For anyone interested in global health, there are a cadre of organizations that typically spring to mind as leaders – the CDC, USAID, and the Gates Foundation for example. I had the opportunity while at HIMSS to chat with folks from another organization that put boots on the ground immediately after the Haiti earthquake, is running programs worldwide on a number of endemic diseases (HIV/AIDs, malaria, lymphatic filiarisis), and operates a high-tech lab in Atlanta to develop field tools for public health workers. This is all from what I knew as a major defense contractor. But you’d never guess the that if you talk to Amy King (VP, Health IT) and Tom Verbeck (CTO, Health IT) of Northrop Grunman. Northrop entered the public health sphere just over a decade ago, looking to parlay the expertise it had developed via defense work – such as IT capabilities from intelligence projects – into a new health IT division. Since then, it has grown to employ over 200 epidemiologists along with scores of engineers, developers, clinicians, and other professionals, all of whom apply their range of talents to world’s biggest global health problems.

You may be wondering where the “mobile health” part comes in. For that, lets talk about a specific project that Northrop worked on to track HIV/AIDs in the Dominican Republic – a great anecdote of how mobile technology, on easy to use mobile devices, plus a strong IT support infrastructure can make a big difference and even turn every iPhone owner in the world into a public health field worker.

I spoke with one of Northrop’s engineers, who had been working on a project to track HIV/AIDs in this South American nnation. The video above is of a pretty simple app – pictured here on a heavy-duty PDA but functional on really any mobile device – that tracks HIV testing results. The public health worker shows up at a clinic outpost and tests everyone there with a rapid HIV test. On the app, they enter the name, some demographics, and the test result. As this process repeats itself all over the nation, this data coupled with GPS information, are synced to a national database built and analyzed by Northrop to identify and analyze epidemic trends. A natural extension of this kind of functionality would also to track HAART compliance, another critical factor in managing the HIV/AIDs epidemic. But while this project was fascinating, his vision for future applications was even more exciting. Imagine an emerging outbreak in the United States of some disease, such as influenza. Northrop releases an app for the iPhone, Android, Windows 7, Symbian, and all the other major mobile device platforms. This app is pretty simple – it asks for a name and includes a validated symptom questionnaire – and records GPS data for every entry. Overnight, everyone with an iPhone has been turned into a public health field worker – the disease can be tracked by millions of people, with the resulting mass of data used to much more accurately monitor disease trends. Updates could then be relayed back to via the app, such as public health notices (such as vaccine availability). Or similarly, take a disaster zone where a flood of relief workers has entered the field – each worker, whether a nurse or the guy driving that laundry truck, could download an app to track say diarrheal diseases. All of this would utilize more or less the same technology and back-end IT infrastructure that Northrop has put into place all over the world.

The possibilities are pretty exciting – Ms. King and Mr. Verbeck are clearly very enthusiastic about the work their team is doing. As Ms. King commented, the opportunities for Northrop to bring over their experience and knowledge from the military and intelligence worlds to public health have allowed them to unleash “the passion of people trying to make a difference.” While that may sound cheesy, I definitely believed her. According to Ms. King, the Northrop team is heavily embedded with many of the major public health players I mentioned above. They are, according to her, “everywhere the CDC is” and work with the CDC, Gates Foundations, and USAID (among others) to connect the dots on often parallel, independent efforts to address the same problem. Mr. Verbeck noted that Northrop employees deployed to Mexico City at the outbreak of the H1N1 epidemic, helping manage and analyze the data collected by the CDC workers. Another area he noted that Northrop is active in is health IT security. As the nation moves to a electronic health records operating, at least on some level, nationally, data security will be important and Northrop’s intelligence work clearly positions them well to engage in this arena.

To be honest, my conversation with Ms. King (who coincidentally was noted as a “Health IT Game Changer to Watch by ExecutiveBiz), Mr. Verbeck, and their engineers encompassed far more than I can fit into a single post. Some of their work, especially the stuff I described above, is a fantastic example of how mobile medical technology – even just simple apps for the iPhone and other consumer devices – can be transformational in healthcare. I’m definitely excited to see where the folks at this “stealth healthcare company”, as Ms. King described it, take public health next.

Updated! This post has been updated below to include comments from the folks at Epocrates

The excitement and hype surrounding the announcement of Apple’s iPad have subsided for the time being, perhaps just a lull prior to the actual release in a few months. Here at iMedicalApps, we were certainly among the many believers and expected that the iPad could make significant contributions to healthcare, such as potentially replacing the physician’s clipboard or medical textbooks.

However, we did disagree at times on the extent to which the iPad could penetrate the healthcare market, for a variety of reasons. The folks over at Software Advice decided to try to get a feel for what the community at large was thinking through an interesting survey they performed. And for Apple, the results of this survey aren’t encouraging – if you believe the results.

Having spent nearly four years learning how to read medical literature, I decided to try to get a better sense of just how valid these results are especially considering the seemingly conflicting results of the Epocrates survey. Chris Thorman, who authored the article on the survey, was kind enough to correspond with me on details of the survey methodology. Here’s a look at the results and our take on what they really mean.

According to the Software Advice survey, the medical community wants a tablet, with a third of respondents saying that they are likely to purchase a tablet. For over half of respondents, the primary factor that would guide their purchasing decision would be ease of use, with a fifth identifying software as their guiding factor. Why do they want it? Over 75% of respondents identified diagnostics management (ordering/tracking tests), medical reference, clinical decision support, prescribing, imaging, and notes as tasks they would like to perform on their tablet. As you read this, an obvious question arises – these are all things the iPad could probably do well, so where does the survey go wrong for the iPad?

The survey also explores the must-have features for a tablet, with over 50% identifying Wi-Fi, durability, lightweight, availability of medical software, and fingerprint access as essential features. Fewer respondents also identified dictation capabilities, RFID reader, camera, and barcode scanning as must-have features. While the iPad clearly does fares well with regards to some of these criteria (weight, Wi-Fi, usability), it lacks most of these identified must-have features. And these are certainly features that many, including us at iMedicalApps, have discussed as notable deficits when it comes to the iPad in healthcare.

However, with any study or survey, the results are only as good as the methodology. Chris Thorman (the author) kindly shared with us the methodology for this survey which involved an online survey which was publicized through online media including blogs, LinkedIn, and  other online platforms. The demographics indicate that out of a total of approximately 175 respondents, about half function in clinical roles (physician, nurse, student) and a little less than half function in management roles (IT, admin staff). I think knowing this is useful for a few reasons. First, if the respondents were all identified via online media, then this is almost certainly a tech-savvy group. So while that may inflate the “plan to purchase tablet” numbers a bit, it also suggests that this group is sufficiently knowledgeable to give feedback on what a tablet could be used for and needs to be successful. Second, it would be interesting to break out the responses of clinical and non-clinical healthcare staff – I could certainly imagine their responses being very different. Lastly, its important to note that a study of less than 200 people is certainly not sufficiently powered to accurately predict the sentiments of the healthcare industry as a whole.

Then there’s the Epocrates survey. Their survey of 350 clinicians suggested that 20% plan to buy an iPad within one year of release, with nearly 40% expressing interest but awaiting more information. So if clinicians are so excited, what’s the deal with the disconnect with the responses in the Software Advice survey. Well, Mr. Thorman suggests an explanation – clinicians are also electronics consumers, and electronics consumers are excited. So just because the regular consumer side of these folks are interested, the clinician side may not be. I’m waiting on more information from the folks at Epocrates on the methodology of their survey, and will update you all if any enlightening information comes forward.

All of that being said, these surveys are valuable because, whatever we predict, adoption or rejection of the iPad in healthcare is ultimately a decision that will be made collectively by hundreds of thousands of providers. So in reality, we’ll just have to wait and see what happens.

Update: 3/10/10

The kind folks at Epocrates shared the methodology of their survey with us. This survey was conducted using an established pool of clinicians – mostly MD’s, but also with PA’s/NP’s – who opt-ed in to participate in Epocrates surveys. From that pool, participants were randomly selected. So here again, we face similar issues with possible selection bias – these are folks who are fairly tech-savvy (if they are using Epocrates already). However, this probably incorporates a broader cohort than the population identified in the SoftwareAdvice survey, which used social media to recruit participants – Epocrates software certainly has broader adoption into the medical community, even the slightly less than tech-savvy folks. So overall, what I take away from all of this is that again we’re asking a group enriched in tech-savvy folks about their thoughts on a new device, but that the Epocrates survey is probably still more representative of the general medical community. Does this mean that the Software Advice survey is wrong? No – both surveys have their merits. What this survey implies to me is that its possible that the medical community, including the tech-wary, may be looking at the iPad with some interest, if I’m right that this survey population is more representative of the medical community. And maybe the “friendly” factor that contributes to the iPad’s appeal to this segment of the medical community will overcome the challenges identified in by the Software Advice survey.

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.

By Dr. Jessica Otte

In early January, Elsevier and Modality released a new addition to their suite of popular iPhone medical apps. It is a true multimedia offering, combining text and video to explain the pre-procedure considerations, the technique and positioning to perform the procedure, and the complications and other advertisements for follow-up care. Overall, 27 different procedures are covered; these range from the basic (catheterization and wart treatment) to the more involved (lumbar puncture).

Being a resident physician, I am competent with some of these techniques to the extent that I can perform them by feel. Some, like circumcision, I’ve never seen, let alone performed. Fortunately, Procedures Consult provides a foundation for each. As I’ve mentioned in other reviews of procedure-teaching apps, there is no substitute for hands on experience under the guidance of an expert. However, applications like these may allow you to skip the ’see one’ stage of the common ’see one,’ ‘do one,’ ‘teach one’ approach to developing a skill.

Navigation is simple. A main menu allows you to view a list of all procedures or procedures by type. You can also search or use bookmarks for quicker access.

Once looking at a procedure’s entry, the pre-procdure text will walk you through indications, contraindications, equipment, and anatomy. Though some sections are written very thoroughly, the weakest consistently is the anatomy. Photos or graphics would really enhance a user’s understanding. For example, in female catheterization, it is not uncommon that a person new to the procedure will catheterize the vagina instead of the urethra; a simple illustration of the anatomy is a critical component to correctly performing this skill, and it is not clearly illustrated in the video.

The procedure section contains step-by-step instructions and each procedure may have numerous videos attached to it, which illustrate the steps. The videos are clear, well-paced, and generously narrated. However, the experience of watching them can be somewhat fragmented; the videos require you to rotate your phone to the horizontal and each section of the procedure is a separate video, which results in a 5 second pause. You can skip the pause by okay-ing a pop up. On the other hand, separation of the videos is a handy feature when only a certain section needs to be reviewed.

The inclusion of so many videos does take up quite a hefty amount of space on your iPhone, and in a magical world, a user would be able to select which procedures need to be on their phone. For me, some procedures – like catheterization – are so basic that I would never feel the need to refer to this software, while others are more difficult to the point of having separate software dedicated to their explanation.

