Apple’s education media event on Thursday suggests Apple are primed and ready to enter the world of digital publishing. As we pointed out in our last article, evidence suggests that Apple is likely to bring important changes to the iBook platform with a particular focus on academia and furthermore push into the education industry. Previously, thoughts have focused on Apple improving the iTunes U platform and trying to use this as a gateway into educational institutions. Others believe that Apple are planning on upgrading the iBooks platform and distribution method to remove the intermediates of the publishing industry.

A number of key players in this industry have made some interesting observations; Matt MacInnis, CEO of Inkling pointed out one of the main issues facing Apple is that they,

“do not have a history of building software specific to any particular vertical market, and so we believe they’ll continue to allow their developers to work in this area.

Cult Of Mac believe that Apple:

“intends to slowly take control of the book publishing industry… by providing the leading tools and cloud infrastructure for authors to create and then market their books directly to readers starting with the education segment of the publishing market.”

Interestingly, MacInnis had similar thoughts to this noting,

“We think Apple could devalue traditional textbooks, but not necessarily by replacing them with something data-driven, interactive and pedagogically sophisticated. Instead, we think Apple could make it easy for others to create baseline content that serves ostensibly the same purpose as a print book, pushing the market dollars in search of more effective learning tools.”

If Apple do introduce a system that connects textbook authors to readers and removes the intermediate publishers, we are likely to see an interesting future in medical textbooks. Apple may be trying to reinvent the iPad as a learning platform and content distribution service in much the same way as companies like Inkling and the Khan Academy are. Using Apple as a source of medical textbooks means that distribution costs may go down enabling easier access. Furthermore Apple is poised to bring a range of interactive features to iBooks as illustrated by their free release of the Yellow Submarine book which demonstrated a range of media, annotation and other creative features. If Apple do offer publishing tools and remove the intermediates in the publishing industry then we are likely to see a very exciting time as MacInnis says,

“Apple will encourage others to produce content for that ecosystem, and if they can reach a critical mass of content, they might very well make the traditional textbook obsolete for iPad users.”

whilst Cult Of Mac believes that,

“Apple will begin the long process of reinventing the textbook industry as a stepping stone to eventually reinventing the entire publishing industry.”

Apple taking control of publishing would have interesting ramifications in what has been a relatively inactive market. Imagine the possibilities of updates to textbooks being pushed to your iPad in the same simple fashion as updating an app. What is clear is that the future of publishing is not page-bound as the educational market has not responded well to textbooks that are essentially PDF copies.

Thanks to Matt MacInnis, CEO of Inkling for offering his unique insight into the issues facing companies such as Inkling in advance of Apple’s media announcement.

Source: Cult Of Mac

The mHealth Summit is the largest annual gathering dedicated to mHealth in the world and convenes a global group of researchers, health professionals & industry. As a media partner for the Summit, iMedicalApps will be presenting an exclusive series of interviews with keynote and prominent speakers titled “mHealth leaders speak to iMedicalApps” between now and the December meeting.

The West Wireless Health Institute (WWHI) has emerged one of a few highly innovative organizations catalyzing growth in wireless health through the aggressive investment in talent and technology. In this iMedicalApps interview with Don Casey, CEO of West Wireless Health Institute, I asked him what he foresaw as the major breakthroughs in consumer health technology over the next 5-10 years and, to Mr Casey’s credit, I am able sum up his vision for you in three words – infrastructure independent care.

The interview with Mr. Casey took place prior to the announcement of the West Health Investment Fund this past week, so I was unfortunately unable to ask him details about the fund’s investment strategy or about their initial portfolio. In my opinion, the fund takes everything WWHI is trying to accomplish to the next level, by allowing them to get into the business of providing risk capital to entrepreneurs and technologies they believe fit well within the infrastructure independent care model they are developing.

In his new dual role as Managing Director of the West Health Fund and CEO of WWHI, Don Casey has clearly emerged as one of the 2-3 most important individuals driving the future of digital medicine. Look for big things to come out of the initiatives under his direction.

[editor's note-the following interview has been edited]

iMA: Why are you participating in the mHealth Summit and what do you hope to get out of it ?

