Health care professionals, particularly physicians, have quickly embraced the iPad: More than 30 percent of U.S. doctors now own one, according to research from both Manhattan Research and Chilmark Research, and sales show no signs of slowing. Manhattan Research said last year that Apple's product "continues to dominate the tablet market in health care," and everyone else is eating its dust.
The reason is that in the iPad, physicians have found a user-friendly product. The tablet doesn't cost 50 percent more than a comparably outfitted laptop, as some of its competitors' offerings have.
And the iPad delivers elegant design, good battery life and ease of use to health care users who have been clamoring for all three since tablets-many developed specifically for the medical market-hit the market a decade ago.
David Carleton, vice president and CIO at Heritage Valley Health System, Beaver, Pa., calls the iPad a "new delivery mechanism" for data and applications.
At Heritage Valley, a homegrown app allows doctors to access a clinical data repository from their tablets. "There's very little that we don't present to them on the iPad," Carleton says.
But it's not time for a victory lap just yet. The iPad and its competitors are not a perfect fit for health care for a variety of reasons, experts say: the small screen size is still a problem, as are the virtual keyboards, which make typing even more laborious for physicians who dislike typing in the first place. The are numerous security concerns with mobile devices and platforms, a big issue in an increasingly security-conscious industry.
In addition, software is still playing a bit of catch-up to the hardware.
Last fall, a small-scale iPad experiment failed at Seattle Children's Hospital. Chief Technology Officer Wes Wright issued iPads to five physicians and two nurses and enabled them to log into the hospital's Cerner EHR through an app that effectively turned the tablet into a Citrix terminal, replicating the desktop environment from each user's PC.
Every one of the users said the set-up was not suitable for their day-to-day inpatient tasks. But Wright does not blame Apple. "We made them use a Windows 7 desktop on top of the iPad," Wright explains. "The point wasn't that the iPad was the problem. It was the software," Wright says.
Cerner designed its EHR so certain elements look best on a large, 21-inch monitor, not the 9.7-inch iPad screen. The lack of a "native" iPad app meant that users had to scroll through a lot of screens to view all the information they needed. The software is optimized for a PC, not a tablet, Wright says.
Cerner, an enterprise systems vendor, does have a native iPad app out now that optimizes views for the smaller display, but it's read-only.
Wright says he is not interested in the app because doctors would like to be able to enter data on the iPad. The vendor says an update in the works, but any app that permits data entry on a mobile device opens up security issues, it adds.
So while iPads and its tablet brethren are not yet a fit for every current clinical environment and software infrastructure, emerging computing trends are breaking down some barriers. In addition, HIT vendors are starting to develop tablet-specific software and role out new devices to make the form factor more customized to the industry.
The greater adoption of cloud-based computing services is making mobility suitable for more enterprise-wide health care deployments, even as network administrators and compliance officers fret about how to meet burgeoning demand for mobile access while maintaining adequate data security.
According to Geoff Webb, director of product marketing for Credant Technologies, a company that specializes in data protection, the shift to the cloud is one of a few computing changes underway that are challenging long-held conventions around tethered PCs as the backbone of computing infrastructures.
For cloud-based services, which store data and run apps remotely, "tablets are the perfect devices," Webb says.
Another tablet-friendly trend is mobility of information: health care data is moving in greater quantities and to more places thanks in large part to the surge in adoption of electronic health records and wider availability of mobile broadband data services.
In addition, mobile users, particularly physicians, are buying their own smartphones and tablets, then asking I.T. departments for access to organizational networks. I.T. security departments as a result are moving away from their historic role of putting up walls to a more enabling position of giving users greater choice regarding access, Webb says.
Desktop mentality
But the counterweight to those trends is the still-ongoing transition from traditional desktop software to a mobile environment.
The problems that provider organizations are experiencing trying to fit a conventional EHR onto tablets does not surprise Thomas Giannulli, M.D., the chief medical information officer at mobile healthcare software developer Epocrates.
"You just can't take a desktop mentality and apply it to mobile," Giannulli said at the recent Healthcare Information and Management System Society (HIMSS) conference in Las Vegas. "You've got to get the software right."
During the conference, Epocrates introduced the beta version of its ambulatory EHR, which is designed to run on the iPad.
The EHR is built to replicate the "rich data entry" of commonly used EHR drop-down menus that create documentation based on user clicks, according to Giannulli. Instead of mouse clicks, iPad users select items with finger touches, and can take advantage of the finger-swipe capabilities to "stack" elements of a patient's record or a list of multiple patients for easier viewing.
The iPad EHR can save and sync to the Epocrates' existing Web-based EHR in real time-so doctors can edit entries on a computer with a real keyboard if they so choose.
