHR application is as fast as Excel, which is dang fast, like instant. And yet our clients constantly want to go even faster and at the same time demand we capture even greater volumes of information. I feel we have seen all Certified EHR’s need to increase the data capture volume to meet current MU requirements, you can bet this will only increase in the future. I admit that I don’t have an iPad. But when I see iPads in practice in meetings and in public, what I see isn’t even close to as fast as my clients would demand for comprehensive medical data capture… And SPEED is the deal killer, I have witnessed the big box EHR’s get thrown out time and time again over issues that all fundamentally all boil down to lack of SPEED.

Some really interesting points of discussion. I love when EHR companies open up their discussion like this to a broader group for discussion and understanding. Reminds me of my early days of blogging and participating on the EMRUpdate forum. We’d have these type of discussions all the time.

My quick thoughts on some of the points above.

I agree that most doctors don’t and won’t do much data entry on the iPad itself, but mostly will use it as a viewing device. The exception might be for things like orders, prescriptions, diagnoses codes and billing items. However, I haven’t seen many people using the iPad for the other charting. Nurses capturing vital signs is another place where data entry on the iPad can work well. I’m interested to see some voice recognition enabled EHR software on the iPad. Although, the iPad processor might not be ready for this type of experience…yet?

$400/month will definitely not be supported by the iPad market. The standard for iPad EHR software up until now has been free. Or I guess I should say that the cost has been bundled into the price of the EHR. I think charging for the iPad software itself would not go over well.

Speed is an issue on the iPad. Although, I think there are 2 parts of speed. One is speed of navigation. The second is speed of data entry. I think the iPad is as good or better than any device when it comes to speed of navigation. It’s the speed of data entry where I think it’s still in its infancy.

VitalHealth iPad Like EHR Interface

During my time at HIMSS, one EHR vendor, VitalHealth EHR, made the pitch to me that they’ve really created an EHR from the ground up that was more innovative and usable than all the other EHR software out there. They described the doctors that stopped by their booth and saw a demo loved their interface and wondered why all the EHR software companies hadn’t done something similar. While an interesting pitch, I asked them whether such a pitch would be able to be heard above all the EMR noise.

After such a pitch I was certainly interested to see the product demo myself. I should say that going into the demo they’d told me that it was still in beta (maybe even alpha). Their website says it will become generally available in Q3 of 2011.

They did a demo of their product on a touch screen computer (I think they should have done it on the iPad. Especially with all the iPad Mania in Healthcare). However, the thing that struck me most was that even on this touch screen computer it looked and felt like an iPad. I’m not sure if they got their inspiration from the iPad and iPhone or if the iPad and iPhone stole it from them (I think I know which), but I was pretty amazed at how similar the interface and navigation felt to that of the iPad.

Unfortunately, outside of the interface, the feature set of the product was pretty disappointing. I asked them to do what I thought would be some pretty simple things (I think it was something with diagnosing) and that feature wasn’t quite built. Not all that surprising since they’re still in beta. Plus, I imagine they were trying to get something together before HIMSS. What will be more interesting is to see them after a year of development under their belt. Will they be able to get the required feature set for it to be a viable alternative? I’ll be certainly keeping an eye on it.

A post like this wouldn’t be worth anything without some screenshots of this “iPad” like interface. I’m not sure these screenshots quite do it justice since the navigation matters too, but you’ll notice some specific design things they’ve done to enable the touch screen capabilities of an iPad and similar devices. Either way, I love seeing EHR screenshots, so here’s a bunch of the VitalHealth EHR screenshots (click on them once to see a bigger shot. Click a second time to see it full size):