Conclusion:

Overall, the application provides a fairly comprehensive list of procedures that might be undertaken in a GP’s office. I really liked that a variety of treatment options were presented for a few conditions, such as warts. Cryotherapy or cautery/curettage videos demonstrate technique while less invasive solutions are offered for patients who may not be amenable to the procedural approach. Despite a good general catalogue, a few things are missing; Inserting an IUD, dis-impacting cerumen, and performing a pap test are more likely in the Canadian GP’s realm than would be a shoulder reduction, however these more common procedures are not part of the software.

Taking a step back, this technology is quite exciting. It would have been beyond any one’s dreams 10 years ago, but these days, few young and technophillic doctors can live without this kind of resource in the palm of their hand. While useful and well-organized, there is still room for improvement with Procedures Consult: Family Medicine – General. As is though, this should find its way into the toolbox of brand new medical students and GPs who are a rusty on a few of the finer points of procedural skills.

Basic Connectivity:

No subscription or Internet required

Best for:

Family practice residents who missed learning a few basic techniques, rural GPs who do ‘the occasional’ of anything, and medical students who’ve never done a procedure before.

Download now from iTunes for $39.99 »

Visit the App Website »

Dr. Otte is a Family Practice Resident on Vancouver Island. She completed her M.D. in 2009 at the University of British Columbia in Vancouver, Canada. She authors a popular blog – Dr. Ottermatic – which can be found at http://drottematic.wordpress.com/. Dr. Otte is also the newest guest contributor to iMedicalApps and we are thrilled to have her aboard!

We just wanted to draw attention to the 10 free promotional codes offered by Clinically Relevant Technologies for an app we recently reviewed – Low Back Pain Management Guidelines. The promo codes are in the comments section of the app review. This app helps bring the most recent American College of Physicians guidelines regarding this incredibly common problem to the point-of-care. The promotional codes can be found in the comments section of this review. If you use one of the promotional codes, please leave a comment with the code used. And be sure to share your thoughts on this app. Thanks again to Clinically Relevant Technologies for making this kind gesture to our readers!!

P.S. Check out their other apps as well, including the CORE – Clinical Orthopedic Exam app which we recently reviewed as well.

Perhaps it is in the middle of Grand Rounds, during a conversation with colleagues, or maybebetween seeing patients – there are times when a quick scan of the most recent medical literature would be helpful.

PubMed Mobile (Free) is an app for Android that allows the user to search PubMed, save articles and searches, view abstracts, and export selected abstracts and citations for future use.

The developer CRinUS also makes the similar apps: PubChem Mobile, and Entrez Sequence.  All three apps are free.

Here, I review PubMed Mobile, developed by CRinUS.

Search

PubMed Mobile app searches are actually quite similar to those of PubMed online.  The Main Menu is intuitive and easy to use.  Drop down menus allow the user to narrow the search using up to 3 fields at one time. 

Search Fields include author, journal title, article title, mesh terms, and numerous others.  The only search Limits are humans, animals, males, and females.  Limiting to “Core Clinical Journals” and “English” language – the two that I use most often – are not included in this app.

A nice feature for Android users who prefer landscape orientation or have a slide-out keyboard is the full functionality in both orientations.  One annoyance, though, is that text entered into textboxes in landscape are lost when flipping to portrait.  The issue, though, is avoidable by simply clicking “search” before flipping.

Search Results and Abstracts

Search results appear almost instantly on Wi-Fi and 3G.  The search results are very similar or identical to the test searches I ran on a computer for comparison.  After searching, articles can be sorted alphabetically by author, journal, or title, or sorted by publication date.   Each article has a checkbox, so that multiple citations can be sent at once, or saved for later (see below).

Abstracts and citations, not full articles nor pdf files, are available for reading.  Despite the hyperlink look, there are no direct links to the browser.

Saving Articles and Searches

Searches can also be saved for later perusal in “My Searches.”  Articles can be saved using the checkboxes and menu key.  All checked articles are put directly into “My Articles.”  The ability to organize articles into subfolders would be a nice feature, but is not present.

Sending Articles

Articles can be exported on Android via email, shared on GoogleReader or another RSS catcher, sent to the printer (using PrinterShare), or shared on one of the many social networking accounts.  The whole process is quick, familiar for Android users, and requires only a few clicks.

PubMed Mobile is great for…

medical students and residents wanting to impress an attending with mention of a relevant and recent paper…or multitasking on a long bus-ride…

PubMed Mobile is NOT for…

printing full-text articles or organizing citations for a research paper.

Likes

• Extremely quick Search and Send on 3G and WiFi.
• Simple to use.  The learning curve is essentially zero.
• Looks and acts like PubMed.  Searches are accurate and nearly identical to online PubMed searches.
• Ability to send multiple searches.
• Saved searches and articles.

Dislikes

• Inability to link directly to a browser for full-text versions.
• Text lost when flipping from landscape to portrait (see above).

More functions we want to see…

• EZproxy support (e.g. through an institutional library)
• A note-taking tool for saved articles
• Synchronization with desktop-based interface or reference managers (Zotero, RefMan, EndNote, etc)

Conclusion

This free app is a fast and user-friendly way of searching abstracts and citations on PubMed, with the ability to quickly send links and citations to an email, printer, or social networking account.  We look forward to future versions of this app, or others like it, that may expand functionality to include full-text links and interaction with reference manager software.

Visit the App Website »

Low back pain is virtually an epidemic in the United States. In many surveys, it is listed in the top 3 most frequent patient complaints resulting in a visit to a physician. It also appears to be more prevalent in the United States than in other industrialized societies, with only a muddle of theories available explain this costly difference. For this reason, a systematic methodology of evaluating the patient with back pain is clearly important. This would help the primary care physician, usually the first evaluate the patient, who is quietly worried that she or he might miss an ominous but uncommon etiology such as metastatic cancer. Also from the public health perspective, this methodology would help prevent multiple, unnecessary and costly imaging studies. And, in fact, many detailed evidence-based recommendations have been published over the years, going as far back as 1994.

While the availability of many evidence-based practice guidelines is of great benefit, the multiplicity also becomes a burden for the practicing physician who needs a quick and handy way to answer the question of what to do for a particular patient. Thus, the birth of a category of desktop and mobile applications named clinical decision support systems (CDSS). This growing and important sector bridges the gap between evidence based guidelines and clinical computer applications. Some of the larger players in this sector, such as Zynx Health, aim to integrate directly into the electronic health records (EHRs) used at hospitals. Others have opted for convenient, free-standing applications quickly available to the physician. The iPhone app Low Back Pain Clinical Management Guidelines is an example of the latter.

This app presents an algorithm using established guidelines for evaluating the patient with low back pain based on the patient’s history and a focused physical exam. [Editor’s Note: This app is based on 2007 guidelines from the American College of Physicians] It suggests when further imaging studies are necessary as well as providing broad criteria for detecting when the more unusual causes of lower back pain should be suspected, such as ankylosing spondylitis and metastatic cancer.

While the very availability of such an application is quite welcome, its usability is clearly the largest factor in its success or failure, especially since it does not have the store-window advantage of being embedded in a larger clinical application. Here, unfortunately, the application design could have been improved. In particular, the organization of the screens was sometimes confusing and some of the more interesting information was difficult to find.

What I liked:

• addresses an important need
• references important articles, explains statistics
• quick reference to basic guidelines

What I didn’t like and What I’d like to see in future updates:

• sometimes difficult to navigate in and out of the algorithm (screen flips and changes do not always make sense)
• would be nice to have a couple of alternative navigation styles to find specific information (e.g. table or search)
• embedded PDFs of some of the key articles in the literature

Conclusion:

Low Back Pain Clinical Management Guidelines puts some of the oldest and best developed evidence based clinical guidelines on the iPhone. One can imagine a clinician occasionally using this app to remind themselves of what to look for when a patient arrives with somewhat unusual back pain. Hopefully future versions will have an even more efficient navigation interface so that useful clinical information will be more quickly presented to a busy doctor.

Download now from iTunes for $5.99 »

Visit the App Website »

In a recent press relase, Inner Ear Solutions announced the release of iTinnitus Solutions 1.1, an app directed at sufferers of tinnitus. First, a bit of background – tinnitus basically refers an a false perception of sound caused by an abnormality in your ear (as opposed to, say, auditory hallucinations which are associated with various types of brain dysfunction). In short, its that annoying ringing that most of us get occasionally.

Some people are chronic sufferers, with their tinnitus resulting from causes including drug side effects, inner ear damage from repeat exposure to loud sounds, or even tumors on the auditory nerve. Having spent some time in an otology (ear) clinic, I saw how debilitating a problem this can be for some, however transient it may be for the rest of us. So can this $0.99 app really bring some relief to patients who are suffering?

So to understand this app, a basic understanding of tinnitus is probably worth establishing (skip this paragraph if you’re familiar with the topic). The basic idea here is that dysfunction peripherally – either the auditory nerve, inner ear, or middle ear – causes a false sense of sound, the “ringing” which can really take any number of forms (ringing, pulsing, clicking, etc). As noted above, the causes vary widely but the end result is really the same, namely damage to some part of the peripheral (outside the brain) hearing structures. The tinnitus generally worsens with a number of different environmental triggers – stress, caffeine, high salt intake, and even being in a quiet environment. Therapy is generally centered around mitigating these triggers and trying to figure out what the underlying cause is. So if a tumor is compressing the auditory nerve, it needs to come out. Or if a new antibiotic was recently started, it needs to be stopped.

However, there are some cases that just can’t be fixed, such as the most common cause – noise-induced inner ear injury. So what then? There are some medical therapies (antidepressants) but, if those fail, sound therapy comes into play. The premise is that ambient noises can drown out the tinnitus and, in some patients, produce a residual suppression of the tinnitus even after the ambient noise is withdrawn. Pillows with speakers embedded in them are, for example, useful in helping patients suppress their tinnitus enough to sleep. Direct delivery of sound into the ear – hearing aids, headphones, etc – have been shown to be even more effective. These sound generators are generate a broad range of frequencies (100-8000 Hz) which can be pretty finely tuned, such as the sound generator from United Hearing Systems. Response rates are variable, with one study showing that the best effect in patients with the worst symptoms.

iTinnitus Solutions, according to the website, claims to help characterize tinnitus by frequency and timing. This feature, if in fact accurate, is of unclear benefit. I rarely saw a specific characterization of frequency used in the otology clinic and nothing I read in the literature suggested that this data is useful in management. What could be useful, however, is the ability to record triggers that are associated with a worsening of symptoms. Much like migraine therapy, identifying key triggers could really help patients manage their tinnitus. So what about the app’s claims to “treat” tinnitus? Some of the key claims like “listening to the tone matching your tinnitus for 10-20 minutes will leave you with a sense quiet” are suspect – according to an otolaryngology reference text, standard sound generators typically aim for a wide frequency spectrum rather than a targeted range (although there is some trial and error fine tuning). It does not appear however that any sort of frequency matching is part of management. In addition, the implication that all patients will experience benefit is absolutely false as both current and reference literature suggest variable and partial responses at best. I also could not find any support for the six week “habituation” protocol that the app claims to support, which basically involves starting at a high level of masking (the ambient noise) and tapering it down for six weeks.

