September 26, 2011

The iPad Invasion
By Julie Knudson
For The Record
Vol. 23 No. 17 P. 20

Physicians are adopting iPads to monitor vital signs, access EHRs, and educate patients.

How popular is the iPad among doctors? According to figures released by Manhattan Research, 30% of U.S. physicians have adopted the device, with another 28% reporting they plan to purchase one within the next six months. That kind of market penetration means that not only are other tablet platforms left to squabble over the remaining minority, but also that doctors have embraced the iPad with a gusto that doesn’t quite rival older technologies—the same study shows that 81% of physicians reported already having smartphones—but is still far above analyst expectations.

Conventional wisdom, however, says that physicians aren’t big technology adopters. So what makes this normally change-averse group such fans of the iPad? Ease of use, portability, computing power, and battery life are among the benefits enjoyed by the hospitals that have deployed them. And it turns out that today’s doctors may not be the old-school conservatives of legend.

“Actually, the radiology doctors are very technology savvy,” says Peter Ghavami, director of informatics at Harborview Medical Center in Seattle. “By the nature of their area of specialty, they tend to be on the leading edge of technology.” Harborview has implemented a pilot iPad program in partnership with GE that uses the Centricity Radiology Mobile Access app and has an active deployment of about 40 iPads. Although the radiology team may be the program’s most obvious participant, Ghavami reports that much of the need to access patient images is coming from other departments. Doctors referring patients to radiology are among the heavy iPad users because the device allows them to access images regardless of where they are.

“That’s pretty powerful,” Ghavami says. “They don’t have to be at a workstation to look up images. Having to go to a workstation really slowed things down.”

In addition to accessing images, Harborview’s physicians also use their iPads to view patients’ vital signs and access reference applications such as encyclopedias, dictionaries, and formularies. Doctors are already expressing a strong interest in broadening the device’s functionality, including expanding into electrocardiogram (EKG) lookup functions.

“We’re hoping to add Citrix to access EMR. We’re working through the process of getting the internal IT approvals so we can open that EMR access to physicians,” Ghavami says.

After conducting formal surveys of the staff, Ghavami reports that physician feedback has been hugely positive, praising not only the iPad’s expansive screen real estate but also the intuitive nature of zooming and rotating when reviewing images. “They like that the tools are very easy to use,” he says. “They like the fact that once they get a five-minute overview, they can pretty much run with it without having to need a lot of IT support.”

In summarizing the technology background of Harborview’s physician staff, Ghavami says, “They tend to be Mac users predominantly anyway, so to them it seems to have been second nature—another device in the evolution of the Mac and Apple environment.”

Docs Do Dig Devices
Manhattan Research senior digital healthcare analyst James Avallone is eager to dispel the myth that physicians are reticent to embrace change. “They’re not really intrinsically technology laggards,” he says, explaining that doctors undertake a “cost-benefit analysis with almost everything in terms of time and efficiency, and that’s really what we find dictates their decisions in terms of adoption a lot of times.”

Avallone believes there are several readily apparent benefits to the iPad, including the screen’s larger size when compared with smartphones (without the drop in mobility), along with strong computing power. “Those things meshed together really make it a device that physicians have taken a shine to,” he says. “There’s really no ramp-up to figure out how to utilize it to the best of its capabilities, and a lot of these physicians already know how to navigate the Apple operating system and work within the Apple ecosystem.”

Young or old, a doctor’s age is apparently no factor when it comes to iPad usage.

“I have people who are relatively senior clinicians, folks who have been around practice now for 30, 40 years, who have adapted to the iPad very quickly. Much more quickly than they have to other new technologies, in fact,” says C. William Hanson, III, MD, chief medical information officer at Perelman School of Medicine at the University of Pennsylvania and author of Smart Medicine: How the Changing Role of Doctors Will Revolutionize Health Care.

Ten years ago, a typical intern “would be walking around with pockets of patient lists, little books containing the hospital’s formulary, lists of the right antibiotics for the right disease,” says Hanson, adding that the iPad can store much of that information. “[An iPad] gives you a way to act on the move because a lot of hospital providers are moving constantly from one location to another. We have patients scattered around the hospital, and if you can do a lot of your activities from a single form factor, it makes life quite a bit easier and much more efficient.”

The iPad in Action
One way Kaweah Delta Health Care District, in Visalia, Calif., supports improved physician efficiency is by allowing nearly 80 hospital-owned iPads, as well as about 70 physician-owned iPads, to access the hospital’s network through Citrix. The tablets are essentially thin clients, tapping into the organization’s infrastructure just like conventional desktops and laptops. This architecture not only supports secure access regardless of device ownership, it also means there’s no protected health information or other sensitive data stored on any of the machines.

Nick Volosin, ISS director of technical services at Kaweah, says the hospital staff has “a good culture of embracing technology, and I think a lot of that is from our medical director [Roger Haley, MD] leading that charge. He’s kind of a programmer by nature and [has] actually developed software.”

