Published in the July 2012 issue of Today’s Hospitalist
TALK TO HOSPITALISTS who take their tablet computers to work, and you’ll likely hear how devices like the iPad have the power to make patient care more efficient. But even the staunchest converts admit that tablet computing still has a long way to go before it realizes its full potential as a communication and clinical tool.
While many physicians have fallen hard for tablets, they’re running into roadblocks retrieving and entering clinical data on the go. Doctors are not only worried about protecting the security of data on mobile devices, but they often hit a wall when they try to connect tablets to EMR systems.
As a result, hospitalists report taking a patchwork approach to using iPads in the hospital. A fortunate few can jack their tablets into their hospital information systems and carry their own functioning EMR around with them. Others, however, can only view (not change) patient data via tablets, and they still need to find a desktop to write patient orders or notes.
Still, many hospitalists believe tablet computers may be the future of medicine. They’re working hard to figure out how to take full advantage of their devices in-house. Here’s a look at how hospitalists are using tablets at work.
Tablet users say that the single biggest benefit of the devices is portability. At the University of Mississippi Medical Center in Jackson, Miss., all the computer stations are located in the middle of triangular-shaped floor wings. Patient rooms, on the other hand, are located on the outside.
“The hospital floorplan is not conducive to rounding,” says hospitalist John Showalter, MD, who’s also chief medical information officer (CMIO). “Physicians have to go through a maze to find a computer and maybe four nurses are using it, so you have to find another one.” That’s incentive enough for him to carry his own iPad. “If a nurse calls with labs, now we’re not fighting over a computer, and it saves time.”
“I’m no longer tied to a location,” says Henry J. Feldman, MD, chief information architect for Harvard Medical Faculty Physicians and a hospitalist at Boston’s Beth Israel Deaconess Medical Center. Beth Israel Deaconess developed its own in-house, Web-based EMR, Dr. Feldman explains, plus the center has secure and ubiquitous wifi. For the hospitalists, connecting via an iPad is no different than being at a hospital workstation.
“I can do anything at the patient bedside that I can do at a physician station, which saves time in my day,” Dr. Feldman says. He’s used his iPad to do signouts while at a Starbucks, for example, and to bring up imaging during a hallway consult with a surgeon.
Even hospitalists who have just read-only capacity with their iPads point to major benefits, such as a better way to work with interns and residents. At Virginia Mason Medical Center in Seattle, each attending has an iPad. “It works well for teaching teams,” says Barry Aaronson, MD, hospitalist and associate medical director for clinical informatics, “because their primary work is review vs. data entry.”
And using tablets as read-only devices also works for patient education. Arun Mathews, MD, a hospitalist and CMIO at the 400-bed Medical Center Hospital in Odessa, Texas, recently showed a patient with DVT the results of a Google image search: the venous system and an IVC filter to help the patient visualize the procedure. The imaging prompted a discussion that helped ease her anxiety.
“She ultimately got the procedure,” Dr. Mathews explains, “and was discharged successfully.”
Personal to professional
For Karen Pinsky, MD, using an iPad in the hospital is a natural extension of the role the device plays in her life outside of work.
“If a tablet is incorporated in every aspect of your nonclinical life, not having it at work seems odd,” says Dr. Pinsky, a pediatric hospitalist who’s CMIO at The Chester County Hospital in West Chester, Pa. She says she manages her “whole life” on the device: doing her online banking, reading books, and scheduling her children’s karate and tennis lessons.
Dr. Pinsky first began bringing her iPad to work a year and a half ago. She says that the tablet nicely augments the hospital’s 10-year-old Siemens Soarian EMR, allowing her to use the device while she “roams” between terminals. She can also remotely access the desktop computer in her office using software “the 2X Application Server “that connects information systems to desktops and tablets.
While she’s walking from the fourth floor pediatric unit to the emergency room to see a patient, Dr. Pinsky says she’ll pull up the patient’s labs. By the time she sees the patient, she already knows the situation and can hit the ground running.
According to Dr. Pinsky, physicians are figuring out how to mesh tablet computers with their own personal style and workflow. For instance, she prefers to sit at a larger device to key in a lot of data for a history and physical. But she favors the tablet for showing diagnostic images to patients and family member. And having the device, Dr. Pinsky notes, makes her more apt to share that information.
In their enthusiasm for iPads and other tablets, these physicians are far from alone. A recent study by Manhattan Research found that among more than 3,000 doctors, 62% used devices and digital media, especially tablets, for professional purposes in 2012, almost double that of 2011. The iPad is the preferred platform, the study found, and one-half of physicians who own tablets have used it at the point-of-care.
Many early adopters “like Dr. Pinsky “started by bringing their own personal iPads to work. But some larger hospitals have stepped up to actually give tablets to physicians.
That’s the case at the University of Chicago Medical Center, which made headlines by supplying iPads to all its residents several years ago. Two years ago, the hospital decided to give iPads to all its hospitalists as well.
