There’s a lot of talk in the healthcare industry right now about bringing health management tools to the consumer. Whether it’s apps for your iPhone or iPad, games to play on your Wii, or free-standing health-and-wellness kiosks at your local pharmacy, digital applications seem to the delivery method of choice right now. I think those of us in the healthcare IT industry sometimes take for granted that not everybody in the US has a smartphone, computer or even Internet access, which to me always begs the question: How great are these bright and shiny health apps if the populations that need them most don’t have access to them? And aren’t Meaningful Use and Accountable Care incentives/payments targeted towards government-sponsored healthcare recipients? The most likely patient population to NOT have reliable access to the Internet?

It’s this concept of a digital divide in healthcare that I am starting to believe will truly bend the curve when it comes to absolute interoperability – the secure sharing of information between patient, provider, payer, vendor, government, etc., anytime, anywhere. Only those patients who have access to these digital healthcare technologies will begin to clamor for them at their next doctors’ visits. Only patients’ whose doctors in turn have reached out to them via email, text or social media regarding the switch to electronic medical records, development of health information exchange and the benefits to care these will hopefully bring will be ready and willing to go with the digital flow.

I was intrigued by a recent news story on NPR the other morning that detailed a recently unveiled government plan – the Connect to Compete Initiative – to offer cheaper broadband access and computers to low-income families. The story pointed out that “about one-third of Americans – that would be 100 million people, give or take – do not have Internet access in their homes.” (I’d be interested to know how many of that population are on Medicare or Medicaid, or have no insurance at all.) Participating companies will offer broadband service to eligible families for $10 a month, while others will offer computers for as little as $150.

Further investigating into the story dug up a more detailed report from Reuters, which explained that eligible families will be those who have at least one child enrolled in the National School Lunch Program. According to a recent Commerce Department report on U.S. broadband adoption, only 43 percent of households with annual incomes below $25,000 had broadband access at home, while 93 percent of households with incomes exceeding $100,000 had broadband.

I think this is a step in the right direction, and am pleasantly surprised that it’s being enacted by the government – who got this digital healthcare ball rolling downhill fast in the first place.

As more and more low-income/average/middle-class Americans – or whatever we want to call ourselves – begin to speak out about the systemic inequalities we experience in this country’s financial, healthcare and educational systems, it’s nice to think (naively perhaps) that somebody just might be listening. As we see an increase in adoption of digital technologies in the consumer space, so too do I think we’ll see a correlating increase in adoption of healthcare IT by the providers that care for them.

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.

My family and I have escaped this week to our favorite vacation destination, Pensacola Beach. And so I sit here writing in the cozy confines of the condo that we call home for close to a week nearly every summer. I gave barely a thought to how I was going to transmit this blog to the HealthcareScene.com servers while here. As it turns out, there is no WiFi, which means I’m relying on my iPhone to do a bit of online research, my laptop for Word, and the hotel across the street’s business center with which to cobble it all together.

My connectivity issues pale, of course, in comparison to those of providers working outside of their hospital’s four walls – be it in emergency situations such as the aftermath of a hurricanes like Ivan and Dennis, which hit Pensacola back in 2004 and 2005, respectively, or as part of a routine provider/patient encounter in telehealth programs. I wonder how providers at Pensacola’s Sacred Heart Hospital, where I was born (and no, I’m not telling you what year), handled patient care in the aftermath of Ivan, which devastated the town and outlying beach communities, and how mobile health solutions might better enable them should Mother Nature pay the same sort of visit today.

Well timed for this blog was the recent news that Epocrates has released the first phase of its EHR system, including an iPhone app, targeted to primary care practices with 10 physicians or less. The EHR, according to a recent report at MobiHealthNews.com, “is initially available as a Web-based SaaS product, includes patient encounter notes, electronic lab integration, e-prescribing and Epocrates’ flagship drug database.”

The iPhone version should be available in a few weeks, and is likely to include remote patient record look-up and schedule access, and e-prescribing. The iPad version, which is in development, will focus on point-of-care data capture. MobiHealthNews.com also reports that an Android app is in the works, but will be rolled out in later versions of the EHR.

It will be interesting to see if later versions also target larger physician practices, which would surely also benefit from mobile technology like this. Perhaps most interesting, at least to providers in places like Pensacola that see their fair share of hurricane-induced on-site emergency care, is that the Epocrates mobile EHR app will “be a native app and it will store patient data on the device,” according to the company, which means that “the device will not need a signal to access the EHR. Any new data will be synched with the record once the phone finds a signal.”

Hopefully that signal will not be as elusive in a community’s time of need as the WiFi seems to be at my vacation destination.

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.

I just caught an interesting piece in on the use of plain old, unsexy carts in hospitals — one whose conclusions which may surprise you a bit.  The piece argues that since hospitals are comfortable using carts to haul around full-sized equipment, they may be slower than expected to adopt hot portable devices in care delivery.

