Many, including ourselves at iMedicalApps, have speculated on the possible uses of the iPad in various healthcare settings.  So we decided to test the iPad in the operating room.  The first question we had was: “Will the iPad work properly in the sterile environment of the operating room?”

The short answer to that question is yes – but in the process we had some interesting findings on how the iPad’s capacitive screen works with gloves and sterile enclosures – potentially affecting how the iPad will be used in the healthcare setting.

Making the iPad sterile:

A simple xray cassette sterile bag, ubiquitous in the OR, holds an iPad comfortably. Once the iPad is inserted in the plastic bag by the circulating nurse, the top of the bag is cut off, folded back, and clamped with a hemostat, as shown in the below picture. The iPad can now be safely brought into the sterile field.

Findings:

Importantly, the iPad touchscreen works quite well through the plastic bag, even while wearing gloves. Somehow, the touch of the plastic bag itself against the glass screen registers as a valid touch. I had no problems navigating with the iPad, or using the pinch and zoom functionality to view radiology images.

This was somewhat of a surprise since, as many people have noticed (see our story of the Pogo Sketch), using an iPhone’s screen with gloves is difficult, and nearly impossible if one is double gloved.

What is the use of an iPad in the OR?

There are a myriad or uses, but the same features that make the iPad great for surfing the web, looking at images, and viewing video also make it a potential hit in the operating room.  Plus, the portable form factor allows for a greater level of flexibility in the OR where space can be limited.

Where I can see the iPad being an asset in the OR will be the ability to bring in relevant medical imaging directly to the operative site, the ability to review relevant anatomy at the point of care (huge), and the opportunity to enhance resident teaching. Also, the ability to access a 3G network allows you to bypass the hospitals network, which can sometimes be restricted – not allowing you to access remote files and office EMRs.  We’ve already shown how a California Hospital is using the Citrix app on the iPad to access their electronic medical records – something we foresee happening more frequently.

My initial impression while using the iPad in the OR showed promise.  First, the ability to put the iPad in a sterile enclosure is a big step.  On top of that, the ability to use it without requiring an external stylus is huge.  These findings alone should put developers and physicians on notice when brainstorming potential applications that could benefit healthcare providers at the point of care – and should change the way they think about where the iPad can be used.

We’ll be bringing you more of our findings in subsequent posts and also delve deeper into the uses of the iPad in healthcare.

Related Posts:

1. iPad could support “Handwriting Keyboard” – A requirement for medical point of care use in health care
2. Surgeon using iPad in the Operating Room
3. Cedars-Sinai Medical Center is experimenting with the iPad in the hospital wards

Lately, I’ve often been asked the question, “What type of smartphone should I get?” by my medical peers.  I’ve been asked this by physicians, residents, medical students, and others. Many of my friends are entering residency and plan on upgrading to a smart phone, while others already entrenched in residency have phone contracts finishing up.

The answer to this question is not easy. Rather, as Facebook nomenclature would demand, “it’s complicated”. From the title you can see I’ve excluded the Palm platform and Windows mobile phones. Palm is currently restructuring since being bought by HP, and Microsoft is in the process of rebooting their mobile division – so both currently do not possess vibrant ecosystems for app development – and won’t be included in this discussion.

How you use your mobile phone is key in choosing the right smart phone, and obviously, not all medical professionals use their phone in the same way. I’ll break down a few different scenarios, and hopefully this analysis will help you make a more informed decision about the right mobile platform for you.

Do you need a smart phone?

First off, you have to decide if you will actually use a smart phone. If you need to check your e-mail at multiple times throughout the day, or feel a mobile reference tool in the palm of your hand is something that would improve your workflow, then you should seriously consider getting a smart phone. However, if you find smart phones cumbersome, too complicated, and don’t ever feel the need to use mobile reference devices such as PDAs, then you probably don’t need a smart phone.

If all you plan on doing with your phone is making calls, then getting a smart phone will only complicate your work flow. To make a phone call on an iPhone can take up to 3 or more gestures – a waste of time for those who don’t plan on using all the other features the iPhone affords.

What is your contract situation?

When it comes to my medical peers, this can often times be the sticking point when making a decision about the right smart phone. Currently, the iPhone OS platform is only available for AT&T, so if you’re on a Verizon family plan or can’t switch carriers, the best option for you is an Android phone or a Blackberry.

You should also be cognizant of the increasing chatter about Verizon getting its hands on the iPhone. Engadget, and several other tech sites have been reporting this could possibly be announced when Steve Jobs announces the iPhone 4G in the coming weeks – but these rumors are not a new thing – and most likely are wishful thinking.

Do you use your phone in a rural settings – and how important is a dedicated internet connection?

It’s no secret Verizon has been bashing AT&T for the quality of it’s wireless service. AT&T has 3G service in cities, but the service can literally come to a standstill at peak hours. I’ve experienced this in New York City, Washington D.C., San Francisco, New Orleans, and Las Vegas. In mid-sized cities, I’ve actually had a pretty good experience with AT&T’s 3G connection.

In those big cities I mentioned, my peers who have Verizon service almost all had a good 3G experience, unlike my own. Recently, I undertook a long road trip, and realized the 3G coverage maps of AT&T’s service that Verizon so aptly pokes fun at in commercials are true. As soon as you leave a city, AT&T’s 3G service drops off and you get the dreaded “EDGE” connection – a significantly slower internet experience. My peers with Verizon phones usually did not suffer the same fate.

This is important if your healthcare work requires you to visit remote clinics and a dedicated Wi-Fi connection is not available. You don’t want to be stuck in a remote clinic with shoddy service. Granted, most mobile medical reference apps are native to your phone and don’t require an internet connection – but if you don’t have good service, looking up key information via the web is going to be a exercise in patience.

Also, many electronic health records can be accessed via the web, and if you health care network has mobile access to these records, having a mobile phone with a strong internet access is essential.

So if you need a phone with a strong internet connection in rural settings, stick to your Verizon service, and consider an Android or Blackberry phone.  Android phones have a superior browser in relation to the Blackberry, so if you need to use the browser to access patient data via portals, go with an Android phone.

