iPads and other mobile consumer devices have made their way into the exam room, bringing with them concerns about security, tech support, and infection control.
Since gadget-happy doctors got their hands on the iPad last year, many have turned it from a toy into a professional tool.
Dr. Jeffrey Westcott, cardiology board chair at Swedish Medical Center, a four-hospital complex in Seattle, even sees it as a lifesaver. It can "help me avoid mistakes by knowing more about the patient when I'm asked to make a decision."
Just the other day, he got a phone call from a pain doctor who wanted to attach electrodes into the epidural area around the spine of a mutual patient and wanted to take her off her anticoagulant in preparation for the surgery. Westcott was at home when he got the call, but he had his iPad and logged into his hospital's Epic electronic medical records system's iPad client and was able to see that the woman had an artificial aortic valve and must remain on the drug for that reason.
"I didn't have independent recall of that lady, but within two seconds I was able to look it up," he says. "That's a big deal, and it happens every day. She could have had a stroke."
Westcott also sees great potential in using the iPad to educate patients on their conditions and treatment. He's so enthusiastic that he's been working as an unpaid consultant to 3D4Medical, a medical imagery company, to create more vivid and accurate animations of common heart conditions. Dr. Lacy Harville of East Tennessee Cardiovascular Surgery Group has been doing the same. When 3D4Medical raised the issue of a consulting fee, Harville brushed it aside, saying "I just want to have this for my own patient's benefit."
Harville, too, thinks these graphics and the accessibility the iPad is giving him are saving lives. They help him convince patients that they really need surgery when, for example, they're suffering from a condition like a leaking heart valve that leaves them weak but not really feeling ill. For years, he has used hand-drawn sketches, but 3D4Medical's animation makes the point more clearly. "When they can see a normal valve, and then see how a damaged one works, it just clicks 10 times better," he says.
Despite all the benefits, many hospital and healthcare technologists are still trying to sort out where the iPad and other mobile devices fit into their medical bags. Ensuring information security and protecting patient privacy both loom large in the context of devices that can easily walk out the door. If it's a doctor's personal device, rather than hospital property, it's going to exit at the end of every shift. While that lets the doctor quickly look up medical records when called at home or at a restaurant, it also opens up the possibility that the device will be left behind on a restaurant table.
Mobile device security is relatively easy to deal with. Strict password policies and the ability to remotely wipe the memory of a device that's lost or stolen can alleviate most security concerns. But other issues are challenging the widespread use of mobile devices in medical settings, including the lack of native support for many non-Windows devices, the inability to disinfect many mobile devices, and device overload, where clinicians are finding themselves toting around too many of them.
Coal Miner Doctors
Doctors and nurses are no strangers to mobile electronics, often looking "like coal miners, with tools hanging all over them," says Yadin David, founder of Biomedical Engineering Consultants and an IEEE senior member. Instead of adding another device to their collection of pagers, mobile phones, and bar-code readers, the goal should be to use one smart device to replace several existing gadgets, he says.
Mobile computing in the hospital means everything from computers on rolling carts to tablet computers with stylus input for taking notes or collecting electronic signatures. It's a market in which Apple's products have had a big impact. When the iPhone came on the scene, its touch screen gave it a larger viewing area than a BlackBerry with its keyboard and made it possible to envision new applications. Even more important was last year's introduction of the iPad, with a 10-inch screen suitable for reviewing radiology images and detailed medical reports.
All these features have won the iPad many fans in healthcare, but that doesn't necessarily mean it's going to be a standard-issue device. Many hospitals already use Windows-powered tablets, including medical-grade devices like the Panasonic Toughbook H1 designed for healthcare environments. There are also alternatives like the Samsung Galaxy Tab, Motorola Xoom, and Research In Motion PlayBook all smaller tablets that have been promoted as being small enough to fit in a lab coat pocket. (Westcott suggests things might go the other way, with lab coats being designed to have bigger pockets to fit the iPad.)
Healthcare technology professionals are adopting different strategies for handling the demand for mobile computing. Some are determined to standardize on one device or operating system, while others embrace a "bring your own" approach where practitioners are allowed to connect their personal devices to the enterprise network.
