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.”

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.

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.

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.

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.

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):

At least that’s the case that was made in this blog post on the Software Advice website. The post is a few months old which is centuries in the tech world, but I have to disagree with them on their take that EMR vendors are slow to move their products to the iPad platform. In fact, I mentioned in their comments that I think every single EMR vendor has an iPad strategy.

They do get it right that doctors are adopting the iPad at a really dramatic pace. Here’s my reasons why it’s been so popular:
1. Battery life that lasts a full shift
2. 3G and Wireless Connectivity
3. Intuitive interface
4. $500 price point

We’re still waiting on some enterprise features that it seems like the Blackberry Playbook is trying to implement for healthcare. However, I’m pretty sure they’ll get there in time or someone will create an app that will create those features anyway.

Back to the iPad, the article only states 2 companies that have an iPad EMR offering. There are many more than that. I’ve seen some from Practice Fusion, GE, and VitalHealth to just name a few.

What I haven’t yet seen is how well doctors like the use of their EMR iPad interface. Is it really that usable for a doctor doing his rounds? Does it work well for clinical documentation? Is it a nice compliment to a desktop environment?

Sadly, I still can’t give my first hand account of using an EMR on an iPad. I got my refund from HIMSS since despite all the free iPad giveaways I came home without one. Oh well, the iPad 2 is out now and it would have been a shame to only won a first generation iPad. I’m told by Christmas there may even be an iPad 3, but I digress.

What might even be more interesting than EMR use on an iPad is the other creative ways that people are using iPads in healthcare. For example, I’ve heard of people using an iPad as a check in device for their clinics. There’s something cool about handing over an iPad instead of a clipboard for your patients to fill out their paperwork. I’m sure some patients would hate it, but I for one would be much happier feeling out the stack of paperwork electronically.

You know how I love to keep track of all the iPad EMR that are announced or marketed. Seems like the latest trend is to give the doctor a free iPad for selecting an iPad EMR. Not a bad strategy. Now if I could just get one of them to provide me a free iPad for reviewing their EMR *wink* *wink* but I digress.

I first read about this EMR that is available on the iPad on the Essinova site. This iPad EMR is being offered by Dr Chrono. Yes, another EMR vendor I’d never heard of before I saw this. Although, there site has them being on CNBC, Fox Business and The Wall Street Journal.

Dr Chrono’s approach is to provide a free iPad EMR app, but they take over the billing for you. Sounds a bit like Athena to me. They also say that they’re the only SureScripts certified ePrescribing app for the iPad. Maybe this was true when the video was made. I know that now there are others.

I guess maybe the next question is whether there’s an EMR vendor that won’t have something available on the iPad in the next 6 months.

At least the above is the title of the Information Week article on ClearPractice’s iPad EHR interface called Nimble. You might remember that I did a short review of the Nimble iPad EMR previously. I still stand by my comments of the Nimble iPad interface not being perfect for the iPad. The keyboard was clunky and slow to appear and the boxes were surprisingly small for a native iPad app.

Here’s the doctor in the article’s take on the iPad EMR:

Having a small office, there’s no space for a desktop in the exam rooms, so prior to recently using Nimble on the iPad, Dr. Lianna Lawson, a solo-practitioner, wheeled a laptop on cart to exam rooms.

“Laptops on carts — I don’t like that, it seems impersonal,” said Lawson, whose practice, Lawson Family Medicine and Aesthetics is based in Daleville, VA. Lawson has been using ClearPractice’s web-based EMR on a laptop for about a year. Lawson added Nimble to her practice in September.

Nimble running on the iPad, “has the feel of a [paper] chart,” Lawson. “Many doctors are traditionalists, so the comfort level with technology is difficult,” she said. “But for physicians not particularly tech savvy or reluctant of about how they’ll meet the meaningful use requirements, this gives a little more comfort and confidence,” she said.

It’s true that laptops on carts are a mess. As I recently argued in a post on healthcare mobile devices, the iPad does seem to have the right size and feel. That combined with the 3G connection helps to change the game. Although, I think we’re going to see more devices that build on top of the iPad’s innovations and provide an even better user experience for doctors.

Here’s another quote from the Doctor about the use of the Nimble iPad EMR:

Now Lawson said she brings the iPad with her wherever she goes, responding to patients “24 by 7,” when they have questions over weekends, or other after-hour concerns. In the office, she can use Nimble “while scooting around” in her exam rooms caring for patients.

There’s been other surprise perks to using the iPad-based product, namely engaging patients while using the EMR, she said. “I didn’t expect this to be the result, but patients can see” and talk about what’s on the EMR as she uses the iPad near them. The interactions can help in building a more solid dialogue between physician and patient — and can even help make records more accurate.

While Lawson was using the iPad during a patient exam recently, the patient saw that an entry on the list of medications in her health record was incorrect, and the patient reminded Lawson that she was no longer taking a particular drug. Lawson updated the information.

The first paragraph highlights what some doctors hate about an EMR. They want to leave the office at the office. They don’t want to be proverbially chained to the office since it’s all literally at the touch of their fingertips. Maybe this is why there were so many work life balance sessions at the AAFP conference I attended recently.

Patients seeing what you’re doing in your EMR has often been seen as good and bad. Some doctors love it and embrace the participation with the patients. Other doctors hate having the patients look over what they’ve done and have to answer more questions because a patient saw something on the screen which they didn’t understand. I think we all know which doctor we’d rather see. Although, we can all appreciate the uneasy feeling of someone looking over our shoulders.

The article did remind me of the images that the Nimble EMR makes available to a doctor. That part is actually really cool and the iPad is the perfect way to display and navigate those images as a doctor describes something to a patient.

I should also remind people, the iPad still doesn’t print. Although, that should be remedied relatively soon. Or there are a few hacks out there to make it happen.

I recently had the chance to see a demo of the recently announced ClearPractice iPad EHR called Nimble. I must admit that it’s pretty slick to see an EMR on an iPad. I think it’s easy to see the potential of an iPad like device tied with an EHR.

While I loved the idea of an iPad EHR, I still think that ClearPractice was missing some of the key elements. For example, a number of the input locations were far too small. I have a feeling they were just trying to cram too much onto one screen and that necessitated the small input boxes which is just not a good design for an iPad.

I also thought it felt a little clunky for the entire iPad keyboard to come up each time you wanted to enter some data. I saw another EHR that was really designed for tablets (and supposedly works on an iPad as well) from MicroFour that did a better job of this in my opinion. For example, when you went to enter the weight, it brought up a 10 key calculator. It just felt more natural the way the data was entered.

I do think the concept that ClearPractice has implemented is going to be a popular one. Their iPad software is just another interface to the same data that’s available on the desktop computer. I’m surprised we haven’t seen this before actually. Sure, it means that the EHR vendor has to maintain 2 different software programs, but that should provide a much better user experience on an iPad than just using some remote desktop tool to access your same desktop EHR program.

ClearPractice also got it right not to implement ALL of the PMS type functions into the iPad. Most of the scheduling and billing staff don’t need to be mobile and so a desktop computer works just fine for those types of functions.

Side Note: For the internet startup nerds (like myself), ClearPractice is a division of EGHC whose primary shareholder is John Doerr, a famous venture capitalist. You can read more about the company’s story in this recent New York Times article.