Don Casey: We felt participation in the first year was important for us as a learning experience and this year we are spending a lot of time and energy around participating in different panels. We have a booth that will be very significant there just because we believe it’s a unique opportunity to engage a cross-section of important stakeholders from government to industry groups. We are very excited to be a part of the mHealth Summit and are looking forward to learning and sharing our experiences in Washington this December.

iMA: What are the near term, mid-term and long term prospects for the business of mobile health?

Don Casey: I think the business of mobile health reached a critical mass about a year ago. You can see this in the growth of the number of health apps in the Apple App Store, somewhere near 13,000, you can see the growth in the Android marketplace, which is a bit more consumer oriented, you can see it in medical professional and clinical arenas as you see organizations like Continua take hold, and importantly you can see venture capital starting to change, whether its Patrick Soon-Shiong, or other folks who are starting to really invest in the industry. In sum we see the prospects as very bright for the industry, its gone from “someday it all going to be about wireless”, to now its starting to happen that way. We believe mobile health has gone from potential to performance.

Why do we believe “mobile health” is a sector that will be an industry with billion dollar, if not tens of billions of dollars in potential from a business model perspective? Its because we believe healthcare costs will be the biggest challenge we face as a society for the next 50 years, and we think the current system of acute management of chronic conditions in a hospital does not fit with where the future will be. So we perpetually talk about how we can design a health care system for the future, and designing the health care system of the future is going to be about how we manage chronic disease. The way to manage chronic disease in our opinion is moving away from infrastructure, expert driven, location-centric care to infrastructure independent care – how do you give people the right treatment, when they need it, where they are? We think the answer to this question is mHealth.

iMA: How do you think mHealth is currently received by physicians? What will be the impetus that affects the culture change necessary among physicians for mHealth to become truly pervasive?

Don Casey: I think a lot of physicians now are looking at it as a novelty. They are very happy to have iPhones iPad Android devices to augment their practice, but they think of them merely as ‘practice helpers’ much like they enjoyed the advent of the Fax machine to facilitate practice management. Most physicians haven’t crossed over into the idea of, ‘how can I use these devices to improve my medical practice’, and I think that is the next big shift that has to happen. This is going to demand that physicians become much more comfortable with having a lot more data readily available, whether its electronic medical records or patients pushing data to them, physicians are going to need to become a lot more comfortable with that. To date this has been a slow process.

What I think is going to change is that, according to our data, 50-percent of physicians in the US have some form of Smartphone. As their comfort level grows with these devices we believe usage will go from ‘practice management’ to practicing medicine, and we see that happening. However, there is no killer app right now, but five years ago you had less than 9-percent of physicians using electronic medical records, now that number is pushing well into the 30-percent range, and if the trend continues by 2015 it will probably be closer to 80-percent adoption of electronic medical records among physicians. In my opinion this will be a game changer because these electronic records will make a ton more information available on the spot, at the point of care, where they need to make critical decisions.

iMA: Does the WWHI work directly with entrepreneurs and how would an entrepreneur engage the WWHI to take advantage of your resources?

Don Casey: We absolutely do work with entrepreneurs, and in the four years since our founding WWHI has interacted with over 400 companies to provide advise and counsel a strategic perspective. We also have 25 engineers ranging from software engineers to biomedical engineers that can help companies begin to solve some of their technical challenges. Our ability to interact with them has been facilitated by Gary and Mary West giving us $100M in philanthropic gifts, allowing us to focus on what companies bring the technologies we believe will be transformative in lowering the cost of healthcare. We actually have a chief of outreach strategy, Dr Mohit Kaushal, who is the individual to contact with regard to engaging the institute.

iMA: That is great, I have talked to a lot of entrepreneurs that really want to work with WWHI but don’t know the proper channels to navigate, I am sure your booth will be inundated with entrepreneurs at the mHealth Summit.

Don Casey: That is great, we welcome them. We have put together a group of venture capitalists that we work with and while we are not going to provide direct grants and funding, we can certainly help them access our network of resources, whether its angel funding, or early series funding many of these potentially disruptive startups need to get to the proof-of-concept stage, which is so hard for many startups to get to.

iMA: You mentioned Patrick Soon-Shiong before, and since he is my favorite topic to write about I thought I would follow up and ask you what you think about the NantWorks experiment and his ideas for a Silicon Beach?