It also can cache data locally on the iPad. (At press time, Epocrates said that it would sell off its Web-based EHR, citing mixed financial results for its core business of point-of-care drug reference services, which are used by more than 300,000 physicians; the EHR had just received meaningful use certification, but Epocrates acknowledged that building out the ambulatory EHR had been a distraction.)
While fully functional, tablet-based EHR software knocks down some walls, a local storage option is not something everyone in ready to sign off on.
In the case of Seattle Children's, the organization has adopted a blanket policy of not storing organizational data on whatever tablets staff might have now or in the future.
"I don't want a thousand iPads out there with patient data on them," says Wright, the CTO.
Beyond the security concerns, some medical specialties are just more suited than others for tablet computing.
Lyle Berkowitz, M.D., medical director of clinical information systems at Northwestern Memorial Physicians Group in Chicago, does not use a tablet in his internal medicine practice.
"Tablets really aren't that useful in primary care offices," he says. But doctors who do hospital rounds might find it easier to carry an iPad when consulting at the bedside, Berkowitz adds.
To speed up rounding, Heritage Valley, for one, has added radio-frequency identification tags to some of its iPads so the user just has to touch the tag to a reader on a hospital PC to log into the main clinical information system.
The process automatically navigates the PC to whatever point of reference the doctors were at on their mobile devices.
No fighting
This, according to CIO Carleton, saves Heritage Valley physicians 20 to 30 minutes per day when doing their rounds because they don't have to fight for devices or keep logging back in every time they go to a different room.
It also offers flexibility to doctors at the Pennsylvania health system's two hospitals and 70 clinics and long-term care facilities. The iPad functions somewhat like a paper chart, in that a doctor uses it for quick review of the patient's status, while data entry mostly takes place on a traditional PC.
"To think that a doctor could gather everything on one screen may be unrealistic," Carleton says, noting, for example, that radiologists are used to having three screens in front of them at a typical workstation.
Tablets, indeed, can be an interesting option in radiology-and some imaging vendors are attempting to capitalize on the potential.
Imaging software vendor Merge Healthcare uses the Web and the cloud rather than device-based applications to deliver high-resolution images and access to radiology reports to mobile devices through the company's iConnect Access system.
Users can go to a URL on the iPad or any other tablet with Internet access to view images and studies while away from their regular workstations. Aside from the mobility, touch-screen tablets also enable finger-controlled image manipulation.
iConnect has Food and Drug Administration 510(k) clearance for diagnostic image viewing on certain high-resolution monitors, but it is not approved for diagnostic use on mobile devices.
Still, tablets can be effective for quick consultations. "A radiologist may use this if he's not at his office or at home, if he's out to dinner, on the golf course, whatever it may be, and may need to see an image," says Gilbert Gagné, Merge's team leader for enterprise solutions.
Merge, like many of its competitors, also is targeting the software at physicians who refer patients to specialists for diagnosis and treatment.
But the radiology market is going to be a tough nut to crack when imaging software tries to move beyond a consultative role to a diagnostic one.
A study presented in January at the International Society for Optical Engineering medical imaging conference in San Diego found that iPads are just as good as standard LCD monitors for viewing medical images, but only as "secondary" displays when high-resolution radiology displays are not available.
Both the iPad and a typical LCD monitor have screen resolutions of 130 dots per inch, far less than the 508 to 750 dpi found in primary radiology viewing stations, according to lead researcher Mark McEntee, M.D., of the University of Sydney.
"iPads and other secondary screens should not be used for clinical diagnosis," McEntee told eHealthSpace.org, an online Australian publication. "There is a range of safety concerns associated with using mobile screens."
Based on his study of eight U.S. board-certified radiologists attempting to identify intracranial bleeding, fractures and lung nodules from X-rays and other scans, McEntee concluded that high-resolution radiological monitors are much better than iPads or standard displays in allowing practitioners to detect "just noticeable differences," a clinical benchmark for reading medical images.
While the new iPad 3, which was introduced the day this story went to press, will have a higher-resolution display, Apple's tablet and many of its competitors still are consumer-oriented products.
That provides an opportunity for industry-specific devices to find a space in the big health care market, says Joseph Hogan, president of Epion Health, a Lebanon, N.J.-based start-up vendor of a custom health tablet called Smart Screen.
Bringing in patients
The Epion product, an Android tablet housed in an antimicrobial case, brings in another important health care constituency, namely patients, Hogan says.
Smart Screen is designed for educating patients in physician waiting rooms and at the point of care by providing educational games, instructional videos and opportunities to join clinical trials and receive discounts on brand-name drugs and medical supplies, based on their specific conditions.
During a pilot just getting underway at 30 physician practices in seven states, the tablets also have a series of apps for clinicians, such as drug references, dosage calculators and health assessment tools.
Supported by on-screen pharmaceutical marketing, the tablets cost nothing for physicians.
Because the information and drug advertising presented is targeted to each patient's specific conditions, "the value of that patient becomes incredibly high" from the pharma perspective, according to Hogan.