So all in all, I suspect the only useful feature of this app will be the ability to correlate symptoms with triggers. The masking therapy is basically equivalent to listening to anything, even music, on the iPhone. And neither this iPhone based masking or habituation therapy have any support in the literature that I could identify, nor is any listed on the website. Let’s be clear – I’m all for innovative solutions to medical problems. But I think this will prove to be a gimmick which at best will cause unsuspecting patients to waste a dollar or, at worst, convince patients to attempt to self-treat rather than visiting a physician to receive real care for their condition. I’d love to be wrong about this and see even a small trial suggesting this iPhone based therapy works. But I’m not holding my breath.

Note: Much of the background information for this article came from Cummings Otolaryngology: Head and Neck Surgery, 4th ed, Chapter 124 “Tinnitus Management Program”

This article is part of iMedicalApps HIMSS 2010 Coverage. It includes a brief review of the Allscripts Remote app for the iPhone as well as details of a conversation with Allscripts executives who revealed that they are moving to development of an Android app.

When Allscripts announced the launch of Allscripts Remote last year, an iPhone application for their popular electronic medical record, it was widely touted as a transformational move. Forbes Magazine called this an app “that could change medicine.” Allscripts origins are interesting, shifting from prepackaged medicine to e-prescribing solutions before entering the electronic health record industry. In fact, according to the marketing folks at the Allscripts booth, they are the largest source of e-prescriptions in the United States. And while Epic, Cerner, and Eclypsis may be the players many of us commonly think about, Allscripts definitely definitely is not little – according to their most recent SEC filing, Allscripts had over $500million in revenue for 2009 with a net income of $26million. By comparison, Epic also had $500million in revenue for 2009. So the inclusion of a rich, clinically useful mobile platform with Allscripts Remote has certainly been a big move in the EHR world.

The iPhone App: Frankly, this is the mobile EHR app that clinicians have been waiting for. Imagine being at dinner with your family. The paging service for your practice sends you a text – Mr. Jones called in because he’s got some swelling in his legs.

With the Remote app, you don’t even have to leave your seat (although you probably should for HIPAA reasons). When you open the app you’ve got several frames that you can enter, but you obviously first go into the EHR and look up Mr. Jones. You get a list of all the conditions Mr. Jones has been followed for (oh turns out he has CHF), his current medication list (he takes 20 mg Lasix once daily), and allergies. So you call Mr. Jones back (you also have his contact information) and he says “Doctor I ran out of my Lasix!” Well, the masters of e-prescribing have you covered. You can simply click on the Rx icon at the bottom of the screen to go over to his med list, tap on the “Lasix” to issue a new prescription, and send it to his favorite pharmacy.

Or lets say things are a little more serious – Mr .Jones has shortness of breath also. In that case, you simply touch the ER icon at the bottom of the screen to locate the nearest emergency room and fax a summary of Mr. Jone’s office record to that ER as you tell him to go there. Mr Jones now says “Thank you doctor – I’ll go as soon as I finish this movie and my bucket of popcorn.” You conclude your care of Mr. Jones by going over to the last field, a documentation icon, which allows you to enter a brief note on the call for Mr. Jone’s primary physician, probably with a comment that Mr. Jones may need some help managing his diet.

I knew that Allscripts Remote could do all of this when I walked in, but I was still amazed. The UI was cool and intuitive, with features like a touch-to-call feature in the patient’s individual record that show you that the folks at Allscripts thought of the little things that make a clinicians life easier.

The Android App: The Androids among us should get excited – I heard at the Allscripts booth that they are currently developing their Remote app for Android with hopes of release in the near future. More on that as we hear it! Remote is already available for Blackberry and Windows Mobile, but not with all the features available on the iPhone – I suspect its with Android that we’ll see the same level of functionality on a competing platform.

Allscripts EHR offerings are pretty diverse, including software-as-a-service solution for as little as $300, geared to the smaller practices that aren’t looking to make a huge investment in an in-house EHR. These kinds of offerings will be crucial for companies like Allscripts to capture the small-practice market, where a 70% of healthcare is delivered according to some studies. These practices, of which up to 80% may be looking at EHR adoption now based on a 2003 survey, may find particular appeal in the web-based EHR’s that we have discussed previously. However, Allscripts Remote is likely to challenge the mobility argument for web-based EHR’s in that this app is designed with an intuitive UI and rich features that clearly fit the clinician’s workflow – it will be interesting to see whether the web-based EHR vendors can develop, at least in the near future, a similarly rich, intuitive mobile interface for their products. As Mr. Hollis from MacPractice -another EHR vendor with a pretty cool iPhone interface – pointed out, there may be much richer possibilities with local apps and software than with a web-based platform.

This article is part of our HIMSS 2010 coverage. It includes a brief review of the iPhone medical app from Logial Images – Visual Dx Mobile – and a conversation with Dr. Art Papier, Co-Founder and Chief Scientific Office of Logical Images.

Although an unimaginable array of technology was demonstrated in the hangar-like exhibition spaces at HIMSS, one of the most impressive uses of technology from a physician’s perspective was in a small booth in far off corner. In it, the voluble and passionate co-founder and Chief Scientific Officer of Logical Images (www.logicalimages.com), Dr. Art Papier demonstrated a web and mobile based application that magically produces a sequence of high quality diagnostic images in response to user queries. Since Dr. Papier is Associate Professor of Dermatology at the University of Rochester School of Medicine, the application was originally dedicated to presenting high-quality images of dermatologic conditions.

This is fortunate in two respects. First, the most important findings in dermatology are visible to the naked eye and thus to a camera, second few clinicians (except for dermatologists) have more than the slightest familiarity with dermatologic conditions whereas skin conditions, according to Dr. Papier, account for 15% of visits to PCPs. The application has since also expanded to include radiology. An iPhone and iPod Touch version  was announced at HIMSS this week.

What Visual Logic has pioneered is a sophisticated structured search that allows the physician to sequentially enter more specific information about the patient’s presentation and be presented with a “visual” differential diagnosis. For example, a physician could enter that the patient is a veterinarian, has fevers and has a rash, and with each entry, the panoply of images on the screen would decrease in number until a match is made by the physician. For radiology, a mouse-over the chest xray conveniently highlights the abnormal portions of the lungs on the image. Dr. Papier has also been awarded a $2 million grant from the NIH to create a standardized lexicon for the field of dermatology.

The ten-year old web application has over 60,000 medical images collected from physicians and institutions showing that show dermatologic diseases along with their variations with age, stage, and skin color. The more than 100 editors of the collection include some of the distinguished academicians in dermatology, according to Dr. Papier. The textual medical content is obtained from peer-reviewed literature and includes treatment recommendations. There is also a consumer oriented version of the database at skinsight.com. In addition to dermatology,  Dr. Papier adds dentistry, endoscopy and pathology as other fields that are amenable to visual diagnosis.

Announced formally at HIMSS is the iPhone version of Visual Logic, appropriately named Visual Dx Mobile, contains over 18,000 images as well as text information such as next steps in management, diagnostic pearls, recommended tests, and ICD-9 codes. In the demonstration of the iPhone app, the image and text display could be seen to be smooth and rapid (see video). One cannot help but marvel at the impressive volume of clinical information now available in a small hand-held device (I wonder if the American Dermatology Association has pondered the implications of launching a small army of amateur dermatologists). The software is generally licensed by institutions but physicians can also buy it as modules, for example the pediatric module would cost $120 per year. According to the company, VisualDx is already in use at more than 1,300 clinical sites, including hospitals, public health organizations, government agencies, medical groups, and medical schools. Current VisualDx subscribers can download VisualDx Mobile for free at Apple’s App Store. Nonsubscribers can request a free trial or purchase a VisualDx subscription in order to access the app.

Dr. Papier emphasizes that the goal is to help physicians make a diagnosis. Much of where health IT intervenes in the clinical process has to do with treatment, such as clinical decision support systems that help physicians select the best or most cost-effective treatment. All of these resources are of little use if the diagnosis is wrong. This is especially relevant the treating physician may not be familiar with the patient’s condition, as is often the case with dermatology.  Even more relevant is that, while every disease has a “classic” or “textbook” presentation, in reality every disease also has innumerable variations. The ER physician, PCP or pediatrician cannot possibly memorize every variation, this is the advantage of specialization and the result of unconscious accrual of pattern recognition. The availability of large atlases is also of limited benefit, since they are invariably organized by diagnosis, which is of little help if you do not already know the diagnosis. With wider availability of sophisticated diagnostic tools such as VisualDx Mobile at the point of care, hopefully more patients can receive quicker and more accurate diagnoses in the future.

This article is part of our HIMSS 2010 coverage. It includes an overview of the MacPractice EHR and its iPhone interface as well as a conversation with Mark Hollis, CEO of MacPractice.

One of the key’s to Apple’s success has been the reliable, simple, and fun UI it has designed for every one of its products. Part of the reason that this feature has stood out is because the Microsoft-based PC world has become known for essentially the opposite. The same is true for many electronic health record platforms built for Windows, where the same security vulnerabilities, networking complexity, and famed “blue screen of death” plague the slightly-less-than-tech-savvy average physician. For this reason, Mark Hollis – CEO of MacPractice – offers a system that runs entirely on the Mac. I had the opportunity to check out the iPhone platform tied to this EHR and also to chat with Mr. Hollis about his vision for this platform and some of the challenges it faces.

The iPhone Platform – From the start, the interface looks pretty slick. There are a number of different functions built in including a calendar of appointments, patient contact information (with a simple touch allowing you to call or email them), charge capture, patient prescription history, and referral management.

The appointment calendar (pictured here with the Rx history) basically consists of the patient’s name, appointment time, and picture. This last feature, a simple picture, is great for two reasons – it could help jog your memory so you remember who this person is (rather than just the diseases they need followed up) and it does wonders for morale (its a lot harder to be unhappy with a packed afternoon schedule when you have those smiling faces looking at you). Honestly though, I was underwhelmed with the remainder of the features. I expected more in terms of ability to view a problem list, recent notes or labs, or other information that would be useful in caring for a patient. This app, at least at this stage, seems to be geared more toward the administrative side of a physician – planning a day, getting all the charges in, etc. I hope that future versions of the iPhone interface improve on the clinical utility of this app.

In addition to this iPhone platform, there are a number of other features that make the MacPractice EHR pretty cool. Among them are the UI which Mr. Hollis noted was designed so that pretty much any office personnel can be up and running with minimal training. It can also be used by patients via a special interface to make appointments, send messages, and so on. For the tech-wary among us, it runs on networked MacBooks/iMacs without a server, which means a far simpler system to manage – according to Mr. Hollis, its not uncommon for a practice to go years without ever needing corrective service of any kind. And if they do, its often fixed with a trip to the Apple Store, thus leveraging Apple’s customer service infrastructure. Finally, its a highly customizable system – this is a particularly useful feature for small specialist practices who often require very different kinds of patient records. In fact, the basic system has been customized for dentists and optometrists as well.

While there a lot of cool features here, MacPractice also faces a big challenge from web-based EHR’s. These systems provide similar benefits – minimal setup and maintenance for example – with very low price points (as low as free). And they too are directed at small-medium sized practices that don’t want or need a complicated, in-house EHR. Mr. Hollis raised a number of very interesting points as to why he believes web-based EHR’s will join the same market space that MacPractice occupies rather than dominate it.