The article notes that while mobile devices remain on hospital IT execs’ radar, carts laden with standard technologies like barcode scanners and laptops continue to be popular.

IT administrators interviewed by Health Data Management magazine said that hauling IT equipment with carts may be a better option than mobile deployment.  And research suggests that they’re not alone. According to a HIMSS study quoted in the article, carts are being used by 45 percent of hospitals in 2011, up from 26 percent in a related 2008 study. That’s a pretty dramatic leap.

It certainly makes sense. The fact is, carts make it possible to haul around a full-size keyboard (along with barcode scanners and medication), which allows nurses to work comfortably with EMRs at the bedside.

On the other hand, the small screens and awkward typing mechanisms used by mobile gear can actually slow down the care process.  Not only that, the small text used by mobile devices can be hard for an aging nursing workforce to read, according to Joan Harvey, RN, clinical nurse specialist at Ocean Medical Center, who was interviewed by HDM.

That being said, hospital IT leaders aren’t ignoring the mobile device explosion. At least one hospital interviewed by the reporter, Good Samaritan of Vincennes, Ind., is testing mobile devices for future use. But execs there are frustrated by problems with compatibility between the different operating systems used by the devices, and differences between devices using the same operating environment. When you consider how much easier it may be to just have nurses drag along a standard PC and keyboard, why would they consider buying an Android tablet or iPhone?

Unless this author’s got his facts completely wrong, he’s made a really important point — that mobile device makers had better get their act together if they want to really step into the healthcare market. No matter how fascinating their potential use cases may be, the reality is that mobile vendors won’t make major headway in hospitals unless they get smart about barriers like the ones mention here.  The cool factor just won’t cut it.

This is a little off topic, but not really since the iPad craze in healthcare is so big. Because of this fact, I was quite interested in this video I found which tests out what would happen if an iPad was dropped. They actually drop 2 iPads. One with a smart case and one without a case. They start off first dropping it from waist level and then shoulder level.

Yes, this is a little hard to watch a2 perfectly good iPads get destroyed, but it is interesting to see what might happen if a doctor were to drop their iPad on their rounds.

Yes, it is worth noting that it’s unlikely that the iPad would drop straight on its face like in this video. It’s also worth saying that there are even more durable cases available for those that are concerned about iPad’s being dropped. Although, I have to admit that I’m amazed that the Smart Case did as well as it did after being dropped.

One of the regular EMR and EHR readers, Judy, recently took up the challenge I posed in my previous post about Every EMR Vendor available on the iPad. She downloaded the LogMeIn Ignition app that I mentioned in that post and tried out her PIMSY EMR software on it. Thanks to Judy for sharing her experience.

The following is her experience and review.

I tested the new LogMeIn app to see if I could access PIMSY EMR from my older Droid and from an iPad. It takes a little getting used to: you have to familiarize yourself with how to navigate on the screen and how to change the size to get the screen view that works for you. Once you get that done you are good to go. That said, there are 2 ways to change the size: a magnifying option at the bottom of the screen or a zoom in bar on the right hand side; you can enlarge as much as needed. There are also 2 options for moving around: you can move the screen with your finger (the cursor stays put) or you can move the cursor like a regular mouse; I prefer navigating around the cursor. Both options make it simple to maneuver.

If you’re used to texting and typing on a smaller keyboard, it will be easier to adjust. The app itself gives you a keyboard that takes up approximately half the size of the screen, so larger phone screens like Droid 2 or iPhone would have a bigger keyboard than a regular Droid, and the iPhone keyboard was comparable to a regular size. For those who aren’t used to navigating and typing on a phone screen, there will be an adjustment period. If you’re connected to dual monitors, you can easily switch to either one, and I was able to watch a video.

The speed is slightly slower from phone or iPad to computer but very good from computer to computer. The app is not offered on a Blackberry. I would highly recommend this app to anyone who wants to connect to their desktop remotely; it worked great to get into PIMSY. Well worth $29.99.

I’m about to make a big announcement about the iPad. Something that every iPad loving doctor will be happy to know about. It’s a simple announcement, and something many of you probably already know: Every EMR software vendor out there is now available on the iPad.

That’s right, you can pretty much run any and every of the 300+ EMR companies software on an iPad. All it takes is an iPad, a cell or WiFi internet connection and some form of remote desktop application. There you go, I solved all the EMR companies iPad strategy problems.

Practice Fusion sent out a press release recently about support of the iPad for their Free EHR. In the press release they highlight a number of the benefits of access to an EMR on the iPad and they describe the use of the EMR iPad model that I talk about above. They use the remote desktop app for mobile devices called LogMeIn Ignition. $29.95 and you can connect to your computer from your iPad. Not to mention that it also support Android and Windows. Yes, that’s right, I guess we could also say that every EMR software is available on Android and Windows phones and tablets as well. Of course, there are also some free RDP options as well, but probably aren’t quite as easy to configure.