Related Posts:

1. Epocrates app now available for Android Smartphone – Medical professionals with Droid and Nexus One rejoice
2. Nexus One and the Android Family vs. the iPhone: What’s the Medical Professional To Do?
3. Should Medical Professionals Get an iPhone or an iPod Touch?

Preface: Albert Santalo is Chairman and CEO of CareCloud, an innovative web-based practice management software and electronic health record technology startup. Care Cloud integrates a fluid and attractive user-interface with an efficient revenue-cycle engine, and has attracted positive attention as well as $2.3m in series A funding. Mr. Santalo is an inductee of the Florida International University Entrepreneurship Hall of Fame and was recently recognized by the Greater Miami Chamber of Commerce as Best Up and Coming Technology Innovator. He was previously chairman of Avisena, a revenue cycle management company. CareCloud was covered recently on this site along with an interview with Albert Santalo. We are excited to bring you a guest post by this industry leader.

By Albert Santalo

There seems to be a lot of discussion these days regarding the turbulent nature of mobile platforms and how the differences between them will impact the kind of software that will be available to physicians and other healthcare professionals.

I want to take some time today to step outside of the deep technical details and discuss why I feel that the concept of the “App” is such a revolutionary step towards empowering physicians with effective, accessible and omnipresent tools.

While most of the smartphones on the market today offer exceptional browsing experiences (it’s amazing how far we’ve come in the last 3 years), the majority of browser-based web apps don’t provide the deep functionality and usability that native apps excel at. That means they can’t properly translate the desktop experience into the palm of your hand.

I’m not saying there isn’t a plethora of amazing utilities and tools available through the mobile browser today, but most lack the ability to fully capitalize on a particular device’s features to deliver a truly compelling user experience. There are some really amazing capabilities that developers can tap into if they build a native app, because native apps can work directly with the hardware and software of the mobile device.

We live in an age where development tools offer an unprecedented set of features that can significantly enhance the productivity of physicians. Web apps might be good for a patient portal, where cross platform availability might be a better option than having each patient seek out and download an entire app, but for real-deal applications, native apps are the way to go.

Here are my top 3 reasons that Apps are such important game changers:

Offline Usability

Medical professionals can’t sit around and wait for a signal – dropped calls are a minor nuisance for the average consumer, but for health workers it can be devastating – imagine not having access to a diagnostic program at point of care, or being unable to interface with the network for even the simplest tasks. Native apps can run in offline mode and then synchronize with the server when a signal becomes available. Now, this of course limits the use of certain functions that require wireless synchronization, but it also means less reliance on bandwidth availability and independence from signal strength, and when a signal does become available, synchronization will happen instantly.

Full Functionality

Currently, web apps can’t access the core features of the device they run on – things like multi-tasking, Bluetooth, address book, camera and microphone are still not accessible from the mobile browser. Most importantly, web apps can’t access the iPhone’s push notifications feature, which ensures that the most timely, important information reaches the physician regardless of what else he may be doing on his mobile device.

User Experience

Web apps have a few shortcomings, but none is more important to us at CareCloud than their lack of a dedicated, device-optimized user interface, and this translates direct to a diminished user experience. The look and feel of each app should be precisely catered to fit that device’s form factor, input methods, screen size, processing capability, etc.


 Web apps typically deliver an “abridged” user interface because they face limitations dictated by the browser, and they usually take longer to load than native apps, because they essentially need to load the entire app every time.

In Conclusion

Web apps simply can’t deliver the fine tuned user experience we at CareCloud strive to deliver to our clients. While the proliferation and widespread adoption of HTML5 may alleviate the symptoms of this problem, critical decisions about memory management, power management, screen size, etc. must still be made for maximum usability, and these standards don’t jive similarly across different platforms.

Of course, there are many other reasons that healthcare IT providers, like ourselves, should go with natively written apps. If the recent argument between Apple and Adobe is any indication, it just may be the safer choice in the long run. Regardless, it’s certainly great that there are so many mobile platform choices out there, and I have no doubt that well-developed, effective apps will be built for each one: it’s only a matter of time.

It’s truly amazing that developers have access to extremely powerful tools with which to develop apps, as well as the means to deliver them easily to customers on the go. We exist today on the cutting edge of a very bright future, one where solutions to many of the world’s problems are only a few lines of code and a couple of taps away. The trick is to ensure that these solutions are delivered within the context of a consistently streamlined user experience, and to achieve this, I believe that developing native applications for each mobile platform is the right way to go.

From time to time, iMedicalApps will invite developers, IT specialists and physicians to comment as guest writers. We feel that a diversity of opinions benefits all of us but remind our readers that the opinions expressed herein belong to the author and do not necessarily represent those of the iMedicalApps editorial team.

Related Posts:

1. Allscripts dominating mobile electronic health records in North Carolina – over 3,300 individual physician practices
2. Voice controlled electronic health records – Nuance could make it happen
3. Why Multi-Tasking on the iPhone OS is not good for Healthcare – Especially for future Electronic Health Record Apps

When I recently walked into my local Apple store to buy an iPad accessory, I saw a group of about 20 people huddled around a large LCD screen while an Apple employee was giving a workshop.

When I saw the LCD screen full of medical applications (picture on the left), I was shocked.  This wasn’t your run of the mill “how to use your iPhone” workshop.

The people gathered for the workshop consisted of healthcare professionals in medicine, dentistry, and other fields.  About a third of the group consisted of physicians.

The workshop was focused on how the iPhone and iPad can be useful for their practices and as reference tools for day to day work.

The workshop was led by an Apple employee who went through a slideshow presentation of useful medical applications, such as epocrates, iMurmur, Airstrips OB, and many of the other useful applications we’ve featured on iMedicalApps before.

Most of the apps we’ve listed in our “top 10 free iPhone medical apps” list were mentioned throughout the presentation.  I was pleasantly surprised to see an in depth presentation on medical applications in the Apple Store – and I couldn’t help but feel the creators of the slideshow had been on our site before. Along with the presentation given by the Apple employee, a MacPractice representative was on hand to demonstrate their electronic health record and how it worked from the desktop to the iPhone and to the iPad [below picture].