First, most web-based EHR’s come prepackaged, and that packaging is largely defined by the “meaningful use” criteria that will allow clinicians to get stimulus funding. However, those criteria are basically geared to primary care – specialists could be left out on this one. That’s an opportunity for customizable, simple EHR’s like MacPractice.

Second, Mr. Hollis notes that the development possibilities are far more rich using Apple’s XCode, giving him opportunities he wouldn’t have with a purely online platform. Finally, there’s the issue of reliability – what happens if your internet goes down? Clinicians who adopt web-based EHR’s will not only need high-speed connectivity, but they may also need some sort of redundancy and managing that could be a headache.

All that being said, Mr. Hollis doesn’t dismiss cloud functionality as unimportant – in fact, its likely to be essential to meet meaningful use criteria. MacPractice is exploring ways to bring data in aggregate onto the cloud for analysis and take that essential step to contributing to population health management. Additionally, they have been engaged in the development of the Stage 1 criteria, being released in June, and plan to be certified as well. I certainly look forward to seeing how this EHR evolves in the coming months.

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.

This is part of iMedicalApps coverage of the HIMSS 2010 Conference in Atlanta, Georgia

Zynx Health was founded in 1994 by three physicians at Cedars-Sinai Medical Center in Los Angeles. Their original mission, unchanged from that time, says Carina Edwards, Vice President of Marketing and Product Management, is to improve patient care and decrease costs. The challenge for physicians, then as now, is utilizing evidence based medicine in day-to-day patient care. While physicians can always search the primary literature or use a database of evidence-based clinical guidelines such as Up-To-Date or Cochrane’s, having recommendations at the critical moment of writing orders is invaluable.

This is how Zynx was created. The company was originally funded by Cedars-Sinai Hospital and now has grown to have partnerships with every major EHR vendor. The point of integration is at computerized physician order entry (CPOE) interface where the Zynx product is strategically placed. Institutions then have available to them more than 100,000 order sets, organized hierarchically. However, Zynx will simplify the process of selection by helping to choose the most popular or relevant order sets for each hospital.

The main value that Zynx adds, in addition to convenient software integration, is its staff of physicians and nurses that regularly survey the literature to produce these evidence-based order sets. When asked if there was any feedback possible from the users who may or may not agree with parts of the orders, Ms. Edwards said each institution has a built-in discussion board where clinicians can exchange comments around the order sets.

Zynx feels that it is currently well positioned since, according to Ms Edwards, Stage II of “meaningful use” states that EHRs must “include evidence-based order sets in computerized order entry (CPOE) at the point of care”. This, of course, is exactly what Zynx provides.

The order sets are available as software-as-a-service and the company has relationships with every major EHR vendor. Almost all physicians access Zynx from inside their EHR or other CPOE product. Interestingly, Zynx is owned by Hearst Publishers, who also own First Data Bank, a complementary database of medications for EHR integration. They also partner with Elsevier, which publishes First Consult. Hospitals are charged by the number of annual discharges while physician groups are charged by the number of physicians.

While many physicians complain at first about the additional time required to enter an order into a computer instead of writing it, the wide availability of carefully research evidence-based guidelines should mean that orders will not only be legible in the future but also carefully reflect the best-practice guidelines, which will have clear benefits for patient care.

Update 3/9/10:
We had a small error in the article. UpToDate is actually published by Wolters Kluwer, not Elsevier as stated.
www.uptodate.com
www.wolterskluwer.com

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.

This is part of iMedicalApps coverage of the HIMSS 2010 Conference in Atlanta, Georgia

A common cause of annoyance for patients is filling out the same forms over and over again.  While just about every adult has experienced this issue, the deeper problem is a single patient will almost always have more than one physician or caregiver. This means the repetitive form filling is really the tip of a much more serious problem of data in silos, with each physician and hospital treating the patient from scratch, exchanging information via faxed notes or (mostly missed) phone calls.

Patient Case Example:

Take the simple example of a female middle aged patient who suddenly experiences chest pain after dinner one night.  She goes to the nearest emergency room and has a rapid and extensive evaluation. Let’s say the results did not point to a heart attack, but there were indeed some abnormalities on the ECG.  The patient ends up being discharged home with the ED physician writing gastroesopheageal reflux as a possible cause, and instructing the patient to follow up with a cardiologist and their primary care physician. The next morning the patient will call the cardiologist and show up in his office that afternoon. In their hand is…..nothing, but they do remember the abnormal ECG they had in the ED.

The patient has no records from the hospital’s ED and unfortunately does not have the PCP’s ECG from last year showing the same abnormality. The cardiologist gets a new ECG, and puts them on a beta blocker and aspirin. The next day the patient goes to their PCP carrying….nothing. The PCP sees the pill bottles and assumes they must have had a heart attack and orders more labs and sends them for a cardiac CT. All this for a simple case of gastroesophageal reflux? It’s not unheard of.

PHRs – Microsoft’s Announcement at HIMSS

Personal health records (PHRs) are the patient component of electronic health records (EHRs) and both Microsoft [Health Vault] and Google [Google Health] are designing software platforms that use them as the key to communication among physicians and hospitals. The concept is simple: any individual can create a free account and store their health records online and give various entities (doctors, hospitals) permission to access them. In this instance, however, Microsoft’s deep enterprise roots gives it a major advantage in hospital integration.

This was demonstrated at HIMSS when they announced Microsoft HealthVault Community Connect to complement their PHR. This software platform seamlessly connects the hospital’s clinical and registration records to the patient’s personal Health Vault.  For example, this allows the patient to log in and pre-register for appointments and fill out all their forms on-line – before they walk in. Hospitals can develop custom “portals” where verified patients can log in to view and download their information – patients can also give permission for the hospital to automatically populate their PHR as soon as they are discharged.

The patients’ physicians can also access the same web portal.  So in our example, the cardiologist would have been able to see the ER physician’s impression of GE reflux as the source of chest pain and the unchanged ECG and stopped there. Even more impressive, if the cardiologist’s office uses one of the many ambulatory EHRs that already integrate with Microsoft’s Health Vault, such as Allscripts, they could directly enter the information from the patient’s PHR into their office EHR. If they do not have Health Vault integration, they can download it as a text (XML) file or print it out and scan it into their EHR.

Microsoft and the Cleveland Clinic Study

As if the potential for this type of health integration was in doubt, Microsoft and the Cleveland Clinic held a press conference on Monday to announce the results of a pilot project to assess the effects of data sharing on chronic diseases. In this case study, more than 250 patients enrolled, many with diabetes or hypertension. They self-monitored at home with glucometers, blood pressure monitors, scales, etc with these devices uploading patient data to their HealthVault. Since 2008, the availability of this data to the physicians was associated with a 26-71% increase in the time intervals between doctor appointments, while heart failure patients came in more frequently, which was actually felt to be beneficial for those patients.

Microsoft also has a mature hospital data integration platform named “Amalga” which sits atop existing hospital clinical systems and allows for a single point of analysis. Physicians can tailor how they view clinical information (labs, etc) instead of using the stock interfaces of EHRs, financial people can perform analysis of payment trends, and just about any type of data can be manipulated.

While other “business intelligence” products are available for the enterprise, Microsoft says Amalga is a new category of hospital software due to the extensive hooks it has into the hospitals’ existing systems as well as the real-time data stream it can generate. Amalga was of particular interest to me since it is the current incarnation of a “Azyxxi”, a software package that was written in-house where I trained at Washington Hospital Center and an example of a group of physicians who started out by solving a local problem in their emergency room then very successfully sold their product to a large software house. This may also be seen as a sign that the increasing attention of the IT industry to the health sector may herald even more rapid and clinically significant innovation.

This is part of iMedicalApps coverage of the HIMSS 2010 Conference in Atlanta, Georgia

One of the numerous sessions today was a lunch hour “town hall” on the current status of CCHIT certification. This is one of many acronyms populating the language of health IT folks, especially recently, and stands for Certification Commission for Health Information Technology. This organization is a nonprofit, 501(c)3 organization with “the public mission of accelerating the adoption of health IT”.

Today’s presentation was headed by Mark Leavitt, MD, PhD, and the chair of the commission.  He covered a large amount of ground and the presentation was followed by some pointed questions from a very educated audience, many of whom were CIOs (Chief Information Officer) or CMIOs (Chief Medical Information Officer) of hospitals.

This commission wields immense power over the future of health information systems by deciding what features of EMR are vital and the standards for interoperability between health IT systems.  They will have a leading voice in what the CMS (Centers for Medicare & Medicaid Services) will deem to represent “meaningful use” and thus qualify physicians and hospitals for a piece of the large pot of stimulus money that is being dangled in front of providers to stimulate EHR adoption.

While the CCHIT has been certifying EHRs since 2006, this last year has brought an intense interest in the organizations workings since currently it’s the only entity recognized by the federal government in certifying EHRs – further solidifying its crucial role in certifying meaningful use.

This “meaningful use” definition takes on a different meaning when looking at the monetary amount at stake.  The February 2009 American Recovery and Reinvestment Act (ARRA) allocated at least $20 billion in incentive payments to hospitals and doctors if they achieve “adoption and meaningful use of certified EHR technology”. Hospitals are maximally eligible for up to $5 million in incentives while physicians are eligible for up to $44k. As Dr. Leavitt explained, adoption will be the easy part, documenting meaningful use will be far more challenging.

This is because the breadth of criteria used to denote full and meaningful use is quite broad (see below) and also includes usability and patient access to digital records. Furthermore, while the “interim final rule” on meaningful use is available, the final rule will probably not be released until the second half of 2010, a fact that led to a lot of audience questions aimed at getting Dr. Leavitt to say what the final rules will be, to which he kept answering he doesn’t know yet. In fact, HHS has not even specified what organizations will be authorized to be accrediting bodies, although CCHIT feels confident they will be among those qualified.

As an example of the breadth of specifications for meaningful use, here are some of the 25 proposed criteria for just Stage 1 of meaningful use:

1. Use CPOE for at least 80 percent of all orders
2. Implement drug-drug, drug-allergy, drug- formulary checks
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT® (at least 80 percent of all unique patients)
4. Generate and transmit permissible prescriptions electronically (eRx) (at least 75 percent of all permissible prescriptions)
5. Maintain active medication list (at least 80 percent of all unique patients)
6. Maintain active medication allergy list (at least 80 percent of all unique patients)
7. Record demographics.
8. Record and chart changes in vital signs; additionally, plot growth chart for children age 2 to 20.
9. Record smoking status for patients 13 years old or older
10. Objective: Incorporate clinical lab-test results into EHR as structured data (at least 50 percent of all clinical lab tests)

*list from healthcareitnews

We do know there will be two formats for accreditation, either a single, comprehensive audit or a “modular” option where individual components of meaningful use are accredited. It was also mentioned that CMS has received a tremendous amount of feedback saying the timeline for adoption is too aggressive.