"I don't expect this to stabilize," says Charles Colander, CIO at Elmhurst Memorial, a 340-bed hospital in Elmhurst, Ill. "Flexibility continues to be the key attribute we need to maintain." So much of mobile technology comes down to personal taste, like whether a doctor wants the iPad's 10-inch screen or something smaller, he says.
But Colander questions whether any devices that come out of the consumer marketplace should be on a hospital's technology shopping list. "They're just not medical grade, so infection control is a big challenge. At least if the doctor buys it for himself, some of that goes away because he's the only one handling it."
The Panasonic Toughbook H1 may not be as sexy as the iPad, Colander says, but it's designed for hospital use, including routine disinfection and the use of a stylus instead of a touch screen. "Frankly, the stylus-type input for full-function use works better with our applications," he says, noting that software originally designed for Windows desktops can be difficult to use with a fingertip touch.
Opinions on infection control and mobile device use vary widely. iPad commercials show doctors happily using the tablet to view medical diagnostic images, but "it's obviously not a healthcare device" says John Curin, head of the healthcare practice at Burwood, an IT consulting firm. "I couldn't disinfect it if I wanted to."
iPad defenders stress that its sleek case and lack of a keyboard mean fewer nooks and crannies in which bacteria can hide. Dr. John Halamka, the CIO of Beth Israel Deaconess Medical Center in Boston and a frequent technology innovator, says the iPad is "completely disinfectable." Even though Apple advises against wiping it with disinfecting solution, doing so seems to cause no harm, he says.
"In a case, an iPad is actually a pretty rugged device for clinicians who spend much of their day reviewing information and want to use this to say, 'let me show you what the gall bladder is,'" says Halamka, who's also a practicing physician.
Halamka's Harvard-affiliated hospital system has about 300 iPads and 1,500 iPhones on its network, all physician-owned devices. Other devices and operating systems are equally welcome, once his IT team verifies that they meet minimum security and encryption standards, he says.
IT can't expect to manage mobile devices like corporate desktops that run a standard operating system image, locked down against user changes, Halamka says. "These are lifestyle devices, not something the IT department is requiring them to use."
Lack Of Native Support
Beth Israel Deaconess was well prepared for the advent of mobile devices because it had already established a policy preventing patient data from being stored or cached on any device except a secure server, and its medical record applications run on any Web-enabled device, Halamka says.
In many other medical facilities, iPad users wind up accessing patient information through Windows, using a remote or virtual desktop interface like a Citrix client. That's partly because most hospital information systems lack native iPad support. Some hospital CIOs also see a virtual client as a security measure. Because the user interface is streamed to the device, no patient data or other sensitive information is downloaded or stored on the device.
Medical software makers are starting to deliver native iPad clients as well. The Epic Canto app provides read-only access to medical records. The startup DrChrono has created a complete medical records system for small practices, delivered over the Internet and accessed on iPads. Other native iPad apps starting to reach the market are more specialized, such as AirStrip Cardiology for remote access to electrocardiogram results.
The University of Chicago Medical Center is providing virtual access via Citrix for the iPads it's providing to each of its 115 resident doctors. Residents use the iPads to retrieve medical records, view medical images, and read journal articles from the hospital's digital library, says Dr. Bhakti Patel, who organized the program. So far, the iPads are being used only for data retrieval and order entry and not for note taking. The residents take them home at night, but the Wi-Fi-only models aren't ideal for remote access.
5 Mobile Strategies
1. Set A Standard Establish and communicate a policy for your organization
2. Bring Your Own If you allow personal mobile devices on your network, make sure they meet minimum security and privacy standards.
3. Go Virtual Virtual desktop technology can put Windows-based applications on iPads and other mobile devices that don't run Windows. That way, data isn't stored locally.