Don Casey: Dr Soon-Shiong is putting together an interesting collection of companies that are going to be able to provide services from early stage diagnosis and patient risk identification through some sort of monitoring and hopefully come up with some outcomes. He has been successful in the past, lets see how he does here. Its a very, very early stage industry. We like to say its not really the Wild, Wild West, but its certainly the Wild West.

iMA: Do you see one company or technology out there that could lead to the break out of mobile health as a business?

Don Casey: I think the company that is leading the breakout is actually Apple. They are taking a consumer-oriented device between the iPhone and the iPad and they are opening a platform for everything from how you manage your weight to how you manage your diabetes into one device. Look at AirStrip Technologies for instance, a very interesting application for iPad, but its not the killer app, we haven’t seen that yet. In my personal opinion the big opportunity is going to be in who manages the data coming off of these devices. In my mind that is the company we haven’t seen yet that will be the big, big winner. You can talk to any doctor and they will all tell you there is no way they want every daily reading of a patient’s vital data, but they do want to know when the data demands they give their attention and potentially take action. So the idea of taking an informatics company that can offer the specificity and sensitivity around an alarming system, I think is going to be the big winner.

It has been very difficult to cut through the understandable distractions provided by the recent passing of Steve Jobs to analyze the product Apple launched last week, the iPhone 4S.

When the device hits stores tomorrow it will probably be the least scrutinized new product Apple has launched in years, however there is one new element you will find in the new iPhone which might be seen in retrospect as the feature which brings body area network technologies to American consumers by Christmas 2011- Bluetooth 4.0.

The BLE standard was first announced by the Bluetooth Special Interest Group (SIG) in June 2010 with the hallmark features of the new protocol listed as :

• Ultra-low peak, average and idle mode power consumption
• Ability to run for years on standard coin-cell batteries
• Low cost
• Multi-vendor interoperability
• Enhanced range

Apple has been the first consumer device maker to begin embedding Bluetooth 4.0 in their products, starting with the MacBook Air and Mac Mini in July. By embedding Bluetooth 4.0 in their devices first, Apple has forced their competitors to follow their lead and integrate the technology into the next generation of Smartphone. More importantly, Apple has created a viable consumer base for developers of applications in the largely unexplored realm of body computing and wearable sensor networks.

IMS Research predicts the decision by Apple to pioneer BLE in their iPhone 4S device should be a huge stimulus for developers of emerging mobile health devices incorporating low energy technology. They anticipate the shipment of greater than 370 million units by the end of 2012, and 1.6 billion by 2015. It is anticipated wireless medical applications will be the most attractive opportunity for realizing the value of the new low energy protocol.

Several companies have already developed Bluetooth Low Energy chip sets including Broadcom, CSR, Texas Instruments, and Nordic Semiconductor among others. The first Bluetooth 4.0 heart rate monitor, developed using a Nordic Semiconductor chip set, was announced this past June (pictured below).

Bluetooth 4.0 enabled devices are backwards compatible, thus BLE will not be replacing the existing Bluetooth protocol used for most wireless interaction on mobile devices for higher latency activity. Instead the chip set includes “Closed Bluetooth”, “Bluetooth Highspeed”, and “Bluetooth Low Energy” in one unified stack.

High speed mode is based on Wi-Fi, while the classic mode supports legacy protocols, ensuring all existing Bluetooth enabled devices will work seamlessly with the new low energy technology. The advantages of the new standard become clear when you compare BLE head-to-head with other personal area network communications technologies.

BLE has big advantages over Near Field Communication (NFC), which is presently one of the leading low-powered wireless communication technologies on the market, the largest being range of the technologies, NFC (0.2 meters) and BLE (50 meters).

For the first time the medical community has good reason to believe the body computing future we have speculated and analyzed might be finally upon us.

Further reading:

Last year iMedicalApps was asked to interview Mike Foley, the executive director of the Bluetooth Special Interest Group. He wanted to reach out to our readers and let them know the huge implications Bluetooth 4.0 has for the medical community.  The following is the interview we did with him: Bluetooth 4.0 is admitted to the hospital – Potential to revolutionize health care devices

The App Store concept is one which has been instrumental in the success of the iOS ecosystem. The tagline ‘There’s an app for that’ has allowed iPods, iPhones and iPads capable of any task bounded only by imagination and hardware to be created.