Drug companies can direct their messages only to relevant patients, and Epion provides sponsors with tablet usage and activity reports to help them further refine their marketing.Hogan expects to deploy 5,000 tablets during the second quarter of 2012 and 20,000 by the end of the year, ambitious goals dependent, of course on the securing of sponsorships and physician acceptance.
Another advantage Hogans touts for the Smart Screen is that, unlike an off-the-shelf consumer product, it does not come preloaded with software that has no bearing on healthcare.
It's an omission which Hogan says helps keep out malware. Epion has developed a console management system so network administrators can better control the mobile devices, including the installation of relevant apps.
Another problem with tablets is the need to sort through all the health care and medical apps in public sites like the iTunes App Store and the Android Market, leading to the rise of custom or curated app stores for tablets and smartphones alike.
Apple itself has created a section of iTunes specifically for health care professionals to separate professional apps from the tens of thousands of consumer health and fitness apps.
The popularity of these apps has spawned other businesses aimed at the health care industry.
Health care boutiques
New York-based Happtique, which stands for "Healthcare App Boutique," has been testing private app stores for healthcare professionals at 11 provider organizations.
The stores are branded with the organization's name and sorted according to its customers' preferences.
"You can deploy the apps the way you want, when you want. Apple doesn't have to see it," says Paul Nerger, chief technology officer.
Health systems can add custom-designed apps, too, that don't need Apple's approval for inclusion in the public iTunes, as long as the organization has an Apple enterprise certificate.
The appeal of the tablet is causing many providers to show up at work with their own portable device.
The bring your own device (BYOD) surge is a mixed blessing for CIOs. On the positive side, it signals acceptance among providers of using digital systems. On the other hand, an influx of devices raises the need for strong security policies.
Resistance is futile?
After resisting the BYOD movement, the Department of Veterans Affairs last summer gave in to strong demand from Veterans Health Administration clinicians and started opening organizational networks to government-issued iPads and iPhones that replaced laptops and BlackBerry smartphones.
VA CIO Roger Baker also announced plans to set up a dedicated app store to serve the entire enterprise, not just the health care system.
The app store, which would reside behind VA firewalls, would provide clinicians with apps to support encrypted e-mail and to view electronic patient records on mobile devices.
Julee Thompson, chief health executive at mobile communications giant Sprint, says that the BYOD trend that has permeated the VA and countless private organizations shows that hospitals are "no longer the center of the universe" in health care. "I really think it's going to start revolving around use cases," Thompson said in December at the mHealth Summit outside Washington, D.C.
Institutions will have to decide such things as whether the extra cost of a ruggedized or waterproof, sealed device housing that can stand up to hospital-grade disinfectants is worth it to help with infection control.
Thompson also described a new tablet from Calgary Scientific that supports 3-D imaging and real-time interaction between clinicians.
A great use case for this product, according to Thompson, is a primary care physicianin a rural area who refers patients to urban hospitals.
The referring doctor could use the tablet from any location with Internet access to view the same images with specialists.
Regardless of how they are used, portable devices are having profound impact on data security. Security experts are finding that hardware is no longer the focal point of network protection.
"We have got to start moving toward a more data-centric view of security," says Webb from Credant Technologies.
For a long time, I.T. security was device-centric, focused on "stuff," such as a box, a firewall or a network. "That thinking has got to change," Webb says.
When it comes to data security, Rob Shaughnessy, CTO of Circadence, a Boulder, Colo.-based company that optimizes networks for delivering data to mobile devices, believes that mobility represents a "fairly steep mental shift for CIOs and enterprises." Historically, CIOs have had to implement policy. Now they have to create policy, he says.
Different challenges
According to Shaughnessy, tablets create a different set of challenges than smartphones because they offer more sophisticated applications.
However, there is not much difference between a phone and a tablet running on the same operating system-Apple iOS or Android, for example-from the platform and policy perspective.
"Tablets should be considered more like smartphones than laptops," Shaughnessy says. "They need the same types of control elements." But tight security creates tension with usability. Shaughnessy, like many other security experts, agrees that there needs to be security for data at rest and data in motion. But that can affect network speed.
"The emerging issue that we're seeing is on the performance side," Shaughnessy explains. There needs to be adequate bandwidth and application throughput to handle demand that is showing no signs of abating." In fact, Shaughnessy believes tablets are becoming the primary means of computing, not just an adjunct. The shift could happen in just a couple of years. It took nearly 20 years from the time the first IBM PCs debuted until the personal computer became widespread even in people's homes.
However, the first iteration of the iPhone didn't come out until 2007. "Smartphones took over as a dominant communications platform in less than four years," Shaughnessy notes. And tablets might conquer the world even more rapidly. "You really can't underestimate the pace of adoption compared with other technologies," he says.
Neal Versel is a Chicago-based freelance writer.