4. Access Via The Web Web applications are another way to provide clinicians with access on the device of their choice
5. Try Native Apps Medical software vendors are starting to ship native apps for iOS and other mobile operating systems. If demand is high enough, consider creating your own iPad applications
Residents are on their feet and on the move all day, so having a personal device they can use to access medical records means they don't have to jockey for a seat at a shared computer, Patel says. Access through Citrix has proven to be fast enough for use in emergency situations, she says.
The medical center solved the portability and disinfecting issues by fitting the iPads with a hard-cover case that has a ModulR shoulder strap attached. The case can be wiped clean with sterilizing fluid without having to touch the iPad itself.
Initially, Patel's program used Apple tools to enforce standard security, and Patel had to provide her own tech support because she moved forward before her IT department was ready to set a mobile computing standard. Now the hospital is planning to implement a device management system from MobileIron that will support multiple phone and tablet operating systems.
Being a trailblazer has been worth it, Patel says. "Now that we've demonstrated it's feasible and doable, IT is working with us. We have their ear on what's going to be helpful and useful, and what's not going to be helpful at all."
Doctors haven't always been enthusiastic about mobile devices. Jeff Cash, CIO of Mercy Medical, a 260-bed hospital in Cedar Rapids, Iowa, recalls the advent of personal digital assistants, when he had to buy PDAs and loan them out just to get physicians to try them. The iPad phenomenon is different. "I haven't had a doctor ask us to provide him with an iPad yet. It's more like, 'I have it, and I want to introduce it into my work life at the hospital,'" he says.
Cash supports those requests with PatientKeeper software, which is middleware that adds a physician-friendly user interface to existing medical records systems. The native iPad client is tailored for the touch screen, making it easier for doctors to record patient notes by choosing from template options that require minimum typing. Vendors must design the system with that in mind for an iPad app to be successful, Cash says. He's working with PatientKeeper to develop a physician order-entry app that would let doctors enter instructions for nurses to follow up on among other things.
The iPad isn't universally accepted in healthcare. The Ontario Shores Centre for Mental Health Sciences in Ontario, Canada, recently standardized on Windows-powered tablets from Motion Computing, which has been making mobile computers for healthcare for years. They're "very rugged and drop tested, and they're small and easy to carry. For the clinical purpose that we have, they've worked very well," says Dr. Ilan Fischler, a psychiatrist and the hospital's acting medical director. The iPad doesn't provide all those advantages, he says.
Ontario Shores' IT group has gone with one standard supported device and has a "hard-and-fast rule against consumer devices," says Tammy Young, the technical analyst who led the Motion Computing implementation. "We don't want 100 different devices out there. If a physician purchases an iPad and asks to be put on the network, we don't do that."
The Motion tablets run Windows 7, so they can be managed and secured just like desktops, Young says. They get a full copy of the hospital's Meditech healthcare information system client; sensitive patient data is stored on the server, not the device; and data on the device is encrypted. So far, there haven't been problems with the devices being lost or stolen.
"If iPads were rolled out, we probably would see them walking off all the time because they're a cool device," Young says. The Motion tablets look much more clinical. "That may be an advantage all its own."
Seattle Children's Hospital CTO Wes Wright has an informal policy allowing devices like iPads on his network, but he isn't interested in supporting native iPad access to hospital systems. By allowing access only via Citrix, he hopes to keep his network more secure. However, he says, it might make sense for Citrix to create a mobile emulator that would combine virtual access with a user interface based on that of phones and tablets, rather than projecting a Windows desktop user interface onto these devices. If the hospital does eventually buy tablets, he's leaning toward the Windows-powered Asus Slate.
Meanwhile, Wright is wondering if tablets are even necessary for his hospital, which is wired well enough that the best way to deliver computer access at the bedside might be to put Wyse Xenith thin-client terminals in every room, hung from a swivel arm mounted on the wall. "We could put those almost anywhere you would want to have a handheld device," he says.
Whatever his technology preference, however, Wright wouldn't dream of trying to take a doctor's iPad away. "I saw that train coming, and I got out of the way," he says.
And that's the same train that many other healthcare IT professionals are either getting out of the way of or getting on board with, as the doctors and other clinicians they work with insist on mobile and remote access to patient records and other vital data.
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