Why locked Android tablets will beat the iPad for hospital use

[Ed. On Thursday, we will publish an opposing viewpoint from another editor. Let us know what you think in the comments section.]

The rush of manufacturers to bring tablet computers to market was much in evidence at the 2011 Consumer Electronics Show (CES) and at the Mobile World Congress in Barcelona. The tablet market was essentially created by Apple with the introduction of the iPad in April 2010, who has gone on to sell an astonishing 15m of these devices in less than a year. The iPad 2, introduced last week, promises to extend these sales numbers.

There has also been tremendous enthusiasm in the medical world for the iPad, with most of the major medical apps now optimized for its larger screen and user interface. At the University of Chicago, internal medicine residents received iPads as part of a pilot study and are giving it “rave reviews“, relishing the ability to access patient records while on the move and to share information with patients at their bedside (see this news clip). Medical uses were even highlighted in the iPad video during the Apple March 2 press event.

With dozens of new manufacturers rushing into the tablet market in 2011, many of them running versions of Google’s Android operating system, the market dominance of the iPad will clearly diminish. Nevertheless, the iPad and other iOS devices will remain a massive market for app developers who will aggregate wherever there is a large customer pool for their products.

However, I believe the deployment of clinical apps specifically will follow different signals. In particular, I predict that tablets meant for real-time clinical use will run locked versions of Android, that allow interaction exclusively with clinical information systems, and be provided by hospitals and other institutions.

The reasons for this include:

  • hospital information services and EHR vendors favor standardized application & hardware deployments for security and ease of maintanence
  • vendors can customize the Android mobile operating system; Google exerts its control only when accessing the Android market, and thus this will be sacrificed
  • paid app downloads will continue to diminish as a source of revenue, as real value shifts to connectivity with other apps and demonstrating cost savings

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Recently, Palomar Pomerado Health, a large hospital system just north of San Diego, announced the development of a tablet application that will allow their physicians full access to patient health records. Already promised is connectivity with three major EHRs: Cerner, NextGen and the Veterans Administration’s VistA system. The application was previewed at the recent HIMSS meeting in Orlando. It was developed using the Android mobile operating system and was funded in part by Cisco, who is providing the wireless infrastructure for a planned new hospital by the health system.

This announcement is interesting in a few key respects:

  • it neatly aligns with a prediction made by Research2Guidance and highlighted on this site that future medical applications will be provided by healthcare institutions, not App stores
  • the app developers did not choose to develop on Apple’s iOS; their stated reason was that “they are not allowed to delve as deeply into the computer’s inner workings as they are [with Android]“
  • the app’s real value is not in its presentation layer but rather in its integration with multiple EHRs

The latter point is highlighted in this quote regarding the app:

It sounds like it’s really cool and valuable …, but I suspect the real value is in the back office cooperation that needs to exist to access the data.

from Dr. Joseph Smith, chief medical and science officer at the nonprofit West Wireless Health Institute in neighboring La Jolla, in the San Diego Union-Tribune.

Integrating patient data across multiple clinical information systems and EHRs is difficult, unglamorous work. However, the relatively easy revenue from paid downloads will become a diminishing source of revenue in the future. Specifically, Research2Guidance predicts that, in the future, value will revert to device sales, monitoring & other medical services and advertising. This will further reinforce the model of apps distribution by health and IT providers, rather than being selected and downloaded by end users.

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I would expect that the actual tablets will be provided by hospitals or EHR vendors, as free incentives, or at low cost. As above, the devices will have the apps preloaded and the operating system will have been modified so as not to allow any other user interactions or access to the Android market. This will greatly simplify provisioning and maintenance of the devices while the hardware will be kept to the bare minimum necessary to run the applications. Note also that we recently reported that Samsung is augmenting Android with new APIs to “make more secure and enterprise compatible apps” for Samsung phones and tablets.

Finally, for those keeping score on Apple vs. Google in the mobile space, what does this mean ? Apple is a hardware company and not terribly interested in commodity hardware and low-margin enterprise pricing. Thus, it may not loose too much. Google is an advertising company and uses Android to collect information on its customers and display ads. If these devices do not use Google’s own apps, it does not get customer data. However it benefits by getting more developer mind share, which increases the value of the platform as a whole.

In conclusion, Apple’s iPad is a highly refined and capable device which can rightfully be said to have revolutionized computing. It will, however, not be the device most likely used by physicians to access patient records in the future. Furthermore, since the value and power of future medical apps will depend on their ability to access patient records, the evolution of the medical app world will likely be influenced by the platform decisions made in the near future.