The physicians use a Citrix connection (a remote access application) to connect to the center’s Epic EMR. But “typing a long note on a touchscreen devices is still a lot slower than on a keyboard,” says Cheng-Kai Kao, MD, a hospitalist who is the group’s iPad project leader. “It does take some practice for people to adapt.” As a result, many physicians still use a desktop computer to write patient notes.
“That’s the limit now for medical use,” Dr. Kao says, though he adds that it doesn’t stop attendings and residents from using tablets constantly in their daily practice. “You see people carrying iPads all around the hospital here, and we’re very satisfied with them.”
Conventional wisdom says that smaller hospitals may have a harder time integrating tablet computers because of the time and money needed to develop and manage a high-speed secure network. But many bigger systems have yet to set a policy governing how their physicians use tablet computers.
The 190-bed Inova Fairfax Children’s Hospital in Falls Church, Va., for example, has no official stance on tablet use, in large part because it’s devoting most of its IT resources to ramping up an EMR across the five-hospital Inova system. (The go-live is slated for November. See “Lessons learned.”) For now, physicians using tablets find themselves in a kind of no-man’s land, at least when it comes to data.
Physicians using tablets don’t have EMR capabilities, says Ruben Nazario, MD, a pediatric hospitalist who is helping the hospital implement an Epic system. But Dr. Nazario says that he’s been bringing in his own iPad to use while rounding and teaching residents.
“We’ve had some conversations about tablets, but the system has not decided the way forward,” he says. While the devices remain an item on the agenda of hospital IT meetings, Dr. Nazario notes that Inova isn’t actively discouraging their use. “There’s no policy against it,” he says, “but no systemized policy about it either.”
Other hospital systems that already have EMRs up and running are moving to help hospitalists embrace tablets more fully. In Seattle, Dr. Aaronson says that Virginia Mason is planning to launch a native app this summer that will allow iPads to interact with the information system.
“Virginia Mason works a lot on process and strongly believes in one-piece flow: You write the order while seeing the patient and doing documentation,” says Dr. Aaronson. “The only way to implement that is to have a device at the bedside.”
Still other hospitals have opted for stopgap measures until better mobile device-specific software comes along. In Texas, Dr. Mathews says that physicians at Medical Center Hospital use Citrix to connect to the hospital’s McKesson EMR.
He and another physician have been part of a pilot study, in which they’ve rounded with their iPads for three months. Their results were “fairly positive,” according to Dr. Mathews. But one downside was problems trying to navigate a scroll bar on a touchscreen. Then there was the fact that the hospitalists needed to re-log into Citrix every time the tablet went to sleep or whenever they went to a different floor.
Now, Dr. Mathews adds, he and his colleague are piloting documentation methods with the tablets as well, comparing typing to using a voice recognition tool such as Dragon Dictation.
Wait and see
The University of California San Diego Health System launched its own iPad pilot project for three months last year after three departments asked for various types of tablets. The hospital bought 20 iPads and assigned them to 13 inpatient services, giving physicians read-only access to its Epic EMR via Canto, an iPad application that Epic developed to allow tablets to work with its EMR.
Physicians were able to review notes, vital signs and lab results, and found portability to be a clear plus. “When you have to go to the next floor with the laptop cart, everything grinds to a halt,” points out Brian Clay, MD, a hospitalist and interim chief medical information officer. “On the tablet team, you just run down to the next floor.”
But while the pilot was a success, the hospital has definitely decided to take a wait-and-see approach. “Are we going to be buying everyone a tablet?” Dr. Clay asks.
“The answer is that we’re not quite there yet. Canto needs to adjust to provider feedback regarding functionality.”
For now, several UC San Diego hospitalists continue to use iPads, and the hospital is considering giving this year’s new residents the option to forego their educational stipend and instead apply those dollars to their own tablet.
One of many options
At this point, few hospitalists say they are willing to pressure their hospitals into ruling for or against tablets.
At Peninsula Regional Medical Center, a 363-bed hospital in Salisbury, Md., hospitalist Christopher Snyder, DO, and two other hospitalists have been bringing in their own devices.
Dr. Snyder, who’s also CMIO, is a big fan of the iPad because of its wireless and touchscreen capabilities. He says that he might start lobbying administrators heavily “once limited software is a thing of the past. But “until the functionality with the apps is there,” he says, “it’s hard to push.”
Even Dr. Pinsky, who by most definitions would qualify as an iPad power user, favors a relaxed approach to integrating tablets into hospital practice. Her hospital recently purchased a couple of iPads and has given her a “test” one to use. While the hospital is exploring building a platform that would support iPad use, it has no plans to supply tablets to all its physicians. That’s fine with Dr. Pinsky.