It’s obvious when Apple first came out with the iPhone they saw potential in the medical industry.  Apple worked closely with Epocrates to make sure it was one of the first applications for the iPhone, and it was even featured when the iPhone 2G was being unveiled.  After this huge initial show of interest, Apple’s extent of reaching out to the medical community has been dedicating a little webspace to show how electronic health records and other tools can be implemented in practice, along with some videos of successful integration stories in hospitals and private practice.

If you go to the Apple webpage showing how their various platforms can be used in healthcare, you’ll see Apple linking six different electronic medical record companies [electronic medical records is synonymous with electronic health records].  These six different companies are: MacPractice, SpringCharts, ComChart, The Life Records, Practice Solutions, and PowerMed.  These software developers share one thing in common – they cater more towards small practices and individual physicians – not hospitals.  This makes sense since most hospitals use big time players, such as Siemens, when transitioning to electronic medical records.

It seems Apple is really trying to get more medical professionals to use their platforms and software when implementing health information technology.  At first, I thought the driver to all this was the increasing popularity of the iPhone and iPod touch with medical professionals. But – after I talked to an Apple employee, they informed me the 2009 American Recovery and Reinvestment Act of 2009 is one of the main reasons why Apple is trying to promote its platform for electronic medical record use – and one of the main reasons for the workshops.

No doubt Apple believes the incentives offered to physicians by the above Act ($44,000 per physician) will lead to a significant increase in adoption rates. It appears Apple wants to leverage their good standing and popularity among health care providers into showing how health information technology on their platform can yield favorable and lucrative results.

At the end of the day, Apple sees an opportunity to capitalize on the potential of rapid adoption of electronic medical records and wants to show healthcare providers how the iPhone and iPad can be used for this type of technology – and after a long hiatus, they are actively recruiting health care providers -right within their own stores.

Related Posts:

1. How the iPhone has paved the way for a quicker transition by the Healthcare industry to an Apple OS Tablet
2. Five iPad Accessories for Health Care Professionals
3. Apple’s iPad Will Fall Short of Transforming Hospital Medical Care, But May Have Potential With Electronic Medical Records

We’re giving away 15 copies of a popular iPhone medical app that has been customized for the iPad in the comments section.

The iPad has finally been released and we’ve got our hands on one so we can provide the medical community a healthcare perspective of the device.  I’ve been using the iPad for the last two days, and these are the initial impressions.

Fits in your white Coat:

The iPad should fit comfortably your white coat.  If you continue on to the rest of the review you’ll see pictures of the iPad easily settling into my white coat, along with my stethoscope.  Granted, my white coat has been thoroughly stretched out with mini medical reference books, papers, and medical devices, but even with a fresh white coat, you shouldn’t have problems tucking away your iPad.

For the iPad to be seriously used in the medical setting, this type of convenience is key.  I can’t imagine carrying it around while I juggle patient notes and other necessities.

The iPad feels heavy in your hands(1.5 pounds), but is thin, measuring half an inch in depth.  The ends of the iPad are tapered, making it feel significantly thinner.  The heavy feel is almost welcome and assuring, it makes the iPad feel strong – making you feel like a drop, with a case on it, wouldn’t break it.  This type of build quality is expected from an Apple device.

*note, the iPad can go deeper into the pockets of my coat, but I left a bit out for the sake of the picture.

Fast enough for Healthcare Point of Care Use

When Apple announced the iPad’s custom designed 1GHz Apple A4 processor, heads turned.  The processors on previous versions of the iPhone were not custom designed by Apple in a similar fashion, but Apple wanted a chip that delivered high performance, while maxing out battery life.

Health care point of care use – using the device while seeing a patient, requires the ability to pull up key information quickly, or the physician patient experience suffers.  I really can’t emphasize how fast the iPad is.  Applications load faster than on an iPhone.  Web-surfing on the iPad is faster than your run of the mill desktop or laptop.  I compared the iPad web surfing experience (time to load a site) to a one year old macbook, and the iPad won every time.  Plus, websites pull up in a similar fashion – you don’t have to deal with a mobile version of a website anymore.

Below are screen shots of how some medical reference sites, such as Epocrates and Access Medicine look on the iPad’s screen:

This is welcome news to electronic health vendors, whose software is often heavy on system resources.  EMR vendors and medical app developers should have no problem making complex, feature rich software for the iPad.

Related Posts:

1. Apple iPad: Promising Features For Healthcare Use and Medical Education
2. iPad could support “Handwriting Keyboard” – A requirement for medical point of care use in health care
3. iPad App Store needs to mature before medical community can adopt the iPad for healthcare use

Health care professionals and students using Android are probably wondering what Android apps may be helpful in the health care setting.

Android developers continue to add more apps to the Market that relate to health and medical practice.  While the field of apps relevant to health care professionals on Android lags far behind the iPhone OS platform, there are several apps worth noting.

Here, we look at some of the more useful medical apps for clinicians, and list a few apps for patients as well.

The fact that we chose a “Top 5″ (and not “Top 10″), indicates just how limited the Android Market currently is for medical apps.

(1) Epocrates

It is hard to believe that an app as useful and effective as Epocrates is available for free.  See our extended review for Android here.

(2) Skyscape

Many Android users will download Skyscape simply to get the Archimedes, a highly useful collection of 100s of commonly used medical calculators.  Skyscape, however, does have other medical resources for health care professionals and students.  For Android users with OS v1.5 or lower who cannot run Epocrates, one of Skyscape’s main features “Rx Drugs” is a fine substitute.  Outlines in Clinical Medicine (OCM) comes with the free version, and is particularly useful for students learning a new topic in medicine (e.g. pediatric vaccination schedules).  Users, however, will find many of Skyscape’s more-robust features unavailable in the free-edition.

(3) PubMed Mobile

As we reviewed previously, PubMed Mobile is a clean app for quick searches of abstracts on PubMed.  It lacks full-text link capability, but allows the user to select and read abstracts, save searches and articles, and send articles to the printer, email, or social networking website.

(4) CPR – Choking

A wonderfully simple video-based app for learning basic life support skills on the fly.  The depth of information may not be sufficient to learn every caveat of BLS – and it certainly does not touch on ACLS, but for a quick refresher or first-time learner this app is a great starting point.