Author:

Felasfa Wodajo, MD

34 Responses to Why locked Android tablets will beat the iPad for hospital use

  1. Dave March 8, 2011 at 3:27 am #

    Android tablets are barely past vaporware right now. I can see your prediction applying to specific solutions in a hospital–monitors, inventory, etc. where users don’t care about lock-downs. I do not believe doctors will agree to use generic tablets that are locked down to the hospital system. I think they will want integration with their personal device so they can access medical records, write prescriptions, etc. while in the coffee shop or on the road. Doctors have already comprise a larger than expected proportion of iPad buyers. I doubt they are going to want to use an inferior and, from all indications, a more expensive product. This is not the cell phone market where non-AT&T customers have to buy an Android.

    • drrjv March 8, 2011 at 4:26 pm #

      I thought the only real advantage of Android was that it was ‘open’ (whatever that is)?

      Most reviewers consider Android pseudo-iPads a work in progress:

      CNET: ” Google still has some work to do before its tablet software experience is as fleshed out and intuitive as Apple’s.”

      Business Insider: “Honeycomb is nowhere near as polished as iOS for iPad. It’s apparent in everything from the app crashes I experienced to the confusing layout of menus.”

      Ars Technica: “If you compare the Xoom against the iPad 2 today, there isn’t much of a case to be made in favor of the Xoom.”

      I’m sticking with my iPad, thank you very much.

      PS: Who needs FLASH – just a bunch of Ads and long web intros!

  2. Pascal March 8, 2011 at 3:38 am #

    I have to disagree on this prediction. You make valid points with respect of the current state of medical informatics in general and EHR systems in particular, but the glacial evolution of these systems has to stop, and solutions are already under way. There are various endeavours under way, for example have a look at SMART (http://www.smartplatforms.org/ ): This platform will provide frameworks to developers – platform-independent and -dependent – which will allow them to easily connect their apps to the hospital’s EHR system, by providing an intermediate layer. There is no need for an app to tie directly into an EHR, which not only increases security (and therefore does not require locked devices for accessing EHRs), but also has the potential to create a universe of apps physicians may use, independend from the vendor of the hospital’s EHR. As I see it, this is certainly the way to go!

    Disclaimer: I’ll be joining the SMART group as a postdoc, so my view is extremely biased. ;)

    • Felasfa Wodajo March 8, 2011 at 3:51 am #

      The SMart platform (and the partially related Dossia collaborative) are exciting developments and I agree may shape the future of medical apps. However, I would argue the success of device independent development platforms would favor the licensed operating system/third-party hardware model of Android. Apple is selling a cohesive ecosystem with a tightly controlled experience and thus these “equalizers” do not favor the iPad or iOS in general.

      • Pascal March 8, 2011 at 6:15 am #

        I agree that the iPad is not favored by this approach, however I feel that neither the Android platform is. In the end many physician-centered software doesn’t require specific hardware (other than a screen), so the only argument for one or the other tablet platform is the quality of the available apps.

        That’s probably a very idealistic opinion, we’ll see what the future brings.

    • drrjv March 9, 2011 at 2:26 am #

      Smartplatforms sounds like a nice name but it remains to be seen where it ends up (sort of like the ‘Affordable Health Act’ which isn’t so affordable). It would be great if it really worked to improve interoperability in health care.

      In any case, wouldn’t it make sense that a ‘Smartplatform’ developer would integrate RDF and SPARQL into a specific App that would run on iOS (iPhone/iPad/?AppleTV), Android or other OS’s?

  3. cronus_k98 March 8, 2011 at 4:26 am #

    I agree that locked down tablets will dominate in the institutional market but that’s only one segment of healthcare. Independent physicians and small groups with little or no IT staff will not be able to customize these devices and I think will stay with the Ipad for ease of use.

    • drrjv March 9, 2011 at 2:30 am #

      I disagree and think the opposite. Devices like the iPad have dramatically opened up the market to devices that have multi-functionality. You will not see this physician carrying around some black box contraption handed out by IT for patient access.