“It’s an individual decision whether clinicians use tablet technology or an in-room device or desktop,” Dr. Pinsky says. “Our job is to make as many choices available as possible, and I’ve lobbied to support iPads as one of several choices. But I would not mandate or promote their use over other devices.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
Not quite ready for prime time
WHILE iPAD HARDWARE GETS HIGH MARKS “nice screen, instant turn on “the software remains a problem. For many physicians, first-generation software means that tablets for clinical use are still a long way from real utility.
“The apps aren’t there yet for it to be a fully functional EMR,” from all vendors, says hospitalist John Showalter, MD, who’s also chief medical information officer (CMIO) at the University of Mississippi Medical Center in Jackson, Miss. “It’s nice for the attending to review, but as a rounding physician, it’s not really helpful because you still have to find a computer and put in an order.”
But limited software isn’t the only concern. One obvious problem with allowing physicians to access patient data on an iPad is security. Although tablets don’t store the data they display, hospitals are busy installing antivirus and anti-malware on devices that tap into their wireless networks.
At Boston’s Beth Israel Deaconess Medical Center, where 1,000 doctors
bring in their own have to access the hospital’s encrypted wireless network, just like they do the EMR.
But the hospital has set up several safeguards, according to Henry J. Feldman, MD, a hospitalist at Beth Israel Deaconess and chief information architect for Harvard Medical Faculty Physicians. The hospital’s information system, for example, can identify the location of the person logging in.
Hospitals also have to have the capability to track a lost or infected device and erase data remotely, says Cheng-Kai Kao, MD, a hospitalist at the University of Chicago who has been leading an iPad project. Additionally, everyone needs a lock screen with a security PIN or password that should be changed every 60 to 90 days.
Some hospitals have also identified another potential problem: They worry that moving an iPad from room to room will spread infectious disease.
Most experts say the solution is no different than sterilizing a stethoscope. Karen Pinsky, MD, a pediatric hospitalist who’s CMIO at The Chester County Hospital in West Chester, Pa., recommends not putting the device down where there can be patient contact and not bringing it into isolation rooms at all. (In that situation, some hospitalists say they simply leave the tablet at a nursing station.) Physicians at the University of Chicago use screen protectors and wash the device with alcohol wipes as they leave a patient’s room.
It’s still the Wild West when it comes to apps for your mobile device. Some institutions like the University of Chicago recommend certain apps and others are considering implementing policies to control which apps are used. But Brian Clay, MD, hospitalist and associate medical director of clinical information services at the University of California, San Diego, says he expects residents and physicians to act professionally and thus aren’t looking to implement policies.
“We can’t police or make recommendations,” he says. Instead, he believes the “collective consciousness” of physicians and residents will lead to appropriate use.
For now, only Apple offers the safety of vetting its apps, so app buyers need to do due diligence. Hospitalists did mention the following favorites:
- Diagnosorous DDx ($1.99): Differential diagnoses for over 1,000 conditions by organ system, symptom or disease.
- Dropbox (free): Stores files that are then accessible on all of your computer and mobile devices. Keeps files in sync and backed up online.
- Epocrates (free): Quick access drug, disease and diagnostic information at the point of care.
- ICD-9 Consult 2012 ($14.99): Search through the different codes or browse by type of disorder (infections, circulatory, respiratory, etc.) or procedure.
- MediBabble Translator (free): Medical translation tool contains physical exam area and thousands of translated questions and instructions, all playable as audio recordings.
- Medicine Toolkit ($9.99): Consists of “Bayes at the Bedside” and “Pocket Evidence” for the latest in clinical reasoning and evidence-based medicine.
- NEJM iPad Edition (free): Weekly issue that includes all content from NEJM print issues plus audio, video and other multimedia features.
- Note Taker HD ($4.99): Helps with writing and organizing handwritten notes, diagrams, etc. Allows you to create pages by writing on the screen with your finger or an iPad-compatible stylus. Zoom and annotation functions available.
- OmniGraffle ($49.99): Has built-in stencils and customizable shapes to help create diagrams, charts and page layouts.
- Pubmed Library ($9.99): More than 19 million citations for biomedical literature from Medline, life science journals and online books.
- Roadshow (free; ad-free upgrade for $4.99): Capture videos from the web and save to your device. Limited to 15 videos unless you go for the upgrade.
- Sanford Guide to Antimicrobial Therapy (Sanford Guide app is free; subscription to antimicrobial therapy is $29.99): Another way to access Sanford Guide content.
- Skype (free): Popular software to call, video call and instant message anyone else on Skype for free.
- Skyscape Medical Resources (free): Package of medical resources including drug information, medical calculators and clinical information on over 850 topics. Premium topics available for a fee (5-Minute Clinical Consult for $99.99).
- UpToDate (free): Synthesized clinical information including evidence-based recommendations.What’s on your iPad?
Tell us what medical apps you’re using. Please send your comments to firstname.lastname@example.org.