The introduction of the Mac App Store heralded a new era in how users obtain and manage software. Apple has been pushing the concept forcefully, initially only offering their latest operating system, OSX Lion, via the App Store.

Here at iMedicalApps, we were very excited about the possibilities that lay ahead when it launched on 1/6/2011. Since then, however, there have been a significant shortage of medical apps.

Many of the apps that were initially placed in the medical category did not belong there, instead belonging in the health and fitness section. Given the relative success of the medical category in the iTunes App store, it is surprising that it has taken so long to develop this category. At launch there were only 13 apps available and currently there are only 116, many of which are still incorrectly categorized.

The key question, then, is whether or not–10 months on–the medical section of the Mac App Store is any good and worth developing.

[READ MORE]

The answer to this is not straightforward. I believe that some aspects of the medical app ecosystem that have been so successful on mobile devices will transfer well to the Mac App Store, although there are also a significant number that won’t. There are a number of reasons for this:

• First off, doctors and healthcare professionals are very busy people. The attraction of many medical apps is that they can be carried around and consulted when needed, wherever you are, at any particular time. As such, mobile apps have exploded onto the healthcare scene. However, healthcare professionals generally don’t spend enough time in front of their own computer to make significant use of any medical apps they may have installed. As a result, the core market of physicians is not present so developers have little incentive to spend time and money developing new innovative software.

• Secondly, the barriers to entry to create a mobile app are not particularly significant. While these are significantly reduced if a developer uses the app store, the actual work of porting a touch based iOS app to OSX is not a trivial task. Thus, many developers are instead focusing on developing for just one platform.

Despite these obstacles, there are a number of areas the Mac App Store may succeed, one being EMR software. The Mac App store is ideal for easy installation of EMR software across a range of computers and the ability to update in a straightforward fashion is certainly very attractive. Another exception is patient centered apps such as those that track and monitor health e.g. weight, blood pressure, glucose or provide evidence based information regarding a specific disease (ala carb counting with Lenny).

Another area that has the potential to be successful is electronic textbooks. We have already discussed whether electronic textbooks are the way forward and it would be an incredible feature if you bought a (physical) textbook and received a code with it that allowed you to download an app version of the book. This already happens with StudentConsult (a branch of Elsevier) whereby purchasing a textbook allows access to an electronic version on the web. There are many flaws with this model which are better discussed in a later post.

There are a number of positives and negatives associated with the Mac App Store. The low barriers of entry discussed here mean that there are significant possibilities for medical app development on the Mac. I feel that the future of the category lies with EMR software, patient health tracking software and medical references. However, the major hurdle to overcome is the lack of mobility associated with apps on a desktop.

On a different note, one area which has received a lot of speculation is whether future versions of the mac operating system will be able to run iOS apps. If this were the case, it would be interesting to study the use and uptake of mobile apps on desktop computers. For now though, the Mac App Store is a fairly limited resource for healthcare professionals and patients alike and it remains to be seen whether this will change in the future.

by:Brittany Chan, MBA, MS3 and Satish Misra, MD

Healthcare communications is rapidly changing – patients now routinely email their physicians, physicians connect with each-other via mobile-based professional networks, and more. The introduction of Apple’s FaceTime video chat sparked excitement and discussion in the healthcare community about its possible use in telemedicine. However, many were wary about associated patient privacy issues and HIPAA compliance.

It seems that this question has now been answered. According to Apple, calls made via FaceTime can be HIPAA-compliant with the appropriate security configuration. The news that this ubiquitous, free communications platform meets these rigorous standards has potentially wide implications for how patients, physicians, and others in healthcare communicate.

To be fair, its not quite as simple as just opening FaceTime and calling your patient. Specifically, the WPA2 Enterprise configuration provides an extra level of authentication when establishing a wireless connection. WEP does not provide the appropriate level of security, and WPA and WPA2 personal settings are questionable. FaceTime calls are fully encrypted as well.