The incentives start with Stage 1 adoption in 2011 and anticipate completion of Stage 3 adoption within 5 years. After this, the incentives dwindle to zero and start becoming penalties.  Some believe the timeline will be revised, like the HIPAA deadline of 2002, that was extended to 2005. Dr. Leavitt cautioned, however, that it would be a poor gamble to put off beginning adoption any later than 2011.

We’re live here in Atlanta, Georgia, at the HIMSS conference.  This week we’ll be bringing relevant posts and interviews related to the conference in breaking news fashion.

The 2010 HIMSS (Healthcare Information and Management Systems Society) conference is now underway in Atlanta in what promises to be a signal year in the world of health IT. The reasons seems to be the confluence of a year long public discussion on health care reform and, very important, the provision in the American Recovery and Reinvestment Act (ARRA), also known as the stimulus bill, that rewards physicians for meaningful adoption of a qualified electronic health record (EHR).

The reward can equal as much as $44,000 over 5 years and is creating a frenzy of vendors asserting that their EHR is certified, meanwhile the community at large is breathlessly awaiting to hear what the government regards as “meaningful use”. The final rules on meaningful use are expected later this year. Partially, as a result this, HIMSS found in its annual survey of its leadership:

“… [these]  incentives and a rebounding economy, nearly three quarters (72 percent) of respondents said they expect their IT operating budgets to increase, bringing that response back to the levels of two years ago.”

In the meantime, the non-profit organization which certifies EHRs (CCHIT or Certification Commission for Health Information Technology) continues to develop deeper and broader specifications on what it means to be a “certified” EHR.

These are interesting developments for physicians in a few ways. Most obvious is the financial incentive to adopt an EHR in one’s practice. As the table below shows, the financial incentive decreases the longer one waits to adopt.

Perhaps the most compelling reason for adoption of EHR standardization is to make interoperability the norm rather than the exception. Currently, if you have adopted one EHR for your practice, the burden of changing to another system quickly becomes the fear and difficulty of transferring your medical records electronically. Therefore, innovation can often be dampened by the fact that physician consumers are mostly locked into whatever purchase decisions they have made.

EHR certification and thus partial standardization also opens the door to new business opportunities. I had the pleasure to meet with Dr.James O’Connor, the CEO of a startup named MDcohort LLC, which is developing tools that enhance the entry and maintenance of data by physicians into EHRs with the goal of having better data available for research.

This could make it easier to enroll patients into FDA clinical trials while empowering physicians in negotiations with parties potentially interested in the data, such as the pharmaceutical industry. It also enhances data collection by integrating research tools, such as disability indexes in the initial data capture. Dr. O’Connor says the specialty societies are key to understanding the needs of physicians in each specialty.

There is much more to learn in this sprawling conference where the energy is palpable. The role of informatics in healthcare will only continue to increase and become more diverse. Physician entrepreneurs like Dr. O’Connor will hopefully continue to make sure it works for the maximum advantage of physicians and patients.

Above table from Chilmark Research

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.

We are excited to announce that the iMedicalApps team will be covering HIMSS 2010 in Atlanta, Georgia next week. HIMSS – Healthcare Information and Management Systems Society – is one of the premier healthcare IT organizations and there conference is a perennial highlight of the HIT community.

The iMedicalApps team will be covering the exhibition floor where vendors ranging from Epic Systems and MacPractice – both EMR vendors with iPhone/iPad interfaces – to Philips and Northrop Grunman, who bring an incredibly diverse array of healthcare IT services to the market.

In addition, we will be interviewing a number of executives from a variety of firms. We will bring you the latest news from the healthcare IT world, with a focus on innovations in applications for mobile platforms. If you have any particular vendors you’d like to know more about, please let us know and we’ll do our best to fit it in.

Health care professionals have been patiently waiting for the expansion of the Android universe to hit the world of medical apps.  With the exception of Unbound Medicine – who have done a very nice job in rolling their products into the Android Market – users of Android mobile devices have thus far been relegated mostly to the world of medical calculators and dictionaries. For Android owners, the release of Epocrates could not have come sooner. If you are in the field of medicine, you are probably familiar with Epocrates.  We reviewed Epocrates on the iPhone before.  And for health care professionals and students, Epocrates, honestly, needs no introduction.  From the short-white-coat student to the tech-savvy clinician, Epocrates has, for years, been an essential tool in refreshing those synapses you made in pharmacology class (or didn’t make). The field of pharmacology is ever changing.  Epocrates helps many of us stay on top of it all, and improve care for patients.

Keep in mind, the version of Epocrates Rx currently available and reviewed here is still in BETA.  So many of the richer features available on other platforms are still missing for Android. Also, one of the difficulties in reviewing any app for Android is the potential for variability in user experience between OS versions, and from phone to phone.  This review is based on the HTC MyTouch, which runs on Android OS v1.6.

Epocrates downloads from the mobile-based Android Market.  Total application size is 6.48MB.  This is fairly large – by comparison, Google Maps with Navigation is only 5.22MB.  Users who do not see Epocrates in the Market are probably running an older version of the Android OS.  Epocrates runs on v1.6 or later. This is a problem for many Android owners who bought phones before Fall, 2009. Unfortunately the only viable solution (that I know of) is to write your phone manufacturer with pleas for OS updates. A free Epocrates online account is necessary to run the app.

Layout and Navigation

Don’t let the poor-quality screenshots fool you, the app looks great on the MyTouch. Epocrates opens quickly, and does not slow phone function while it runs.  The app runs well and looks sharp in both portrait and landscape orientations.  On T-Mobile, you can even search Epocrates while on a phone call.  Can your phone and your network do that?

The main menu contains:

• Search Epocrates
• A self-promotion banner (“Start using Pill ID now”)
• Favorites Menu (including Interaction Check and Pill ID)
• Tools Menu (including Drug Reference, Tables, and Med Math)
• Other Menu (including History, and Help)

Every screen in the app contains the “e” button, which brings the user back to the main menu in one click.  Those familiar with Epocrates on other platforms will find the user interface and navigation very familiar.  New users of Epocrates on Android will be able to navigate the very intuitive UI with little effort.  The “Add to Favorites” button located at the bottom of the page allows you to put almost any drug or table in the Favorites Menu.  This is a great function for the wards – particularly for those services where there are only a handful of drugs commonly used.  On a Cards rotation, med students could put diuretics, beta-blockers, ACE inhibitors, and statins right on the front menu.  The History menu creates a log of your navigation through Epocrates, and allows a quick return to previously viewed sub-menus and pages.

Other features

Like Epocrates on the iPhone, the Android BETA version has many useful features that run very well on Android.  Briefly…

• Interaction Check:  Some clinicians have an encyclopedic memory of drug interactions.  For the rest of us, this feature allows a quick check of interactions – benign or deadly.  Up to 30 drugs can be added to the interaction list.  Very useful for those middle-of-the-night calls about changing Mr. Johnson’s antibiotic.
  **Interactions can also be viewed for each drug, or added to the Interaction Check List from an each Drug Reference page
• Pill ID: A standard feature of Epocrates.  For identifying the ambiguous round pink pill that the patient in the clinic or ED sort-of remembers taking.  Photos of each pill can be enlarged with a click.
• Drug Reference: Browse by Drug Class.  For example, Cardiovascular –> Antiplatelets –> anagrelide.  Extensive drug information with open-and-close menus, including:
  • Adult Dosing
  • Peds Dosing
  • Blackbox Warnings
  • Contraindications/Cautions
  • Adverse Reactions
  • Drug Interactions
  • Safety/Monitoring
  • Pharmacology
  • Manufacturer/Pricing
  • Pill Pictures (same as the Pill ID menu)

• Tables: An under-appreciated feature of Epocrates with helpful clinical suggestions, guidelines, and protocols.
  Looking for the Beers Criteria of potentially inappropriate drugs for geriatric patients?
  Walk into a code – patient in Asystole/PEA – and don’t remember which IV drug to give?
  This menu has those answers, and many more too numerous to mention here.
• MedMath: Over 40 clinical calculators.  A nice add-on feature with many commonly-used medical calculators, but not nearly as comprehensive as other medical calculators like Skyscape’s Archimedes (another free app available on the Android Market).
• Help: A minor menu containing Abbreviation List and Epocrates Support information.

Likes

• All the features of Epocrates, running well on Android.  Fantastic, as expected.
• Attractive and user-friendly UI.
• Extensive and relevant information.
• A very useful tool for clinicians at the point of patient care.

Dislikes

• Screen sensitivity was uncharacteristically unresponsive on the MyTouch.  This problem was usually fixed after flipping through a few menus, and coming back to the problem area.  A mild annoyance if this is a “beta issue”, but a major problem if not resolved in future versions.
• Only available for Android Operating System v1.6 and newer.
• The banner below the search bar announcing features of the app.  Not needed, and consumes valuable screen property.
• We patiently await the arrival of premium clinical features in future.

Conclusion

The newest member of the Epocrates family is a long-awaited and warmly-welcomed addition to the Android OS.  While still in Beta, this free version of Epocrates Rx performs well (with the exception of some screen insensitivity problems that may be specific to the MyTouch), and lives up to what health care professionals and students have come to expect from Epocrates. Epocrates Rx (Free) is a must-have app for Android owners in the medical field.  And you can’t beat the price tag. We look forward to future releases of other Epocrates products (including Rx Pro, Essentials, and Essentials Deluxe).  Our readers can expect a continued and extended review, complete with more screenshots, when these versions are introduced to the Android Market.

Link to Website and Download: http://www.epocrates.com/products/android/

Editors Note: This is the first medical app review we’ve done for the Android platform. We’re excited that Brett will be providing the site reviews of Android medical apps, along with iPhone medical apps.

Emergency rooms are notorious for their long waiting times – that’s pretty common knowledge. But now the Hospitals of Central Connecticut are looking to a new medical app for the iPhone to help improve their emergency room wait times. Having spent a fair amount of time recently working in an emergency room, I (and probably everyone with similar experiences) can assure you that no one – physicians, nurses, administrators – want it to be that way. Much effort has been made in improving patient triage, workflow management, and other areas of opportunity that could increase the efficiency with which a patient is managed when they get to the emergency room. Some emergency rooms, like Hospital of Central Connecticut, are now looking to improve efficiency even before the patient arrives at the emergency room. The New Britain Herald reports that a new medical app released for the iPhone this week allows patients to view waiting times for the emergency rooms at two local hospitals in the hopes that patients with non-emergent complaints will head to the less crowded ER.

The premise here is pretty simple. There are two campuses of the Hospitals of Central Connecticut in roughly the same area – New Britain and Southington – and only fifteen minutes apart. The vast majority of patients who come to emergency room don’t really have emergencies, at least not the kind where that time makes much of a difference. So a patient in, say, the North End area with a deep laceration on their hand who needs stitches may check his or her iPhone and see that Southington Hospital has a five hour wait while New Britain only has a two hour wait. This patient, with a non-emergent problem, is now headed to the hospital that is in a better position to treat him or her – a win-win for the patient and the hospital.