Now, I’m sure the purest out there are going to come and say that there’s a lot of difference between a remote session to your computer than a native iPad EMR application. They’re right. In some ways, the remote connection to your computer is better. There’s no new EMR interface you have to learn. You have remote access to all the files and programs on your main computer. You have all the preferences you’re use to having at your desk. I could go on, but there’s certainly some benefits to remotely accessing your computer on an iPad.

Some might argue that the latency (Translated: slowness) of a remote session could be a major issue. I think these comments are from people on super slow connections and/or people who haven’t used the latest remote desktop sessions. Remote access has come a long way and the experience of using a computer remotely is almost as good as being at the computer itself.

The more important argument that I’ve left out is actually the EMR user interface. The problem with most EMR user interfaces is that they were designed with a mouse and keyboard as the input devices. The keyboard can generally be overcome with good templates, voice recognition, the iPad keyboard, etc. However, the mouse is a more difficult challenge since the precision of the mouse is so much better than your finger (This is the true fat finger issue).

Point being that while you can certainly access your EMR remotely on the iPad, it’s going to be important to know how well your EMR software is designed for a touch screen interface. Spacing of elements in your EMR, size of buttons and a number of other design elements can drastically change your experience using a touch screen interface. Plus, that doesn’t even cover the unique touch screen gestures that are available like swiping, 2 finger taps, etc.

Yes, it is fair to say that EVERY EMR software out there can be run on an iPad. However, that definitely doesn’t mean that you will want to run that EMR software on the iPad. The good thing is the cost to try your EMR software on the iPad is really low. Once you’ve tried it out, let me know your experience so that others can learn as well.

Recently I came upon two interesting data points which support the idea that iPads are catching fire in the world of academic medicine:

*  University of California at Irvine’s medical school has an initiative underway, known as iMedEd, whose mission includes giving new iPads to every member of its incoming med school class.  The tablets, which were first issued last year, come loaded with all of the materials students need for their first year.

*  Stanford University’s School of Medicine began distributing iPads to incoming students in 2010, arguing that the new technology would help them “make significant changes to the current model of medical school education.”

Meanwhile, high-profile medical blogger Kevin MD has gone so far as to say that iPads should be mandatory for medical school students, and it’s hard to argue that there’s something big happening here. And he’s not alone.

Interestingly, much of the action seems to have taken place in a rush, about mid-2010. My Google searches didn’t turn up any more recent examples of medical schools going wild for iPad technology (though med bloggers continue to stump for the iPad as though they were working for Apple’s marketing department).

Still, my instinct is that the Stanford and UC Irvine examples of iPad adoption aren’t just flashes in the pan. Honestly, despite my deep and abiding love for my iPhone, I sort of “don’t get it” when it comes to the iPad. Still, it’s hard to argue that there’s a groundswell of support for the device’s use in medicine.

However, don’t get your hopes up that this will create a generation of EMR-friendly doctors. From what I’ve been told, even schools that tap into the iPad’s neat capabilities are still teaching students to document medical data the old-fashioned way — dictation or hand-written notes.  Oh well — you can only push through so much cultural change at a time.

Just the other day, I went on sort of a rant complaining about the excessive hype around iPad use in healthcare. I wasn’t suggesting that using iPads is a bad idea,  but I was venting about the hyperbole around Apple’s latest darling.

That being said, I’ve just had a chance to be reminded why putting iPads into the hands of clinicians, or at least smart tablets, is long overdue.

Just a few days ago, a relative was in a large suburban hospital which has sunk big bucks into GE’s  Centricity (one of those big gun EMRs our illustrious publisher John Lynn calls “Jabba the Hutt” products).  While I sat in the room with my friend for a while, nurses came in and out a few times to take vital signs, document medication allergies and check in on my friend’s level of pain.

Do I even need to say that despite the frighteningly powerful engine sitting there rumbling within the desktops at the nurses’ stations, every one of these interactions was documented on paper?

I can only imagine a few ways that these nursing notes could get into Centricity, and none of them fill me with confidence:

*  Nurses may be scanning in their documentation as they create it, then they or someone else double-checks the OCR results

*  Transcriptionists could be entering data from paper notes into the Centricity system, with all the attendant potential for error this creates

*  The hospital — which is otherwise extremely automated and seemingly very efficient — has just decided to create a “church and state” environment where some forms of data get into the EMR immediately and some stay on paper

Don’t get me wrong: I realize some of you reading this may already have or be developing  solutions to solve just this problem.  The systems I’ve seen to date, however, seem to be aimed at smaller doctors’ offices and probably wouldn’t scale to a huge tertiary care facility.

I do wish there were better point of care data collection options out there. If, in fact, tablets like the iPad are the best fit, I swear I’ll buy a few for physician friends myself.  But shouldn’t hospitals and practices be doing that?