According to an email from Apple to ZDNet:

iPad supports WPA2 Enterprise to provide authenticated access to your enterprise wireless network. WPA2 Enterprise uses 128-bit AES encryption, giving users the highest level of assurance that their data will remain protected when they send and receive communications over a Wi-Fi network connection.

In addition to your existing infrastructure each FaceTime session is encrypted end to end with unique session keys. Apple creates a unique ID for each FaceTime user, ensuring FaceTime calls are routed and connected properly.

FaceTime has numerous potential applications in healthcare. Simple applications include a primary care provider communicating with his or her patients or a hospitalist checking in with a patient when they can’t get to the room. It also opens the door to more complex apps utilizing the iPad and iPhone 4 forward-facing cameras as part of telemedicine systems.

This is favorable from a financial standpoint, since only HIPAA-compliant devices are eligible for government grants. As such, the iPad may now find further use in telemedicine programs, particularly those seeking to back up their interventions with data. With the prospect of increased federal funding and the growing popularity of telemedicine, the timing of this announcement could prove to be particularly fortuitous.

One interesting question, particularly in light of the recent FDA meeting, is what kind of regulatory attention this may attract for FaceTime. Intended use, a heavily debated topic at that meeting, could prove to be particularly complex here – a consumer app with healthcare applications that are, to some extent, being promoted by Apple.

FaceTime has the potential to broaden the exchange of information among physicians, provide greater convenience to patients, and improve the quality of patient care. The assurance of a secure connection may prompt more physicians to adopt iPads in practice for communication as well as other uses, though it may be prudent to await confirmation from a regulatory body.

Sources:

ZDNet
MacRumors

AT&T announced recently that they currently support 13 million so-called “emerging devices” on their network, which are consumer electronics which have embedded connectivity or work in tandem with existing smartphones. AT&T Emerging Device Organization launched in 2008 with the mission of “introducing wireless capabilities into a wide variety of emerging wireless devices beyond the traditional handset.”

The company recently announced the appointment of its first chief medical information officer (CMIO), Dr Geeta Naggar. Additionally, AT&T has partnered with the Department of Health and Human Services Office of Minority Health and American Association of Diabetes Educators to launch a new mHealth initiative to test mobile devices for diabetes self-management.

Some examples of the companies developing the 13 million emerging devices include Zephyr Technologies which struck a deal to embed AT&T 3G/4G technology inside its body-worn sensors. BlueLibris is an “On Star for people”, allowing device owners to press a button to talk and transmit medical data such as heart rate and blood pressure. AT&T is providing Vitality GlowCaps wireless network connectivity for the intelligent pill caps designed to help patients take medicines regularly using phone call or text message reminders.

Separately, AT&T announced it will be redesigning its 2,200 stores to include a “wall” featuring these emerging devices, presumably including mobile health devices and wearable sensor technologies. This is a very big deal for start-ups in the mobile health sector, everybody should be trying to get their products on the “wall”, and its an even bigger deal for the consumer patient who can now access body computing devices at a relatively low cost.

This move will likely be considered a direct threat by Apple and I predict it won’t be long before we see a similar wall at Apple Stores featuring every connected health device available, a topic we addressed last week on iMedicalApps.

It’s also reasonable to presume Verizon, Sprint, T-Mobile and other competitors in the brick and mortar cellular business will follow AT&T’s lead and welcome developers of emerging devices to put their products on their shelves. They will also likely embed their proprietary 3G/4G technology into these consumer health products to create additional monthly revenue from existing subscribers.

While the Smartphone itself is a very powerful mobile computing device, if it can be bypassed in the transmission of critical patient data, this would remove a layer of complexity in the workflow of mHealth technologies and services. The companies with the best chance of emerging as best-in-breed mHealth providers may well be those thinking beyond the smartphone app today.

With the recent hurricane affecting the lives of numerous people on the East Coast, we are reminded of the plethora of apps that position themselves as being useful during these disaster type scenarios. You might remember the Pocket First Aid app we reviewed last year — the one that helped save a mans life in Haiti.

While different situations are going to call for different actions,  the App Store and Android Market are full of apps that can be used in an emergency situation.

The question then becomes how to sift through all the various apps and decide which ones are worth using and which ones should be tossed away.  TechNewsDaily provided a solid list of some apps that might be useful.  