There are obvious dangers however with this kind of app. The most obvious is that patients with dangerous symptoms will end of wasting valuable time because they try to go to the hospital with the shorter waiting time. Imagine a stroke patient who may only present with left arm weakness. The symptoms have been there for about an hour and a half and he opts to go to the hospital thirty minutes away rather than the one five minutes away based on wait times. Brain-saving reperfusion therapy has to be given within three hours of symptoms onset, at least per current protocols – time is literally brain for this patient. Similar scenarios aren’t hard to imagine for patients with chest pain, a transient loss of consciousness after a traumatic injury, and other situations where time is critical to outcomes.

Hospital officials naturally emphasize that patients should err on the side of caution and call 911 for anything close to an emergency. Its just that some patients may have a tough time figuring out what that is. However, there are obvious benefits to clear cut situations where therapy is needed soon but not right now, and they tend to be injuries – a broken arm, a cut, and so on. Features like an introductory screen detailing situations where it is appropriate to use this app or danger signs that warrant immediately calling 911 may help mitigate some of the potential dangers. Used very judiciously, these kinds of apps can help improve regional management of emergency medical facilities.

Whether diagnosing a heart defect in a newborn or discovering a life-threatening rumble in a elderly man’s abdomen, I think all clinicians can relate to that surge of excitement we feel when we discover something that we could use to help a patient. But as I’ve progressed through my training, I’ve also observed how these findings inevitably lead to confirmatory tests – echocardiograms, ultrasounds, and so on. Our clinical acumen is simply not good enough. I’ve often heard the argument that, for this reason, the stethoscope is an outdated tool. Perhaps it almost was. Companies like Thinklabs, however, feel very differently and are reinventing the stethoscope to meet the needs of modern medicine. Meet Thinklabs’ ds32a digital stethoscope with the Stethoscope Medical App for the iPhone. Together, they not only improve the clinician’s ability to hear sounds, but also to review and share the audio and waveforms – all on the iPhone.

Thinklab’s stethoscope/iPhone app combination certainly isn’t the first recent leap forward for the stethoscope. We’ve talked before about 3M’s digital stethoscope with Zargis Cardioscan software. The 3M/Zargis package pairs a cutting edge stethoscope with ground-breaking analytics. Having had the opportunity to use digital stethoscopes before, I can attest to the fact these devices vastly improve on our ability to hear heart sounds. On top of that, the audio is transmitted via Bluetooth to a computer running Cardioscan, which helps analyze the waveform and make a diagnosis. In its “Innovation of the Year” article, Popular Science estimates that this technology could save nearly $10 billion/year in unnecessary tests (I suspect this is a huge overstatement, but the cost-saving opportunities are real). Thinklabs has upped the ante by adding portability, a proven user interface, and adaptability to the stethoscope with its digital stethoscope/iPhone medical app combination. As the manual describes, the stethoscope pairs with the iPhone via an adapter cable. The software on the iPhone then allows viewing of the waveform and frequency data, with editing functionality including trimming the audio and annotation. It does not, however, allow for the kind of analysis that Cardioscan performs.

And therein lies perhaps one of the biggest challenges for Thinklabs. I suspect their software will exhibit all the things we’ve come to love about many iPhone apps, generally centering on an easy and fun user interface. And taken alone, the ability to record, review, transmit heart sounds from the bedside is revolutionary. Thinklabs, however, isn’t the only manufacturer that thinks so. Zargis was approved all way back in October, 2009 as an iPhone medical app developer, and their press release certainly suggests that they view the mobile platform as an enormous opportunity. So while Thinklabs’ stethoscope/iPhone medical app pair are bound to be impressive, I suspect that the behemoths of 3M and Zargis are not far behind – and are likely to bring their analytic software to a mobile platform.

The stethoscope has been a clinician’s best friend since the advent of modern medicine in the 19th century, with the first stethoscope being introduced in 1816 by Rene Laennec in Paris. The stethoscope reached its current form, more or less, in the 1960’s, courtesy of Dr. David Littmann. Based on what we know so far, Thinklabs is certainly among the innovators ushering in the next iteration of the stethoscope.

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]

It is a great pleasure to present this interview with Pieter Kubben, a Dutch neurosurgeon who is an impressive amalgam of clinician, researcher, and software engineer. He is currently in a neurosurgical residency while completing a PhD in intraoperative MRI-guided surgery for brain gliomas. As if this is not enough, as a “hobby” (his term), he also writes software, with a particular interest in computerized decision-support systems.

He has three iPhone applications currently in the App Store, including his newest one implementing the WHO surgical checklist(iTunes link). His other apps, Neuromind and SLIC, have been downloaded 8,000 times. Importantly, he is not just writing the software, but is also publishing his ideas in medical journals to spur changes in the way clinical decisions are made in the future. We encourage you to follow his blog at http://digitalneurosurgeon.com or on Twitter @DigNeurosurgeon. It is exciting to see a one individual with so many talents and to think about the great ideas yet to come from someone with such broad perspectives – we delve into some of those ideas in this interview.

1. When did you first start programming ?

My parents bought their first pc when I was 17 years old. I started web development in HTML one year later, and my first programming experience was Delphi. Afterwards, I started focussing on web development with PHP and MySQL. Using these technologies, I created a collaborative web-based framework focused on web and mobile computing and won two international awards. Now I am working in Adobe Flex / ActionScript and the iPhone for clinical decision supporting systems (CDSS). More information is available from my website (http://dign.eu if you don’t like typing long URLs ).

2. Did you ever consider a career in software or IT ?

Yes, I even have been invited for a healthcare IT job by an international medical software company. They found me using a headhunter, which was quite flattering. However, I do have some strong ideas, which I suspect would not fit well within such companies at this moment in my career. I prefer the combination of being a clinical doctor (neurosurgeon in training) while spending a part of my time on healthcare IT. That is the reason why all my software is currently free. Maybe I need to incorporate some financial aspects in the future, to keep the system running. But at this moment, that’s not keeping my mind occupied. My goal is improving the software in such a way that it can really make a difference.

3. Why do you think doctors have been resistant to adopting information technology in their work ?

There are many ways to Rome, and one is not necessarily better than the other. Up to now, you could talk about “believers” and “non-believers” but current research is starting to show the benefits of CDSS and mobile computing for physician guideline adherence, and this may help to convince more doctors in the future. I suggest looking at the study “A Computerized Handheld Decision-Support System to Improve Pulmonary Embolism Diagnosis” by Roy et al (Ann Intern Med 2009). With regard to evidence-based practice, I think this study did an important job. Further, the young doctors who are more familiar with such technology will be more likely to use it, which will also help to demonstrate the added value of such techniques. I hope this will lead to initiatives from medical doctors. I would not want politicians and healthcare insurance to tell us doctors how to practice medicine.

4. How did you decide to implement cervical spine injury classification as an iPhone app ?

Cervical spine injury is an important issue in neurosurgery and orthopedic surgery. It requires urgent diagnosis and a treatment plan. There is a good classification available by Vaccaro et al (Spine 2007, vol 32 (21) p 2365-74 ) and evidence-based guidelines for surgical treatment by Dvorak et al (Spine 2007, vol 32 (23) p 2620-9 ). Both offer imporant advice, but you need to bring it to the patient. For my own work, I am convinced that having it available on a mobile platform helps. That’s why I developed the software, and wrote a manuscript about it which I intend to offer for publication within some months.

5. How did you decide to implement the WHO Surgical Safety Checklist as an iPhone app ?

For the same reason. A publication by Haynes et al (NEJM 2009) has shown clear benefits of using this checklist. The book “The Checkllist Manifesto” by Atul Gawande, the WHO Safe Surgery programme leader, is also very inspiring. Whether you prefer to talk about checklists, e-guidelines or CDSS, I think the message is the same: we cannot remember everything, and we make mistakes. If we’d remember 9 out of 10 issues, we do great in high school. However, we may cause disasters in medicine if that last 10th item is crucial. For that reason I do believe we should use CDSS and stop pretending we’re too good for that. We’re not.

6. How has blogging affected your work as a doctor ?

Not that much, I guess. I try to update my blog a couple of times in a month, sometimes twice a week. Most of my IT time goes into software development, but I also like to explain a little of what I am doing. And both my blog and Twitter give me a chance to get in contact with similar minds. So if people have questions or want to contact me, they can visit my website or Twitter.

Learning a new skill can be an intimidating task for budding health care professionals – especially when it comes to learning medical procedures.  There is a difference, any doctor will tell you, between reading about a procedure and actually doing it.  Educators are beginning to take full advantage of new technology – like the iPhone/iPod – to help bridge the gap between comprehending and performing medical procedures.

Procedures – Hospital Collection is a new app that uses bulleted text, clinical images, and audio/video instruction to familiarize the learner with the preparation, relevant anatomy, and individual steps of common procedures in the hospital setting.

This app is not the first we have reviewed that offers instruction on performing routine hospital-based procedures. In many ways, Procedures – Hospital Collection is like the more expensive Procedures Consult – Internal Medicine App in its content.

So… how does it stack up to Procedures consult?  In this post we’ll do a full review of Procedures – Hospital collection, and use the Procedure Consult series as comparison

For $19.99 MeisterMed’s Procedures: Hospital Collection uses hi-resolution video clips that look in many ways like the Procedures Consult family of apps or the New England Journal of Medicine Clinical Medicine videos that may be familiar to many medical students, residents and physicians.

As the name implies, the content is most applicable to those users in the inpatient hospital setting.  Modules included are:

1. Arterial Line Placement
2. BiPap & CPAP*
3. Bone Marrow Aspiration and Biopsy*
4. Femoral Line Placement
5. Glidescope Intubation*
6. Internal Jugular Line Placement
7. Internal Jugular Line Placement with Ultrasound Guidance*
8. Laryngeal Mask Airway*
9. Lumbar Puncture
10. Orotracheal Intubation*
11. Paracentesis
12. Pulmonary Artery Catheter Placement
13. Subclavian Line Placement
14. Thoracentesis
15. Tube Thoracostomy (Chest Tube) – (Procedures Consult has Needle Thoracostomy)

* Not one of the 30 procedures included in Procedures Consult – Internal Medicine

Navigating the App

The user can search, return to previously bookmarked pages, or simply browse one procedure at a time.  Each procedure page has three menu items: Procedure Details, Images, and Watch the Video.

Procedure Details:

Under the Procedure Details menu, the user will find indications, contraindications, complications, equipment, step-by-step instructions, lab analysis (if applicable), frequently asked questions, coding, and references.  This format differs from the “Pre-procedure, Procedure, Post-procedure” layout of Procedure Consult.  Navigation through the menus is not as fluid or intuitive as we would have hoped – transitions between pages have a lag of a second or two, and it is often difficult to distinguish linked-text from plain text – but the depth and quality of information in the Procedures Details menu is definitely on-par with competing apps.

Images:

Hi-res clinical images and corresponding captions are found under the Images menu.  Clinical images from the bedside are very large, generally high in quality, multi-touch capable, and convey the key steps of the procedure.

Important anatomy concepts are shown in figures (e.g. Mallampati Classification, landmarks for LP), but are lower in quality and fewer in number than similar figures in competing apps.  We would have liked to see more high-quality anatomy figures in color.

The Images menu lacks integration with corresponding items in the Procedure Details menu, and is clunky to use.  The user cannot view the image and its caption at the same time, which makes for the tedious process of opening the image, returning to the Image menu, opening the caption, returning to the Image menu, then moving on to the next image.