(5) Mobile Security Apps:

SmrtGuard and Contact Owner

This is a bit of a cop-out, lumping two apps into one ranking.  Mobile security, however, is of utmost importance in health care, particularly as app developers move to create mobile interaction with electronic medical records.  SmrtGuard is the most functional free security app.  Through a remote website users can track, data wipe, call-forward, remote listen, and backup data on their mobile device and SD card.  So if you lose your mobile device with sensitive information on it, you can wipe its data remotely.  The app is free, except for two features – remote backup and data restore to a new mobile device – which require an upgrade to the Pro version ($2.99 per month for 12 months).  Contact Owner is a basic app that displays a message about the owner’s contact information (or the information for an emergency contact) on the lock screen.  With contact information displayed on the lock screen, a person who finds your lost phone knows who to contact without accessing the phone’s data.

Conclusion:

Again, if you look at the top 10 free medical apps list we made for the iPhone OS, you saw a wealth of useful medical applications, that provide a great deal of value.  Unfortunately, the same cannot be said with regards to free Android medical apps we have listed here.  They do provide value – but do not provide functionality even close to the level of the iPhone App Store.

We seriously hope this changes in the future.  The Droid and Nexus One are popular Android devices – offering great hardware waiting to be tapped.  We only hope Google can get their Market in order, and find ways to motivate developers to tap into the hardware these phones have to offer. If you know of some free Android apps we didn’t mention, make sure to leave a comment and let the rest of the community know.

Other Free Apps
Listed here are other medical apps – many of them medical calculators – that may be of interest to your practice or learning needs.  Note: many of the calculators are similar to those included within Epocrates or Archimedes (Skyscape).

• BMI Calculators (many of them)
• EuroSCORE – European System for Cardiac Operative Risk Evaluation Calculator
• Ankle Brachial Index
• A-a O2 gradient
• Fluids & Electrolytes
• Glasgow Coma Scale
• Insulin Calc
• Breast Cancer Risk Calc
• OB Dating/Calc
• My Days – Menstruation and Ovulation History
• Ovulation&Pregnancy
• AAOS Now – Monthly news magazine of the American Academy of Orthopaedic Surgons
• BeatDroid
• Psych Drugs
• Doctor Finder
• AgileMedSearch – an alternative to PubMed Mobile
• AgileMedCalc

Free Apps for Patients

• StopSmoking
• Pregnancy Ticker Lite
• OnTrack diabetes – blood glucose log
• Know your BMI
• Hands-only CPR – CPR directions and videos for the the untrained
• Calorie Counter
• Diet and Food Tracker
• Body Fitness

Iltifat Husain contributed to this post

Related Posts:

1. List of 60 Android medical apps published
2. Epocrates app now available for Android Smartphone – Medical professionals with Droid and Nexus One rejoice
3. Epocrates Rx for Android gets reviewed – Our first Android medical app review

Apple has made it clear that current iPhone apps will run on the iPad.  For many of the medical apps we’ve reviewed, its welcome news, but it won’t make the user experience of these apps any different.  However, there are a few medical apps currently on the iPhone whose user experience should be greatly enhanced by the iPad’s 9.7 inch 1024 x 768 pixel display.

The following are the top 5 medical apps we’re excited to see in action on the iPad.  This list is focused for health care professionals, and stay tuned for another list for medical students.

(1) Blausen Human Atlas – When I think of the iPad in medicine, this app embodies one area in which the iPad could shine.  The Blausen Human Atlas includes 3D figures of human anatomy, an expansive medical glossary, over 1,000 still images, and a library of videos explaining common medical conditions like GERD and osteoarthritis.

Basically, everything in this app is designed with the goal of improving patient-physician communication. A provider who is trying to explain cholecystitis to a patient could access videos that explain the disease, still images to clarify any confusing points, and even 3D figures of GI anatomy to explain the corrective surgery.  The app performs admirably on the iPhone’s 3.5 inch display, but on a display more than twice this size – the iPad’s – it should shine.

Links: Blausen Human Atlas App Review
[iTunes Link]

(2) Visual Dx Mobile – This recently released app aims to be much more than a reference tool for dermatologic disease, aiming to be a point-of-care decision support tool when it comes to skin lesions. Perhaps I’m partial to it because rashes are the bane of my existence, but this app condenses an enormous library of information into a novel format – the “visual differential diagnosis.” And that is what I would love to see on the iPad – large, high-resolution images that would help me distinguish herpes zoster from dermatitis herpetiformis or chancroid from LGV.

Or, similar to the Blausen Human Atlas app, I could use the “Find a Diagnosis” function and use the information and images for melanoma to show a high-risk patient what he or she needs to be looking for. Again, the interactive and fluid user interface could only help enhance the communication between myself and my patients.

Links: Visual Dx Mobile App Review
[iTunes Link]

(3) Procedures Consult from Modality, are a series of apps that provide the user with extensive information on a number of procedures. With apps geared towards Internal Medicine, Family Practice, Ob/Gyn, and a number of other specialties, this family of apps has something for most specialties.

The highlights of these apps are the fantastic video tutorials complete with a narrator, interspersed still images to highlight key learning points, and integrated “clinical pearls.” There are even post-procedure videos that highlight things like how to submit pleural fluid to the lab.

The Procedures Consult series was clearly designed with the learner in mind. And as good as these videos are on the iPhone, they will be even better on the iPad – I can’t stress enough how helpful it will be to see, say, an LP on the iPad screen vs. the iPhone screen. And another big plus for these apps is that all videos are stored locally on your device, a crucial feature in the hospital or even rural clinics where internet access may be iffy.

Links: Procedures Consult – Internal Medicine review, Procedures Consult – Family Medicine review, Procedures Consult – Musculoskeletal review
iTunes Links: Internal Medicine Procedures, Musculoskeletal Procedures, Family Medicine Procedures

(4) OsiriX or eFilm – When the iPhone first came out, the image that most blew me away was the display of radiology imaging on a phone. These are the apps that make it happen and its probably not a surprise to anyone to see them on the list. The ability to access the brain MRI, ordered to rule-out a stroke from my call room at 3am (saving me a trip to a radiology viewing station), sounds great.