  4. Fuyu March 8, 2011 at 5:07 am #

    I will agree with this predicion in the future, but now Androids are only suck, and now android tablets still cost much more than apple’s ones. There’s no ecosystem yet. Apple will take lead for at least 5 years

  5. Cr0aker42 March 8, 2011 at 5:44 am #

    Working in a very large health-care oganization, I can tell you that our physicians will rebel against any system that is locked so tightly that they can not install their own “tools” for patient care. Health IT too often stifles innovation and creativity through the use of “security” and “system integrity”. I can tell you that while it’s more work to support an open ecosystem, you can do it with just as much security. It makes your physicians a lot happer, and most importantly, more productive. In the end, isn’t that the point?

    • Felasfa Wodajo March 8, 2011 at 6:04 am #

      I’d like to work at the institution where physicians’ rebellions actually drives hospital IT (ha ha)

      Think about all the black box Dells and Lenovos strewn about hospital countertops ? Did anybody ask the docs which version of Windows to run or what hardware configuration to use ?

      In the future, tablets will be as common as clipboards. I agree there is no _technological_ reason why physicians should not then have access to a thriving ecosystem of interconnected apps.

      • Doug Holton March 8, 2011 at 10:19 am #

        “In the future, tablets will be as common as clipboards”

        That’s actually the best reason the ipad will likely not succeed in professional settings (possibly including education) – no stylus. I’m working on a project for example where students in engineering courses do digital note taking – they have to be able to draw graphs and equations and so forth. It is possible with an ipad, but it was not designed with that in mind, plus it is expensive to buy the apps, and there’s no place to keep the stylus.

        The HTC Flyer and other android tablets are coming out with a stylus and integration with the software, such as palm rejection and handwriting recognition. The real competition is with Microsoft tablets (like the HP Slate) – but Windows 7 is still not a very good tablet OS. We’ll see about future OS’s though like Windows 8 and also Linux alternatives like Ubuntu and its uTouch support.

        • Iltifat Husain March 8, 2011 at 1:50 pm #

          This is a very interesting point. And Steve Jobs had made clear there will never be full stylus support for the iPad. We actually did a review of the various stylus accessories available for the iPad, giving some examples of how it could be used for writing short medical notes:

          /20…

        • drrjv March 9, 2011 at 2:34 am #

          I much prefer not having a stylus personally and iPads and other tablets don’t seem to be supporting them. A better solution: improve the interface to make using a finger even easier.

      • Iltifat Husain March 8, 2011 at 3:28 pm #

        I have to agree with Felasfa on this one. Unfortunately, at the end of the day, hospital institutions don’t really care about what exactly physicians want from an IT standpoint. Example: Basically every hospital you walk into has what Felasfa just mentioned above.

    • Ryan September 23, 2011 at 10:15 am #

      They can rebel all they want, the truth in the article is based on the complexity of EMR. Security must be paramount. Its beyond perceived, the legal and civil liability of losing, misplacing/misusing or allowing outsiders access to these records could be staggering.

      By locking down these devices so they can ONLY connect to authorized systems helps to minimize risk. And no doctor in any real hospital system has enough clout to shout down the legal team, nor the income to weather the potential lawsuit or fines.

      The option may be as posted above, Citrix. Working as an ECM vendor I have found Citrix’s current offerings to be useful, if a bit limiting. However even then I would think IT would still not want to give up control of the device itself.

  6. Alexander Protonotarios March 8, 2011 at 7:46 am #

    Look how many comments you get when you post something against Apple :). I believe if hospitals (or healthcare systems in general) make the use of tablets official in everyday healthcare, new healthcare optimized OSes will arise (actually there is a huge healthcare industry ready to create them if they see that this is happening).

    • Iltifat Husain March 8, 2011 at 1:54 pm #

      Yea, the problem is, it appears much of the industry is still severely lagging. You would think that 100 million plus iOS devices in the ecosystem would get them to move — but not so.

      • drrjv March 9, 2011 at 2:37 am #

        You’re right! Health care IT professionals will have to be dragged, kicking and screaming to a vision of a new paradigm in technology! Time to leave 1980 guys. There is more to the world than .Net!

  7. SiMBa37 March 8, 2011 at 12:11 pm #

    I’m just so impressed with that video from U. Chicago using iPads in their residency. Why wasn’t my IM residency like that?

    • Iltifat Husain March 8, 2011 at 1:53 pm #

      Yea — definitely a pretty impressive video. I’m sure they are using metrics to see how the iPad is performing as well, will be really interesting to see what the results are.