In an emergency situation, first-aid treatment is vital for those who need it and numerous apps are avaible to for this:

“Popular first aid apps for Android users include First Aid (free), Pocket First Aid and CPR ($2.99) and Emergency First Aid Guide ($0.99). For iPhone and iPad users, try American Medical Aid ($2.99), Pocket First Aid and CPR ($3.99) and First Aid Guide ($1.99).”

Additionally, a good plan is just as critical to keeping yourself safe and healthy as being able to treat wounds.

“For Android users, check out Disaster Readiness ($0.99), Disaster Survival Guide ($1.36), Survival Preparedness ($0.99), Emergency Kit Organizer (free) and Are You Ready? (free), an app from the Federal Emergency Management Agency. iPhone and iPad users should try Emergency Supply List ($0.99), Disaster Survival ($0.99) and Disaster Alert (free).”

Disasters are unforseen events that have a dramatic impact on people’s lives. While nobody wants to experience them, there is some, albeit small, comfort in knowing that there are apps availabe to assist during these events. There is even an app to convert text into morse code which may come in handy–you never know. We will do our own review of useful apps in disaster scenarios in the future.

Source:  TechNews Daily

By: Brian Wells, MS4, MPH

It’s a known truth of any research project: If one wants strong conclusions, one must be able to back them up with equally strong evidence.

Fortunately for researchers, an entire field dedicated to such evidence is available to us. That field is biostatistics.  However, even experienced researchers sometimes shudder at the thought of doing long calculations and setting up statistical models.

Enter Biostats Calculator for the iPhone and iPad.  The Biostats Calculator app allows anyone to quickly and accurately make statistics calculations to arrive at a decision.

For example, let’s say you are sitting around the conference table debating on whether studying drug X’s clinical and economic impact would be feasible. How many people would you need? How big of a difference are you looking for? What’s the sensitivity of test A versus test B? How would looking at a proportion versus a value alter the outcome?

Biostats Calculator can do all of these without the cost and complexity of a desktop statistics package.

iTunes blurb:

“Biostats Calculator provides a comprehensive collection of biostatistical calculations. It is designed to provide easy access to the most common tests without resorting to a complex desktop statistics package. It also includes a sample size calculator for epidemiological studies, and can measure the utility and power of diagnostic tests.”

Tests included in the package are:

• Odds Ratio
• Relative Risk
• Chi-Squared and Fisher Exact Test
• Unpaired t-test
• Mann-Whitney U Test
• One-way ANOVA test
• Paired t-test
• Wilcoxon signed-rank test
• Pearson correlation
• Spearman rank correlation
• Sample size calculator
• Diagnostic test utility

Software strengths:

• Without a doubt, this software is great for quick calculations and small datasets.
• It provides a good sample of the normal parametric and non-parametric tests typically used in statistics.
• For most scenarios, the included tests will be sufficient to assess the data.
• I can see this software being a boon to students learning biostatistics or to those needing to make quick calculations without access to a full blown statistics package like STATA or SPSS.
• To its credit, Biostats Calculator does provide a short tutorial with every test explaining the test’s purpose and how to interpret the outcome.

Software weaknesses:

• Entering large amounts of data would be too time-consuming.
• The program should incorporate a way to upload data via a web interface.
• Additionally, it would be good to include other tests such as Durbin-Watson or generalized estimating equations as these can be important in building models and assessing the accuracy of statistical conclusions.

Overall rating:

• I would be hard pressed to rate this software as a must-buy.
• It will find use among those learning biostatics as it provides not only the tests and calculations but an explanation of each test and its applicability.  However, for serious researchers, this software is too limited in terms of tests and data entry.
• There should be an easy way to test for things such as autocorrelation and to rapidly enter and store datasets and to maintain multiple sets of stored data for comparison.

Video:

For learning or basic statistics use, this package represents a good deal and an easy way to quickly learn some of the basics about statistics. However, for now, professional researchers should stick to desktop tools which provide more features and ways to analyze and display data.

Price: $9.99

BioStats Calculator on iTunes: http://itunes.apple.com/us/app/biostats-calculator/id325068885?mt=8#

By David Ahn, MD
Apple recently created an entire website profiling how Medtronic’s device representatives utilize the iPad to market products to doctors.