Not long after introducing the iPad to Kaweah, Haley, a practicing nephrologist, was using it on rounds with patients in the ICU and the acute dialysis unit. Other staff members, who were already accustomed to virtual desktop infrastructure through their use of iPhones, didn’t take long to catch on. “The iPad itself is kind of a contagious device,” explains Volosin, who sees it as a good in-between tool that offers the right balance of size, power, and mobility.

Doctors at Kaweah can access any application or data set on the hospital’s network that’s reachable through their desktop. “[They] have full access,” Volosin says. “X-rays, they can pull up patient monitoring, patient telemetry, and EKGs. We even have it where the OB/GYN doctors can see the fetal monitor strips live.”

This high degree of mobile access allows doctors to better utilize and manage their time, while the device’s light weight and 10-hour battery life make it ideal for use on busy days. Plus, the Citrix setup at Kaweah allows doctors to seamlessly move from desktop to iPad without losing their place.

“Once they’re in the [patient’s] room, if they need to do more typing—and the iPad is not a good device to use for that application—they can actually switch to use the PC in the room and reconnect right where they left off from the iPad,” Volosin says. “They’ll have the full mouse and keyboard experience, and then they can disconnect and reconnect back to their iPad and go on to the next unit or room and again have all their applications open right where they left off.”

Patient education is another area where the iPad is making serious inroads.

“[Physicians] are able to actually bring up an x-ray image and zoom in just using the natural Apple pinch-and-zoom and show the patient right at the bedside,” says Volosin, adding that doctors may now be sharing more results and information with patients, largely because the iPad offers a convenient alternative to more cumbersome paper and film.

Physicians at Harborview are also using their iPads to better engage patients in their care while simultaneously saving time. Ghavami explains that outpatient visits are now much more streamlined. “What we have seen is that doctors actually bring up the image on their iPad, and they just walk into the room, show it to the patient, and walk out. It’s a lot quicker,” he says. “We’re saving several minutes per patient visit just using iPads in that manner.”

The introduction of the iPad has made rounds more efficient, too. “In the past, [the physicians] had to roll a cart with a PC on it,” Ghavami says. “That takes a lot of time and space to do that. Now they just take the iPad on their rounding and multiple people can look at it, look at the images for that patient right there at the bedside. That has been very useful to these doctors.”

The iPad’s ability to enhance patient interaction deserves further scrutiny, according to Avallone. In fact, Manhattan Research plans to conduct further research into how likely physicians are to “use [it] at the point of care with patients due to the large size of the screen and how the interface lends itself to that,” Avallone says, adding that he expects projections to reveal plans to expand the device’s use at bedside.

Hanson believes physicians will eventually be working with electronic devices whether they like it or not, making it imperative to have patients be comfortable with doctors who use technology such as iPads. “The key thing that we’re going to need to understand is what are the best form factors or approaches that we can use to improve that interaction between the patient and the provider rather than letting the attachment to the technology take the provider away from the patient,” he says. “I think we’ve gone through a period now where the technology has tended to pull the provider away from the patient, and we need to get back to the bedside.”

The iPad’s portability allows doctors to “work with a patient in a way that is more traditional in terms of hands-on and at the bedside,” he notes.

Sticking Points
While the iPad has been a good fit for Harborview’s needs, Ghavami says there still are hurdles to overcome. “[The devices] seem to be very consumer-focused and not very enterprise focused,” he says. “This is our dilemma. This is where I, as an IT person, have to really bridge the gap. These devices are not medical grade.”

While iPads can be remotely wiped and support a range of IT policies, “there’s still a lot of work that needs to go into making these enterprise-level solutions,” Ghavami notes.

Kaweah’s approach recognized those concerns and found a way around them. “The iPad is really a consumer device,” Volosin says. “I know they’re working on tools to make it more enterprise friendly, but by us allowing it to just be a thin client with Citrix, we’re not too concerned about managing [physicians’] applications because we’re just connecting them to applications that we manage in our data center.”

Avallone, who says application and access issues are evolving, points out there’s a high level of physician interest in creating additional applications and gaining greater access to EHRs through the iPad. More robust application development activity is just getting started, he says.

“In the short to midterm, we’re going to see more vendors come into this space,” Avallone says, adding that there’s also talk of linking iPads into hospital service systems and increasing their role in more back-end types of activities such as clinical note taking. “I think generally, as physicians become more comfortable with the device, we can expect to see some more advanced activities occurring on it.”

Physicians have raised some concerns about the difficulty of inputting large amounts of information into the device, according to Avallone. “Obviously, as time goes on, that’s something that probably will be less of an issue as physicians become more familiar with the touch keyboard and using it for longer-type activities and typing in greater amounts of information,” he says. “But right now that seems to be an issue that physicians are dealing with.”

Avallone cautions that everyday concerns such as sanitation also need to be taken into account, along with the device’s relative fragility and lack of durability when compared to other healthcare-grade tools. “Physicians aren’t in a foam pit so that does become an issue at some point,” he notes.

— Julie Knudson is a freelance business writer based in Seattle.