  8. drrjv March 9, 2011 at 7:28 am #

    Our hospital is gearing up to offer a Citrix interface, which allows anyone with a compatible device, such as an iPad (and I presume Android device) to access hospital information systems (HIS). So rather than having ‘locked’ devices, by using Citrix or VMware View, one could use a ‘personal’ device and access HIS without any real issues of compatibility or security.

    http://itunes.apple.com/us/app
    http://itunes.apple.com/us/app

  9. Jared Sinclair, RN March 10, 2011 at 6:36 am #

    With dozens of new manufacturers rushing into the tablet market in 2011 … the market dominance of the iPad will clearly diminish.

    Although he doesn’t say so in as many words, it is clear that Wodajo perceives the battle between iPad/iOS against Android tablets through the lens of the old Mac versus Wintel story. The reality is that Apple is in a very different position with iOS and the iPad then they were with the Mac. Apple’s competitors simply can’t match the iPad’s price without sacrificing crucial features like battery life, screen size, or build quality. No one has come close to matching the $499 iPad’s specs without costing several hundred dollars more, and that was before the iPad 2 was announced. If anything, the market dominance of the iPad will clearly increase in 2011.

    Vendors favor standardized application and hardware deployments for security and ease of maintanence.

    Of course they do, and iOS 4 and Apple’s enterprise tools make it easy for small teams to manage hundreds of iPads. Device profiles can be remotely installed and updated. Apps can be distributed wirelessly, bypassing the App Store entirely. iOS 4 also supports commonplace IT standards like VPN networking and Microsoft Exchange.

    Vendors can customize the Android operating system.

    I don’t see why this is relevant. Between native apps and web-based applications, what else is there worth customizing? The iPad supports networking standards like VPN, and its security features for passcode protection and remote wiping already meet government standards for mobile healthcare devices.

    Paid app downloads will continue to diminish as a source of revenue, as real value shifts to connectivity with other apps and demonstrating cost savings.

    Continue to diminish? This is not only irrelevant, it’s also dead wrong. There are somewhere around 500,000 apps in the iOS App Store, with thousands more being added each month. Apple has deposited collectively over 2 billion dollars into developers’ bank accounts since the App Store launched, with most of that money having been earned in the past year.

    The devices will have the apps preloaded and the operating system will have been modified so as not to allow any other user interactions or access to the Android Market.

    One wonders if Wodajo has even touched an iPad. The ability to download or delete apps can be disabled with only a few taps. Furthermore, as mentioned earlier, device profiles with preloaded apps and user restrictions can be distributed wirelessly.

    Apple is a hardware company and not terribly interested in commodity hardware and low-margin enterprise pricing.

    While it is true that Apple doesn’t deal in commodity hardware, they have made it clear publicly that they plan to price the iPad aggressively. The iPad 2, for example, retains the $499 entry price of its predecessor, but with twice the speed, more RAM, dual-cameras, and a sleeker design. There are simply no comparable alternatives on a feature-by-feature basis at that price point.

    Wodajo also overlooks one key fact that I think will drive the iPad’s entry into the healthcare space: the tide of technology adoption has shifted from the enterprise to the consumer space. It used to be the case that new technology began at the enterprise level and then trickled down slowly into the consumer space. Consumers are now the early adopters. Smart mobile devices are changing people’s personal lives. There is a growing expectation among consumers that they be able to use their smartphones and iPads at work.

    Doctors in particular love the iPad. Anecdotal evidence abounds. The folks at my local Apple Store tell me that around one fifth of the customers looking to buy an iPad are physicians. I see iPads frequently at my hospital. A friend in my hospital’s IT department takes calls every day from doctors saying, “I just bought this iPad now please make it work with Cerner!”

    • Felasfa Wodajo March 10, 2011 at 10:20 am #

      Thank you for the thoughtful and extensive remarks. I will try to answer your points below.

      > if anything, the market dominance of the iPad will clearly increase in 2011.

      I did not dispute this or even bring it up, I was discussing the role of tablets in hospital settings where the important advantages you listed are not as critical

      > iOS 4 and Apple’s enterprise tools make it easy for small teams to manage hundreds of iPads.

      Yes, that is correct and for many deployments, it may all that is needed. Hospital IT departments, right or wrong, perceive that their security and uptime needs to be more challenging and will prefer devices already modified for hospital use.I am predicting that vendors will be coming in the future with modified Android devices already be tuned for hospital deployment. 

      > Vendors can customize the Android operating system - I don’t see why this is relevant.

      See above. In truth, the security and privacy requirements of financial institutions are actually more stringent than hospitals. Nevertheless, hospital IT seems to function like a closed system.