The article includes a two minute video showcasing the various apps that Medtronic has developed in-house.

This site is featured on the front of Apple.com (listed first under “Hot News Headlines”), and continues to demonstrate the recent trend of how passionately Apple is marketing the iPad as a viable product for the medical community.

More significantly, the webpage provides a real-life example of a medical company fully utilizing the enterprise capabilities of the iPad. Medtronic’s own in-house development team created over a dozen apps distributed on their own internal App Store. These apps range from creating versatile product demonstrations to sales apps that assist in placing and tracking orders. While Apple’s mainstream App Store has gained quite a lot of publicity, the ability for companies and hospitals to create their own in-house apps often flies under the radar.

The beauty of apps that are designed in-house is that they can be custom-tailored to your specific practice or patient population. Several hospitals (such as Cedars Sinai and Beth Israel Deaconess) have already been creating in-house apps, and we look forward to more hospitals and practices joining this movement and taking full advantage of the iPad or other mobile devices.

The site and video are definitely top-notch and are worth a visit.

By: David Ahn, MD and Iltifat Husain

Apple released a new installation of their iconic TV advertisements over the weekend with a new series for the iPad 2 entitled “We Believe.” Interestingly, the commercial places a surprisingly heavy emphasis on medical applications for the iPad. The spot features three apps that were not developed by Apple themselves, two of which are directly medical.

A shift in focus becomes immediately apparent when viewing the ad. Instead of the hip upbeat pop music, there’s a gentle piano melody playing in the background. Instead of showcasing the variety of apps like the original iPad TV ads (“iPad Is…”), they only focus on brief glimpses at several apps. The voiceover reads the following lines:

This is what we believe: technology alone is not enough. Faster, Thinner, Lighter… those are all good things. But when technology gets out of the way, everything becomes more delightful… Even magical. That’s when you leap forward.

The first app shown in Air Strip Patient Monitoring — an FDA approved app that allows for real time vital sign monitoring.  We’ve featured this app on iMedicalApps before, and previously posted live demos that the AirStrip company has given us. The second app shown is the radiology viewing app Mobile MIM, the first FDA approved mobile radiology imaging app .

Apple prominently featuring medical apps in their latest commercial continues to show how iPads are being used for general medical use, which was earlier mentioned directly by Steve Jobs at the iPad 2 announcement.  The iPad 2 announcement featured medical uses of the iPad prominently, and with two out of the three “non-Apple” apps being medical ones in this commercial, Apple continues to highlight medicine’s mobile role. Continue on for the embedded video commercial.

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

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

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

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

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

The reasons for this include:

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

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

This announcement is interesting in a few key respects:

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

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

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

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

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

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

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

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

On Tuesday, Apple announced new App Store rules that aim to redirect a larger share of revenues from app subscriptions and content sales to Cupertino. Widely expected by developers and consumers for some time now, these rules will have broad implications as they will apply all forms of digital media accessed through iPhone and iPad apps. The rules essentially mandate that apps that sell content, either as one-time purchases or subscriptions, include an in-app purchase option – with 30% of revenues going to Apple.

As Steve Jobs puts it,

“Our philosophy is simple—when Apple brings a new subscriber to the app, Apple earns a 30 percent share; when the publisher brings an existing or new subscriber to the app, the publisher keeps 100 percent and Apple earns nothing,” said Steve Jobs, Apple’s CEO.

NewsCorp, which recently released “The Daily”, is an example of the standard that Apple is seeking to apply to all digital media developers. While most press around this announcement focuses on the impact on large companies like Amazon, the Washington Post company, and so on, these rule changes will also have big impacts on the fledgling industry growing around mobile medical apps and should serve as a warning to the health IT industry as a whole.

Perhaps the most widely talked about developer that will be impacted is Amazon. As described at Computerworld, Amazon will have to remove its link to its Kindle store from the app. Instead, it will only be allowed to sell e-books via its the Kindle App through Apple’s In-App purchase system, representing a loss of 30% of revenue for Amazon, or online through the Kindle Store. Further, Apple has mandated that the price set for the In-App purchase must be the same as that in other venues like the Kindle Store.