To view them on the beautiful high-resolution screen of the iPad will be even better. And the capacitive touch screen means I can manipulate these images and, hopefully soon, even annotate them or send messages to the radiologist asking about a strange incidental finding.

Last year OsiriX was used in a study to accurately diagnose acute appendicitis using the iPhone – showing huge potential for these apps.

Links: OsiriX App Review
[iTunes Link]

(5) Papers – This award winning medical app allows you to easily view research papers, and allows your to put all of your literature into mobile form.  One of the biggest knocks on the iPhone is how its difficult to read pdf files due to limitations of screen size.  The Papers app does a remarkable job of optimizing PDF viewing capability on the iPhone, and this same functionality will only enhance the user experience on the iPad.

Links: Papers App Review
[iTunes Link]

Other Noteable Medical apps worth mentioning:

*Merck Manual Professional Edition

*Epocrates Electronic Health Record

Iltifat Husain contributed to this post

Related Posts:

1. Five iPad Accessories for Health Care Professionals
2. Top 10 Free iPhone Medical Apps for Health care Professionals
3. iPad customized medical apps already in the Apple App Store

It looks like the wishes of many iPhone and iPad users are soon to be answered. AppleInsider is reporting the approaching update of the iPhone OS, version 4.0, will include a “full on solution” for multi-tasking. While they acknowledge that there have been at least three previous such reports, this news is apparently from sources with a proven track record of providing reliable information. Unfortunately, there’s not much information on how Apple’s “solution” gets around the issues that had long been cited for the absence of this support – battery life, resource utilization, and security. However, those three factors are critical to the iPhone’s use in clinical practice. And with the growing adoption of mobile interfaces for electronic health records and e-prescribing, these three areas are critical to determining whether the iPhone and iPad will continue to develop as clinical tools. However, even assuming Apple has come up with a way to mitigate the negative effects multi-tasking would have on those critical areas, multi-tasking is a losing proposition for clinicians.

There are certainly a number of potential benefits to clinicians with multi-tasking added to the iPhone. One area is involves mobile electronic health record platforms. Clinicians would gain the ability to cycle from, say, the Allscripts app to review the labs of a patient with a suspected PE to an app like MedCalc to calculate the Wells score. Or perhaps while trying to sort out what that weird lesion on the MRI is, a clinician could cycle on their iPad from eFilm to iRadiology or PubMed to get a better idea of what he or she is looking at.

However, while those are certainly useful capabilities to have, its questionable whether they are even improvements over current practice. For example, take the electronic health record example. If I am entering a note on that patient and then want to calculate a Wells score, as long as the electronic health record app saves my current progress before closing, I can then use whatever other apps I want. Better yet, developers could build those kinds of calculators into the app. A number of electronic health record vendors with iPhone interfaces commented to me at HIMSS that they were planning on integrating Nuance’s Dragon software, or other similar dictation software, into their apps. They could certainly do that with medical calculators – in fact, I’d argue that would be better because it brings these evidence-based tools just one step closer to the clinician.

In addition, whatever Apple’s solution is here, multi-tasking adds unavoidable security risks to the iPhone and iPad. For example, spyware embedded in another app or downloaded from a website by the unsuspecting clinician could then run in the background and pull information off of the electronic health record app. Since these devices could handle sensitive patient information, prescribing of controlled substances, and other processes that require secure operation, multi-tasking at the very least makes it easier for spyware and other viruses to infiltrate the device and cause some big problems.

In addition, whatever Apple does here, the speed and battery life of the iPhone and iPad will be degraded by the addition of multi-tasking. In other words, take away the multi-tasking capability and the device will get longer battery life and faster processing speeds. And when it comes to utilization in medicine, those gains would probably outweigh the benefits that multi-tasking brings to the table.

So while multi-tasking could be a boon to consumers, who would be able to stream music or utilize VoIP services like Skype while responding to emails, medical professionals should be a little more skeptical about this potential addition. Given the choice, its hard to see how the benefits of multi-tasking justify the sacrifices we must make to have it.

Related Posts:

1. Epic developing iPad app to complement popular iPhone electronic health record app
2. Why Apps are the Future of Mobile Health
 and Electronic Health Records
3. MultiTasking: iPhone OS 4.0 and what it means for the healthcare industry and medical users – Part 1

One of the pleasures of a large meeting like HIMSS is the chance to meet remarkable people who are creative and productive but with whom one would not otherwise cross paths. Dr. Yan Chow is a physician who’s career has spanned several spheres. He holds an advanced software engineering with three patents for network storage architecture and has launched a few Bay Area tech startups. Later, he decided to pursue an MBA and entered the Univ. California Berkeley School of Business as the “second oldest guy in the class” and, he says with a twinkle, graduated as valedictorian.

He continues to practice as a pediatrician at Northern California Kaiser but is also the director of the Kaiser Permanente Information Technology’s Innovation & Advanced Technology Group. This is a remarkable position that only a health care institution as large as Kaiser can create. In essence, his job is to survey the newest technologies and decide which ones could be implemented in the larger Kaiser health system. It is, undoubtedly, the dream job for any health care technology aficionado. But for the institution, it is a strategic asset that helps it to avoid costly purchasing mistakes. Kaiser also maintains the Sidney Garfield “Laboratory for Innovation,”a 35,000 Sq ft space with fully mocked up patient and operating rooms where real doctors and nurses trial new technologies. Dr. Chow told me a remarkable story of just how valuable these investments can be.

Some time ago, a rolling battery-powered computerized nurse medication cart was introduced. The idea was to allow nurses to dispense medications and perform their charting at the bedside. It seemed like a great idea and the Innovation Center acquired a few and set out to test it. As Dr. Chow tells it, within a few minutes, they determined it was not workable and they recommended against purchasing it. Some time later, a group of health executives was touring the center when the story of the rolling medication carts was told. Suddenly, one of executives “turns white” and, just when they thought he was feeling ill, he divulged why. Apparently, his hospital had seen the product and quickly spent a huge bundle acquiring 3,000 of them. They now sit in a closet and nobody uses them. So, it turns out, that like everything else in medicine, what works well in the laboratory does not always work well in practice.