If we were designing this app, we would prefer to see the Images menu scrapped, or at least better integrated into the Procedures Details menu.

Video:

Ok, here’s the bread and butter of any procedures app or online teaching tool – the video.

Most videos are 3 to 5 minutes long, from preparation stage to completion.  Video footage for each of the procedures is generally well done.  Some procedures are staged in lighting that is less than ideal, but in general the video is clear and effective in showing key steps of the procedure, with “down-time” edited out.  Close-ups of appropriate steps are included.  The narrator guides the user through each step, sprinkling in the tips and tricks of an experienced clinician. Audio clarity is good.

Users may find the narrator’s unscripted approach distracting.  We did.  A well written script for each video — and some editing-out of messy sentences — would have undoubtedly cut down on “um, ah um” and probably ensured that more relevant narrative points be included.

Key point: a major strength of procedural videos is missing from this app. Videos on this app lack intentional pauses to emphasize the clinical pearls, anatomical relationships, safety reminders, and key techniques that are most important for the learner to remember.  Other effective procedure video apps and online videos use on-screen text or overlaid anatomical figures to make key teaching points. To maximize the learning experience to the user, we would have liked to see this integration of text-based key learning points within the video.

Likes:

• All the information is there… you just need to know how to get it.
• References included, and generally up-to-date.
• CPT Coding information included (missing from Procedures Consult)
• Entire content downloaded to the device (no Internet connection needed)
• Fully searchable and bookmarkable.
• HUGE clinical images with multi-touch zoom.

Dislikes:

• Key information in the text is not highlighted (bolded or different color)
• Text size not adjustable
• Clunky process of clicking back-and-forth between images and captions
• Narrator “ums,” run-on sentences, and abrupt stops.
• Navigation of the user interface is slowed
• Lacks integration of video, images, text, and audio into one coherent learning experience
• Only 15 procedures (compared to 25 on Procedures Consult – Internal Medicine)

Notably missing Procedures:

• Incision and Drainage of Cutaneous Abscess
• Pelvic Exam/Pap Smear
• Phlebotomy

Conclusion:

At $19.99 Procedures – Hospital Collection is a good buy for residents and students who are somewhat familiar with each of the procedures, but who need a quick brush-up on the needed equipment or step-by-step process just before seeing a patient.

In comparison to the Procedure Consults – Internal Medicine app, users with no procedural experience – like many medical students – may miss out on many helpful “clinical pearls” and find the in-video learning experience to be lacking with Procedures – Hospital Collection.

But for half the price, this app provides more than sufficient information to learn the techniques and concepts behind the 15 included procedures, if only the user is willing to put up with a few more menu-clicks and less stream-lined audio and video quality.

This app succeeds in providing a comprehensive procedure learning tool, but fails to match the intuitive layout and high quality text-audio-video experience of the higher priced Procedure Consult App Series. And although Procedures Consult – Internal Medicine is twice the price, it also has almost twice the number of procedures.

Editor’s Addendum and comments

Our apologies, we needed to do a better job of distinguishing the procedures available in Procedures Consult – Internal medicine, and those in Procedures – Hospital Collection. We have updated the 15 modules we first listed for Procedures – Hospital Collection, labeling the procedures not included in Procedures Consult – Internal Medicine.

Also, the following procedures are available in Procedures Consult – Internal medicine, and are not available in Procedures – Hospital Collection: Atrial Blood Gas Sampling (In addition to Radial, Brachial and Femoral Approach included), Basic Airway Management, Cardioversion, Central Venous Catheterization: Femoral Approach, Cerumen Removal, Defibrillation, Epistaxis Management, I&D of Cutaneous Abscesses, Intravenous Cannulation, Local Anesthesia, Nasogastric Intubation, Pap Testing, Phlebotomy, Stapling Devices, Tick Removal, Transcutaneous Pacing, Transvenous Pacing.

I’d like to further stress the depth of the Procedures Consult – Internal Medicine app’s videos, text, and pictures. Although Procedures – Hospital Collection does show how to put in an a-line, Procedures Consult shows alternative approaches, with alternative in depth videos as well. The depth and breath of the video, text, and pictures in Procedures Consult – Internal Medicine are better than the Procedures – Hospital Collection app, as is the navigation and overall user interface.

But when making a decision on which app to purchase, look at the procedures offered by Procedures – Hospital edition that are not offered by Procedures Consult – Internal Medicine. If those extra procedures are key for you, and the extra procedures offered by the Procedures Consult app are not, than Procedures – Hospital edition would be a very good choice.

Download now from iTunes for $19.99 »

Visit the App Website »

Brett Einerson is one of our newest guest writers.  He is a fourth year MD/MPH student at Wake Forest University School of Medicine and the University of North Carolina Gillings School of Global Public Health.  He is a native of Minnesota and a graduate of Bethel University in St. Paul.

In the future he will be entering residency in Obstetrics and Gynecology. He is interested in evidence-based practice, comparative effectiveness research, physician decision-support systems, and practice guideline development.

This week, Microsoft announced the end of Windows Mobile and introduced its successor, a completely redesigned platform called Windows Phone 7.  While Microsoft’s creative energies don’t appear to have been expended on the new name, it may be because they were drained after redesigning just about everything else about their platform.

Even the more skeptical reviewers of Windows Phone 7 at least acknowledged the breadth of the overhaul of Microsoft’s mobile platform. Here at iMedicalApps, we’ve spent a lot of time talking about the iPhone/iPad and the opportunities their unique user interface, ever expanding suite of medical apps, and other key features present for the medical world. One challenge we’ve frequently acknowledged, however, is that while many health care providers carry Apple in their pockets, Microsoft dominates the remainder of the healthcare world. And as more and more health systems look to adopt electronic medical records with mobile interfaces, Microsoft’s latest volley couldn’t have been at a more opportune moment.

Before delving into this, lets consider the qualities that made the iPhone OS popular in the first place. The obvious first point is the revolutionary iPhone OS user interface. If history is any guide, its hard to imagine that Microsoft will really come up with anything better than Apple. But that’s not what they need to do. For a shot at adoption in the healthcare world, they could probably get by with something that’s simply almost as good and let other strengths make up the difference. In any case, judging by the demo clips and information I’ve seen so far, it looks like Microsoft has created a distinct user interface that could be a lot of fun to use. But we’ll have have to wait and see.

The second key feature of the iPhone OS that makes it a hit in the medical world is it’s dynamic and active developer community. Apps range from low cost solutions for specialty-specific issues, such as apps for urology, to interfaces for EMR’s like the Haiku-Epic combination. Aside from the “hubs” (software that integrates information from multiple sources into one spot, such as Facebook, Twitter, Gmail contacts into the People hub), there’s not enough information to yet assess what the developer community would face for Windows Phone 7. Hopefully, by MIX10 in mid-March, we’ll have some more information and a better idea of how Windows Phone 7 stacks up.

But the one area Windows Phone 7 is very likely to hold a clear advantage, especially in the medical world, rests on the mere fact that its a Microsoft product. Virtually every widely used EMR is on a Windows Operating System, so integrating a Windows-based mobile device would certainly be easier than an iPhone OS device. This also means integration with the Office suite, Outlook, and all of the other Microsoft enterprise software that is being used at virtually every hospital and health care practice in the country.

Plus, Microsoft is touting the fact that this new mobile OS will fit in perfectly with its rapidly growing SharePoint server software, basically the cloud component of Office. For health care centers already using Microsoft software, all of this represents an upgrade of what they already have, rather than having to deal with the obvious issues that would come with the iPhone OS.

All of that being said, its certainly not clear that these potential advantages will materialize nor that Microsoft can match the strengths of Apple. In addition, Google’s launch of Android, its movement towards cloud-based enterprise software, and its experience in information management are assets that suggest it will be a healthy competitor. For the foreseeable future, Apple holds an enormous lead thanks to its robust developer community, widespread acceptance, and the fact that it has demonstrated that Windows compatibility issues are surmountable (based on desktop experience). So for me, what is most exciting about this new Microsoft OS isn’t any inherent quality it has, but that it represents a legitimate new competitor entering the mobile medical world.

In a recent Microsoft forum on health care technology, researchers made clear the company is hoping to have a larger presence in the healthcare arena using the Windows Phone 7 series platform and the Xbox 360.  They are also experimenting with connecting these products to HealthVault, their personal health records platform.

The “dream” is that a user could photograph each meal with their phone to have the application return data such as caloric content, food group and allergy information for each item on a plate, said Eric Chang, director of technology strategy at Microsoft Research Asia, in an interview.

Other Microsoft researchers are looking at how the company’s Xbox 360 could be used in hospital rooms.

I think Microsoft has already seen how interactive gaming devices, such as the Nintendo Wii have been used for health care purposes – and want in on the action.  An example is how the Nintendo Wii has been used to help burn victims with their rehab process.  The Wii’s ability to recognize physical movements has been used in burn centers to improve patients mobility while recovering from burns affecting the hands and arms.  Microsoft has its own interactive gaming device releasing this year, and it’s not restricted to hand movements.

With Project Natal, Microsoft’s controller free gaming and entertainment experience, the possibilities for physical therapy and other medical use are huge [Natal plugs into a Xbox 360].  Unlike the Wii’s interactive experience, which requires you to have a controller while making physical motions, the Project Natal Platform can recognize your whole body movement, and could be used to rehab more than just your hand.

Imagine having interactive games that simulate your physical therapy workout.  Most patients hate physical therapy because of the initial pain they have to endure, making compliance one of the chief issues.  An interactive gaming experience such as Project Natal could be used to enhance this experience – and take patients minds away from the pain.  With Nintendo Wii laying the groundwork for health care physical rehab use, it’s only a matter of time we see Project Natal in the same light.

Source: [PC World via Gizmodo]

If you’re a physician, medical student, or in any other health care related field, trying to find the best free medical apps for the iPhone is a hassle.  Apps such as “Dream Meanings”, “Relax Ocean waves”, and “Stool Scanner Lite” dominate the Top Free Medical Apps list in the App Store.  Our top 10 iPhone medical apps list contains no such app, and this isn’t a re-hash of the top downloaded free medical apps either.  Rather, this list contains the top 10 free iPhone medical apps health care professionals and students can actually use on a day to day basis.

1) Medscape

We mentioned this app when it was released in the summer of 2009.  At the time I doubt many thought it would ever eclipse Epocrates in the top free medical apps section of the App Store, but with significant recent updates it’s accomplished this feat.

This app always had a great drug reference section, with over 6,000 generic, brand, and OTC drugs, along with a drug interaction checker.  But with recent updates, Medscape now has a Diseases and Conditions section, along with a Clinical Procedures section.  These added sections aren’t just fluff, they actually contain concise and useful information, with videos and pictures to boot.  We plan on doing a full review in the near future.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

2) Epocrates

The free version of Medscape might be ranked higher on our list, and in the App Store, but I guarantee almost every medical professional still has at least the free version of Epocrates.  My peers and I often joke about how Epocrates is the “most trusted name in Medicine” – because it’s the one app med schools and medical institutions aren’t afraid of pushing.  We recently did a full review of Epocrates.