      > One wonders if Wodajo has even touched an iPad.

      Huh ?

      >Doctors in particular love the iPad. Anecdotal evidence abounds

      And why not ? It’s just that when they walk into the hospital and pick up a tablet to check on their patient, it probably won’t be an iPad.

    • drrjv March 10, 2011 at 1:41 pm #

      Wow, one of the best posts I’ve seen on iMedical! Great comments from a person ‘in the trenches’ actually developing smartphone Apps:

      http://itunes.apple.com/us/app

  10. Bill Manguine March 27, 2011 at 9:20 pm #

    Microsoft Sharepoint – which many hospitals already use + Windows 8 Tablet = future

  11. Rich May 25, 2011 at 2:18 pm #

    It is unlikely that hospitals or EHR companies will develop their own locked, medical specific ROMs (the interface that you use that is installed on the Android operating system). The only thing that the Apple iPad has going in it’s favor is standardization. All iPads are the same so creating an app for one is the same as another. Creating a ROM is tablet specific and then creating the apps to run on that ROM will be specific to that tablet as well. 

    Which is easier? Creating a custom ROM and then the custom apps to run on that ROM or just creating a custom app to run on the stock ROM. The latter.

    Blocking market access or removing the market application is an easy enough endeavor and is more feasible than creating a custom ROM. Market access is not necessary with Android (unlike iOS) as Android is an open operating system that allows “sideloading”, the installation of non-market apps. 

    Android’s lower price point, open source, lack of “planned obsolescence”, and non-regulated market will put it at the front of the medical tablet and application race. Apple requires you to buy new hardware on an 12-18 month cycle. Every large update to their iOS is incompatible with previous hardware. The cost of upgrading and implementing new hardware every year is cost prohibitive even for the largest hospitals.  The Android operating system is able to be loaded on older hardware while still innovating faster than Apple. The “End of Life” for Android hardware tends to be 2-3 years. Even Google’s first real Android phone, the Nexus, is still capable of running the latest Android releases. 

    Android is eating an Apple a day.

    • Felasfa Wodajo May 25, 2011 at 2:56 pm #

      These are interesting comments, thank you. I agree, that creating a completely custom ROM is not necessary but the interface will probably be changed enough so that the average user cannot modify settings or install new apps. This means the hospital IT does not have to worry, once the tablets are deployed, that they will be modified.

      As to the comments about Apple’s “planned obsolescence”, that is mostly ad hominem and not particularly relevant to this post. Nor is there anything intrinsically interesting about the “openness” of Android (whatever that actually is) to consumers. The comment that major iOS updates require new hardware is simply wrong. Finally, as I alluded to in the post, I doubt that the margins on bulk sales of low end tablets to hospitals would be terribly interesting to Apple anyway.

  12. Mtsb10247 May 31, 2011 at 8:21 am #

    Good luck with that fragmented Android hardware market. As a software developer would I rather work in the immature hackery that is Android or the mature, intuitive and well-documented stability that is iOS, namely iPad2? The choice is obvious. The only thing Android has going for it is that it’s Java-based…i.e. a larger developer base. I’ve yet to see an impressive Android app beyond Angry Birds (ported from iPhone).

    • Felasfa Wodajo May 31, 2011 at 9:24 am #

      please keep the android vs iOS wars on appropriate websites
      thank you

  13. BenT-RN January 26, 2013 at 8:37 am #

    Possibly a dead article (no posts for 2 years), but here we go. . .

    First, Most hospitals are banning all phones (for nurses at least) because of stupid use (photoing and posting patient info. . . Duh!!!). It makes sense for hospitals to go with something more customizable (have you seen the kindle fire/nook color/nexus 7 lately) that can lay a restricted set of pertinent hospital related apps on top of a solid OS (android 4.2 jelly bean) and lock down the app store access and camera hardware (if the tablets even have it).

    Second, the hospital partners that provide support (IT departments or wide area vendors) usually supply the hardware, monitor the use/repair/security of said devices, and generally lock out other “distractions” such as games and the ability to do extraneous things like visit ebay or install extra software. The infrastructure is there, it is just a decision of which is easier to work with, apple or android. The hospitals have been slaves of Microsoft for decades, I don’t see windows 8 making things better/easier/more secure/less expensive.

    for less than the cost of your typical 23″ monitor, you can have a fully functioning tablet, all it needs is an enterprising group to offer the integration. I hope to see more advances in this arena, but it will still take some time, 2 years later and no update on the article.

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