Dr. Chow’s primary focus, however, is in looking even further ahead. His group is tasked with “…identifying and assessing new and emerging technology that may be adopted by Kaiser in the delivery of care three to five years from now.” He thinks of it like a “think-tank” where cutting-edge technologies are evaluated. Some of the ideas they are looking at include tele-medicine, mobile health, location tracking, virtual reality, genomics and robots. And, while the group has been asset for Kaiser, it has also been a boon for vendors who now have a single point of contact when they want their product to be evaluated.

Part of the advantage Dr. Chow has is that the Kaiser economic model favors distributing patient care responsibilities across multiple levels of care givers. In other words, since Kaiser practitioners are not constrained by the fee-for-service model, patients and mid-level providers can be far more integrated into the health delivery than in other outpatient settings. Thus, they are able to deploy communication platforms where patients and nurses are more involved in patient care – doctors only get involved when their expertise is truly needed. In a typical office, if you communicated with your patients by email and phone only, you would quickly go out of business.

Since its early days, Kaiser has always seen itself as driven by evidence-based medicine. The founder of the original physician group, Dr. Sidney Garfield, informed his physicians that the future of medicine lies in computers and that they better adapt to it – back in the 1970′s! It seems that this same forward-looking attitude continues to live on in the Kaiser Innovation and Advanced Technology groups.

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AirStrip Technologies was founded in 2003 by Dr. Cameron Powell, an ObGyn from San Antonio TX, and his partner Trey Moore, who is the software architect behind the products. Their first product, AirStrip OB was launched in 2005 and received FDA clearance in 2006. It allows for a physician to view the real-time fetal heart rate monitor of a woman in labor on an iPhone over a 3G connection. As Donna Morrow, RN, Vice President of Client Services told me, one of the least favorite parts of her job as a labor and delivery nurse was trying to describe a fetal monitor strip to a physician over the phone. When AirStrip OB came to her Houston hospital, she was an instant convert – enough in fact to leave her job of 15 years and join the company.

The real breakthrough for the AirStrip Technologies came when Dr. Cameron was one of the featured presenters during the keynote address during the 2009 Apple Worldwide Developers Conference. In between the usual cadre of developers, suddenly walks on a physician. I remember gasping when watching his demo of a real-time display of a wave form an ICU. While eventually being able to view lab and other static data on the iPhone seemed predictable enough, actually seeing a real live patient’s heart beating on your phone was obviously a turning point for the iPhone platform and medical technology in general.
Dr. Powell himself says that presentation was a turning point for his company in an interesting interview with HIStalk. He also says that the company made an early strategic decision to focus on highly refining the OB product before branching out into other opportunities. Importantly, the company invested in developing a robust application model that could be extended easily into other products. They refer to this as the AirStrip Remote Patient Monitoring (RPM) and it is, in effect, a platform that allows for the secure deliver of live streaming data that can displayed visually. Having engineered their product in a modular fashion and with a well-developed relationships with hospital-based monitoring technology providers, they are now able to roll-out a suite of applications on multiple smart-phone platforms.

The company is now announcing a suite of AirStrip Observer products, which will also include AirStrip Critical Care, Cardiology, Imaging and Laboratory. From their website, AirStrip describes the products as follows:

AirStrip CARDIOLOGY offers remote access to valuable data for the cardiologist including telemetry strips, EKG data, pulse oximetry, ventilator pressure measurements, end-tidal CO2 monitoring and arterial pressure monitoring.

AirStrip CRITICAL CARE delivers ventilator flow tracings, patient vital signs data and rhythm strips. Practitioners can access virtual real-time and historical data.

AirStrip IMAGING is a mobile PACS solution that can be accessed from virtually anywhere, providing practitioners with access to data previously accessible only at the bedside or on a hospital workstation.

AirStrip LABORATORY provides on-demand access to lab results and readings via an HL-7 feed. Users can refer to current or historical results through the patient medical file by simply selecting the required results view.

Ms. Morrow demonstrated the Critical Care product in the accompanying video and says FDA clearance is “imminent”. Even the quickest encounter will again show how amazing this will be to physicians. Multiple waveforms are displayed simultaneously, including ECG, blood pressure, pulse ox and temperature. Other screens will show laboratory data, I&Os. With a single tap, many of these parameters can be graphed over time, quickly showing trends over time. The interface is so fluid and accessible, I predict physicians will be standing at the bedside with all the hospital provided computers and monitors next to them and be looking down at their iPhones since it will be so much quicker and easier.

Another key feature is that data is not stored on the iPhone, helping reduce security concerns. Physicians are able to review up to 4 hours of previous data. Worth noting, there is currently no capacity to enter documentation into the iPhone.

AirStrip recently won a nationwide contract with HCA hospitals and is planning installation in 70 of their 110 hospitals. The OB and future Observer products are provided as a service, with the hospital paying a regular subscription fee. The pricing model for Critical Care will also be a strategic asset. The OB product is priced by the number of physicians. However, since several physicians can be involved in the care of a single ICU patient, the company is planning on pricing the Critical Care product on a per-ICU bed basis. What this will mean is that suddenly large cadres of physicians the in the hospital, across multiple specialties, will be using AirStrip Critical Care. It will not be long before they will be demanding the rest of the Observer suite of products for their own departments. Going forward, it will be cheaper anyway for hospitals to deploy software that individual physicians and nurses can use on their handhelds rather than trying vainly to keep up with with ever increasing numbers of dedicated fixed and portable computers, each needing maintenance and upkeep. And thus, the next era of patient monitors may well be beginning.

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In this video we check out two of the Dragon Medical Mobile Apps (releasing later this year) for the iPhone, Dragon Medical Mobile Dictation and Medical Mobile Search.  We recorded this video from Nuance’s booth at the HIMSS conference

Nuance, the makers of Dragon Medical Dictation, a favorite dictation service among many physicians, announced at HIMSS they are bringing the same medical transcription service to the iPhone.