The free version, called Epocrates Rx, includes: Drug interactions, Pill Identifier, Drug Info, and Medical Calculator. Surprisingly, Medscape doesn’t have a medical calculator, you would think this added functionality would be easy to do.  In our review of Epocrates, we go over all the different versions in details, along with pricing – we were definitely impressed.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

3) iRadiology

This app is a must download if you’re a resident or a medical student.  Even if you’re not in that category, you might want to download this app just for fun. iRadiology has a catalog of over 500 radiology cases designed to help medical students and residents improve their plain film, CT, and MRI reading skills.  We did a full review of this app recently.

The cases are derived from Dr. Gillian Lieberman, who is currently the Director of Harvard Medical Student training and Associate Director of the Residency Program at Beth Israel Medical Center.  We interviewed her when iRadiology was released – and she provided some great insight into the inspiration for the app.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

4) MedPage Today Mobile

What’s not to like about MedPage Today?  The website is a fantastic resource for medical professionals, and a lot of the content is in partnership with the University of Pennsylvania School of Medicine – further securing its academic credentials.  Their motto is, “Putting Breaking Medical News Into Practice”, and this app helps you with this cause via mobile access.

In addition, you can get audio and video through this app, allowing you to get CME credits while using MedPage Today mobile. With the most recent update, MedPage Today mobile now allows you to do a full text search of all articles published on their website since 1/1/07, definitely a welcome addition.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

5) Medical Radio

This is a product of ReachMD, probably most famous for its XM Satellite Radio broadcast feeds  (XM 160) of medical information – and these feeds are available live through this app.  MedicalRadio allows you to keep up to date with changing clinical guidelines, and I’ve found the medical talks to be informative and useful.

We haven’t done a full review of this app, but the original iteration of this app, ReachMD CME, made it into our old top medical apps list.

Links: iMedicalApps Review (old version of app), Website, iTunes
Cost: Free

6) MedCalc

We’ve always been fans of MedCalc, now the most popular free medical calculator in the App Store. There’s not much to say about it, other than it’s created by physicians who are dedicated to keeping it as a free resource for medical professionals.  Also, don’t forget Epocrates Rx (free) has a great medical calculator built.

Links: iMedicalApps Review, Website, iTunes,
Cost: Free

7) NeuroMind

NeuroMind is one of the two medical apps on this list that we haven’t reviewed on iMedicalApps.  Its a great tool for medical students, neurology residents, and even neurosurgeons.  It contains a wide range of information, from basic neuro-anatomy to the WHO Safe Surgery checklist items.

Links: Website, iTunes
Cost: Free

8. Drug trials

Drug Trials is an app we featured on one of our “recently released free medical apps” list.  If you find yourself using clinicaltrials.gov, then this is a great app to have. It’s packed with features such as eligibility criteria, e-mail out functionality, and it can even use google maps to show the location of the trial!

We reviewed another similar app awhile back, Clinical Trials, but Drug Trials is just as good or slightly better. And unlike Clinical Trials($7.99), this one is free.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

9) Eponyms (for students)

Webster’s definition of Eponym is: one for whom or which something is or is believed to be named.  In medicine, we encounter this all the time when memorizing obscure diseases or pathologies.  This app contains over 1700 of these medical eponyms with short descriptions of each – A nice learning tool for students.

Note, this is the “student” version of the app.  If you’re no longer a student the developers ask you to download the $1.99 version of the app – and it contains the same content.

Links: Website, iTunes
Cost: Free

10) MSK Radiology Teaching File – LITE

This was another app we featured on one of our regular columns, “recently released free medical apps”. MSK Radiology is the lite version of Radiopaedia.org’s Radiology Teaching Files: Volume 3, an app designed to teach radiology.  Although this is a lite version, I was surprised to find out how much information it packs in 10 full cases.

This lite version comes included with some relatively common pathologies and even though it’s free, you could definitely get some good learning accomplished if you’re a resident or a medical student.  There are other LITE versions of Radiopaedia.org’s content with similar formats.  Usually I wouldn’t include a LITE version of an application in this list of free medical apps, but this app had plenty of content.  Also, if you find the cases useful the full cost is $4.99 for each set of 50 cases, not a bad price.

Links: iMedicalApps Review, Website, iTunes
Cost: Free

Conclusion:

So there you have it, the top 10 free medical apps for the iPhone and iPod Touch that are actually useful to medical professionals.  We’ve reviewed 8 out of 10 of these apps, and I encourage you to look at our full catalog of reviews, where we’ve reviewed a diverse group of apps with various price ranges.

Dr. Yousif Alkadhi and Satish Misra contributed to this post.

At the time of this post these applications were free, this can obviously change over time.  If you’ve got some free medical apps you love to use, make sure to comment and let the community know.

STDMeister is the first legitimate STD app made for health care professionals in the App Store.  It was only a matter of time right?  Although the proper phrase is STI, sexually transmitted infection, it’s safe to say the phrase sexually transmitted disease (STD) isn’t going away anytime soon – especially for those of us in the medical field.  This STD app aims at helping medical personnel diagnose, manage, and treat STDs.  The developer of this application is MeisterMed, and we’ve reviewed some of their prior medical apps before, with mixed results.  This might be a unique application at a low price point, $3.99, but how useful is it for health care professionals? Hopefully at the end of this review you’ll be able to tell.

When you open up the application you’re presented with a funky looking monster/bug cartoon that I’m assuming is supposed to represent an STD.  Underneath the freaky STD cartoon, you have 5 buttons to choose from [2nd picture].

The three key navigation pathways on this page are Topic Index, Treatment Algorithms, and Image Atlas.  The topic index has a wealth of information on not only STDs, but ancillary topics, such as abstinence.  Once you pick on your topic of choice, in this example, Chlamydia, you’ve given a link to pictures, diagnosis, treatment algorithms, and many other related subjects.  If you want to skip directly to the pictures or algorithms, you can do so on the front page.

Once you click on algorithm, you’re taken through an interactive algorithm of treatment options [reference the pictures].  You’re asked the age of the patient, if they are pregnant or not, and then given treatment recommendations.  You’re also given alternative treatment regimens in certain cases, with an option to view more treatment details.  The algorithm feature is where this app shines, and where it could be utilized the most in clinic.

Throughout the application, there is a toolbar at the bottom of the screen.  These buttons allow you to go to the home screen, search, bookmark your current page, write a custom note, or go back to the previous page.

The search function is severely inadequate. When you search for a pathology, instead of the most relevant options showing up, such as the beautifully done algorithm I mentioned above, you’re presented with a hodgepodge of pictures and other random topics related to your search, requiring you to scroll down until you hopefully find what you’re looking for.

The bookmark function is excellent.  I found it most useful for saving treatment regimes that I reference the most.

The Image Atlas contains over 200 pictures related to STDs.  The pictures were informative and there are even pictures of histology slides, a nice touch.  I included one picture, and left out of the more “intense” pictures in case anyone is reading this at Starbucks or any other public place [if you can give the diagnosis of the picture I included leave it in the comments section.  You’ll win some respect - no prize].

What I liked:

• Current Price point of $3.99 is nice
• Good amount of information on STDs – Not too long, but concise
• Multimedia – pictures are useful
• Treatment algorithms are fantastic, and the highlight of this application
• Bookmarking feature – Very useful, you can bookmark key treatment algorithms!

What I didn’t like and What I’d like to see in future updates:

• Navigation and User Interface – There is no arguing apps produced by MeisterMed contain great information, but we’ve griped about the navigation in previous reviews. Maybe it’s because we’re used to the iPhone’s fluid interface, but simple things could make this app better – e.g, Search function that returns more relevant results, back button placed on the traditional left side, etc.
• Delayed opening of app, on account of STD cartoon showing up – minor, but when I want to look up information ASAP, those extra 2 seconds are frustrating
• Search Feature – mentioned issues in the navigation and user interface section above
• Would be nice to see references from literature or medical texts

Conclusion:

Overall, STDMeister is a great medical app for the iPhone and iPod Touch.  There are definitely issues that need to be worked out, such as the navigation, search function, and other user interface problems, but the other features of this app definitely makes up for those shortcomings.  The interactive treatment algorithm alone is worth the low $3.99 asking price for the app.  This fantastic feature allows you to quickly pull up the treatment options, and offers alternative treatments with detailed explanations as well.

This app would be most useful for those working in STD clinics and primary care settings where there is a high rate of sexually transmitted diseases.  Physicians, Physician assistants, and nurses could definitely make use of this application in those settings.

Download now from iTunes for $3.99 »

Visit the App Website »

*Note to readers: this is obvious, and even somewhat mentioned when the app opens, but when using apps offering treatment options or any medical suggestions, make sure to use your own clinical judgment.  Apps such as Epocrates and Medscape have robust databases that get updated when standard of care changes occur – always be up to date on these changes through your own research.

It’s probably not an exaggeration to predict medical students of the next decade will not lift a physical textbook. In fact, even ownership of a discrete entity, formerly referred to as a “textbook’, may be a historical footnote. Instead, students may simply rent the chapters they need for a particular course, paying a recurring subscription fee to the publisher for the period of usage. This system could foster innovation and allow for dynamic ebooks that change with standard of care, as I’ll discuss in this post.

For many medical students, who have grown numb after repeatedly paying $100 to $200 per book, this more financially sane model can’t come soon enough. In fact, college students buying multiple texts for a course lasting just two or three months are probably even more eager for such a system.

However, while renting textbooks may seem like a strange and wondrous departure for those of us who still pridefully maintain shelves of outdated medical textbooks, the more necessary revolution will actually be upending the illusion of completion when a textbook finally reaches the printing press.

By this, I am suggesting the barrier between finished textbooks and the rapidly evolving nature of medical knowledge most certainly needs to be more porous. Going even further, the interactive and non-linear nature of learning are at odds with the centuries-old format of a linear, immutable text.

This is not to say that textbooks are anachronisms. Something very valuable comes out of the care and scrutiny of an author polishing each paragraph and page with great care. But, why should the craftsmanship stop at the moment of publication?

This is where the iPad and its future kin come in. The proliferation of ebooks and, in particular, e-textbooks will be great for students and practitioners alike. At a minimum, ubiquitous availability and more reasonable pricing models will open the doors to more sales and more happy customers.

But, this will just be the beginning. The real golden opportunity will come from continuing the engagement of the authors with the readers and, even more importantly, the readers with each other.

What this would open is a world where learning occurs just as much in the “wild” as it does in the classroom and where the roles of students and teachers start to intertwine. In other words, something like the real world, rather than the sterile enclosure of the lecture hall.

I imagine the authors of a book continuing their engagement with their readers and even acting as occasional consultants, further enlarging and enriching their reputations. I imagine a “book” that changes over time and re-engages the readers when new information arrives or when they perform searches on their device.  We all know how change can happen instantaneously in the medical field – these changes or new evidence based care could be implemented immediately with ebooks on the iPad – much like updating an app.

In short, what I am looking forward to is an electronic book that soars beyond the simple conjugation of a screen and a book – and is significantly more dynamic than the tangible good.