Many readers may have noticed the recent arrival of a free Nuance “Dragon” app in the App store.  This simple app allows the user to speak directly into the iPhone and receive a nicely transcribed text document 15-30 seconds later, ready for email or for copy and paste.

At that time, Nuance did not specify their future intentions, but many speculated a medical version would be forthcoming.  Indeed, at HIMSS, Nuance announced three new iPhone medical apps: Mobile Dictation, Mobile Search, and Mobile Recorder, all named with the prefix Dragon Medical (i.e. “Dragon Medical Mobile Dictation”, etc).

Dragon Medical Mobile Dictate

The medical app of immediate interest to physicians is the Mobile Dictation one, which is similar to the free Nuance application, except for the very important distinction that the back end is now connected to the very reputable Dragon medical transcription engine – highly optimized to transcribe doctor speak. Like the most recent version of the desktop Dragon Dictation application, the specific “training” time is required, although the application does learn the user’s voice over time.

Currently, the application only returns text into the iPhone, albeit quickly, and the physician is required to transfer the text into another app via email or cut & paste. We were told the Mobile Dictation app should be available by Q3 2010 (late summer).  Pricing is not yet determined and it will initially launch on the iPhone but per Nuance, Android and Blackberry versions are planned.

Dragon Medical Mobile SDK

The real power of the application is the accompanying SDK (software development kit) that Nuance is previewing.  This SDK will allow electronic health record (EHR) vendors to directly access the application from inside the EHR.  For example, Epic’s Haiku iPhone app could allow dictation directly into a patient’s record in Epic without leaving the Haiku app.

Thus far, we are told that Eclipsys will be incorporating it into their nursing documentation module since they already partner with Nuance, although, having seen the demonstration, I would suspect the SDK will gain wide and quick adoption by the other EHR vendors. The other obvious future integration will be with the newly announced Epocrates iPhone based EHR – almost making the smart phone a complete doctor’s office.

Dragon Medical Mobile Search

The second application is called Dragon Mobile Search and is analogous to Google’s iPhone app in that it performs a search based on voice transcription. The difference is this app searches medical databases, such as Medscape, Epocrates, Medline or Google.

The search sites are displayed as a series of icons across the screen which the user can rotate through, described like a carousel by Nuance [reference above video]. It seems to work well enough but is hampered by the fact that the searches are presented to each site as a simple text query without the sub-categorizing that the Google app performs, which quickly allows the user to drill down to the actual item of interest. Perhaps if those databases exposed specific APIs for search, it would be more powerful. I would expect usage of this to vary on the individual level since its not always more efficient to say one word than it is to type it.  Nuance has a solid release date of April 30 for this medical app.

Dragon Medical Mobile Recorder:

The third application, Mobile Recorder, acts as a catalogue for previous recordings and allows the user to identify recordings with individual patients, if there is integration between the application and the physician’s or hospital EHR.  This recorder is designed for healthcare organizations that use Nuance’s enterprise dictation and transcription software, eScription, or the Dictaphone Enterprise Speech System.

The obvious advance for physicians will be use of Nuance’s SDK to integrate voice dictation dictation directly into EHR applications and thus make it seamless, rather than adding to the physician’s workflow.

In a separate announcement, Nuance also reported their advances in natural language processing. This consisted of two parts, the acquisition of a company named Language and Computing, described as a “a pioneering developer of clinical narrative processing technology” and a strategic partnership with Massachusetts General Hospital which had an internally developed natural language processing application they called “Smart Dictation”.

The vision is that a physician can simply dictate an encounter and, using natural language processing, the key parts of the note such as chief complaint, history, exam, etc. can be pulled out and used to populate structured data fields inside the EHR.  Pretty ambitious.

Like every other vendor at HIMSS, Nuance proposes this could help healthcare institutions comply with “meaningful use” and thus qualify for HITECH (stimulus) funds. More reasonably, they also claim this could help healthcare organizations with “data mining, coding for billing, disease management and clinical decision support.”

Nuance’s announcement seems to have generated a fair bit of interest, judging from other websites and the traffic at the booth. I suspect this is justified as physicians are only too happy to get rid of their dictaphones and not have to sit in front of a computer microphone, not to mention paying for transcription.  I’m also curious to see what other applications the SDK might find a home – reducing the need for keyboards, especially as a new generation of tablets starts to fan out into the health care field.

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I interviewed Robert Quinn, Senior Vice President of Engineering and CTO of Epocrates at HIMSS 2010, and he spoke candidly about the many features Epocrates electronic health record will have, especially related to the iPhone.

Yes, that’s correct. Epocrates, the mobile medical app that nearly has the distinction of being the one “indispensable” application for every physician’s smart phone, is going to have a big brother soon.

The ten year old company, based in San Mateo California, believes its base of more than 900,000 clinicians worldwide and its experience with mobile medical development gives it the wherewithal for understanding what physicians need and expect from a mobile Electronic Health Record (EHR).

They are targeting solo and small physician practices and with a price point that is expected to be very competitive. “This was a logical next step for Epocrates,” said Rose Crane, chief executive officer of Epocrates, when making the announcement.

Integration with the iPhone

I had the opportunity to speak with Robert Quinn, Senior Vice President of Engineering and Chief Technical Officer about the forthcoming product. They are planning a shipping target of Fall 2010. The product will have both a mobile iPhone app and web interface. They plan on integrating the features of the iPhone, such as the camera, as well as dictation directly into the app, an interesting feature especially in light of the announcement today by Nuance that they will be shipping a medical transcription application for the iPhone.

They will also utilize the iPhone’s Push Notification Service to alert doctors of important or timely information (and hopefully not overuse it). Given Epocrates’ depth of knowledge of pharmaceutical formularies, he said e-prescribing will “of course” be built in.
Although the mobile application will synchronize with the web application, it will continue working even when there is no internet connection. Data will be stored on the handheld device in a secure, encrypted manner and synchronize when a connection is available, a real issue for hospitals where there are many “dead” zones. There will be condition-based templates for easy entry of clinical information. The application will be written as a native iPhone application.

There will also be integration with a revenue-cycle platform so physicians can charge and submit codes, through a partnership with a “known” company, although Mr. Quinn would not say who that will be. Epocrates anticipates they will achieve CCHIT certification by the time of release. The EHR will be delivered as a software-as-a-service (SAAS) model, meaning the physician will effectively lease, not purchase it.

This could be an attractive low-cost product for solo or small group physicians who do not have complex office staff EHR integration needs. In particular, for the physician who already uses their smart phone for many work activities, the potentially painless transition to using it as the primary interface into their office EHR may be very appealing.

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It’s fair to say almost everyone has bought at least one accessory for their iPhone.  My own collection consists of two items, a simple protective case, and protective case with a built in battery.  I can’t emphasize how crucial my battery case has been, especially when I hit the 20th hour of a 30 hour on call shift and my iPhone’s native battery is about to die.

The Wall Street Journal recently reported on the development of iPad accessories, and how companies such as Griffin, Gelaskins, Sanho, and others are scrambling to manufacture products as fast as possible.  Time is money in the accessory business, and the iPod/iPhone accessory business is big money — totaling 3.7 billion in 2009 alone.

Medical app developers have already mentioned how they will be customizing their products for the iPad.  Epocrates and Macpractice are examples of two significant players who have already committed to the iPad platform — and there are more.

With that said, there’s no doubt some health care professionals will be using an iPad, whether for reading medical books or for EMR purposes.  So then two key questions come to mind: What accessories do we want to see and whats already out there?  The following are 5 key accessories:

1) Stylus

The iPad has a capacitive touch screen, similar to the iPhone, requiring the natural conduction ability of your body to register movement.  If you have gloves on, your fingers lose their “conductive” ability, and a capacitive touch screen is your worst nightmare — you cant do anything.

To remedy this, a stylus is needed.  Luckily, there’s already one available for the iPhone, called the Pogo Sketch.  Since the iPhone and iPad both have similar capacitive touch screens, this stylus should work just fine with the iPad.  Now if only the rumors of the iPad having a handwriting style keyboard come to be true…

2) Medical Grade Case

If you’re using your iPad with gloves, you better have a medical grade case as well.  Many health care IT folk have complained the iPad could pose problems in the medical setting because it’s not “industrial” enough, and could be hard to disinfect.  The solution to this is simple, develop a case that solves these issues and make sure it meets the requirements to be used in medicine.

3) Battery Case

One of my favorite iPhone accessories is my battery case(pictured below) that extends my iPhone’s battery by about 50% — helpful on those 30 hour shifts.  Why not bring the same type of battery case to the iPad?  Proportionally, the iPad is similar to the iPhone’s dimensions, and designing a bigger battery case for the iPad couldn’t be that hard.

The extra portable battery life would be especially key for health care providers who would be using the iPad for patient interactions.

4) External Camera and Video recording adapters

There are plenty of rumors swirling about the iPad and how its been built with the intention of having a camera and video recorder, but until this functionality is tangible, we’re hoping a 3rd party developer can step up to the plate and deliver on the goods.  Granted, they’ll need permission from Apple to connect the hardware directly to the iPad — and that’s no easy task.

5) VGA / AV out adapter

It would be great to show patients interesting medical videos you might have on a bigger screen, such as video from the Blausen Human Atlas app.  Also, if the #4 feature mentioned above comes to fruition, you could easily show pictures or videos of interesting pathologies on a big screen.  Key for grand rounds or any other large gathering.

So there you have it, 5 accessories health care providers who plan to use the iPad in practice are sure to appreciate.  I’m sure there are other accessories as well, and if any come to your mind make sure to let the us know in the below comments section.

Update: One of our commenters did an great job of explaining that the iPad will be shipping with the option to have the #5 accessory — awesome. Now if the #4 accessory mentioned, an external camera/video recorder is there, than having VGA/AV capability would be even more useful.

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Google’s smartphone operating system – Android – has been around for well over a year, yet the marketplace continues to lag behind Apple’s App Store with its meager collection of useful medical apps.  The biggest player in mobile medical reference software is now changing this perception.  Today Epocrates announced the availability of a free beta version, Epocrates Rx, for the Android platform, officially making it an android medical app. [We recently did a full review of Epocrates, including Epocrates Rx, for the iPhone].

This is exciting news for health care professionals who have Android phones – because their numbers are growing.  Google recently announced 60,000 Android handsets are shipping each day, coming out to 5.4 million handsets per quarter.  As a reference, Apple sold 8.7 million iPhones last quarter.

With this proliferation of Android phones, especially the Droid and Nexus One, many in the medical field can now feel more confident in buying the Droid or Nexus One.  That’s how big of an affect Epocrates has.  Almost one million healthcare professionals rely on Epocrates as a medical reference, and for most who have smartphones, its the first app we download.  I’ve had multiple friends with Android phones they love, but their only complaint is they don’t have Epocrates – not anymore.

Epocrates is taking a similar approach to releasing the software as they did for the iPhone: release a free beta version, Epocrates Rx, and then release the premium versions later this year.  Our guess is the premium versions will mimic the ones available for the iPhone, Epocrates Rx Pro, Epocrates Essentials, Epocrates Essentials Deluxe.  In our review we take a look at the features included in each of these versions.

There is one issue many Android users might gripe about: You need a device with Android v1.6 or higher.  If you bought an Android phone even a few months ago, there is a chance you might have Android v1.5.  This issue is one we’ve highlighted in the past, the lack of compatibility with different versions of Android.

Here are some details on the free Android version of Epocrates Rx.

Features:

• Drug Information – Ability to access thousands of brand and generic drugs, with indications, contraindications, retail pricing, mechanism of action, and lots more
• Pill ID – Identify a drug based on the color, shape, or imprint code
• Drug Interactions – One of the most popular features Epocrates offers.  Can check the interactions for up to 30 drugs at a time, especially useful for your geriatric patients.  Hopefully they aren’t on 30 drugs though.
• Tables and Calculators – Includes MedMath, a feature rich calculator we mentioned in our review of Epocrates.

Heads up: We’re going to do a full review of this Android version later this week.

Update: Palmdoc.net has a great article about how Epocrates for WebOS is coming “real soon”. [Web OS = think Palm Pre]

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