This obviously has clear implications for Epocrates, Lexi, Up-to-Date, MDConsult, and other developers who provide (or will presumably soon provide) medical information at the point of care for a fee. Additionally, Elsevier, Kaplan, and other publishers of medical reference texts will be affected. For those that don’t already utilize in-app purchases and revenue sharing with Apple, it means a hit to their bottom line. Also nestled within Apple’s announcement is another caveat,

Customers purchasing a subscription through the App Store will be given the option of providing the publisher with their name, email address and zip code when they subscribe.

When it comes to medical apps, a big part of their value is access to physicians and other healthcare providers – a high value market. In the sphere of medical apps, this means that Apple will now have access to a very valuable demographic that had previously been hidden among the millions that use the iPhone and iPad. Furthermore, the statement suggests that this information may be denied to developers. As we discussed when we covered the Epocrates IPO, access to this demographic is a key part of the value proposition of app developers – loss of even a fraction of that market could be very detrimental.

What will be more interesting is what happens as electronic health record systems go mobile. Between Epic Systems and Eclipsys alone, 2009 brought in over a billion dollars in revenue. As an increasing fraction of a clinician’s time is spent on mobile platforms, apps like Haiku will begin to gain a lot more value.

While these systems involve far more complicated licensing agreements than say a subscription to a Lexi product, given the amount of money involved here, its tough to imagine that Apple will not eventually seek to claim a piece of the pie. And if that piece is again nearly a third of whatever value it assigns to the mobile platforms of these systems, it could mean a hit to these rather hefty bottom-lines.

By: David Ahn, MD

Health care workers throughout the country daily face the growing pains of the transition from paper charts to electronic medical systems. Not only are there frustrations within each system, every hospital seems to have selected a different EMR.  When I was a medical student at UCSD, I was exposed to 4 separate EMR’s (Epic, PCIS, CPRS, Centricity, etc) during my rotations at various San Diego hospitals.

In this Wild West era of electronic health systems, here are 5 reasons how the health care field could benefit if a company followed Apple’s Paradigm.

1. Apple Solidifies Emerging Markets

The iPod was not the first MP3 player on the market, and it wasn’t the last. The iPhone wasn’t the first smart phone, and it wasn’t the last. The iPad is not the first touch-screen tablet computer, and it won’t be the last. However, each of those 3 devices took niche and naive markets, made them mainstream and appealing to the general consumer, and became the standard in each market.

In this time of the dawning of electronic medical record systems, there are plenty of systems that exist, some more successful than others, but not one that has emerged as the de facto standard. Each system looks and handles vastly different than the next, and many take a good deal of training and education to learn. This is an ideal field for a company to design a novel approach that “just makes sense” – as Apple has done.

2. Apple Specializes in Intuitive and Friendly User Interfaces

The iPod had the click wheel to navigate thousands of songs, and the iPhone incorporated the touch screen keyboard into a new OS designed from the ground-up for touch interaction. These designs are intuitive and user-friendly. One of the primary difficulties with adopting EMR’s is non-tech savvy physicians are hesitant to shift their practice habits. Furthermore, current EMR’s continue to frustrate users with complex and confusing user interfaces. A fresh and intuitive Apple-esque design for managing health records and clinical encounters could appeal to users of all expertise. You don’t have to reinvent the wheel, rather, look at existing interfaces that are aesthetically appealing and go from there.

3. Apple Makes Hardware and Software

Apple designs two operating systems (iOS and Mac OSX), which power the iPhone, iPod, iPad, Macbooks, Mac Pro’s, iMac, and Mac Mini. This impressive arsenal of handheld devices, notebooks, and small and large desktops cover nearly every possible use of hospital: powerful Mac Pro desktop machines for radiologists, iMac’s for nursing stations, Macbook’s-on-wheels for rounding medical teams, and iPod touches for nurses and doctors.

There are two primary advantages to being involved in both hardware and software. The first benefit is increased support for older systems and less opportunity for unforeseen bugs and incompatibility glitches, as there are only a limited number of configurations to support. The other primary advantage is the ability to custom-design hardware and/or software specific for the needs of medical professionals.

For example, the previously mentioned iPod Touch could be equipped with barcode scanners for nurses to help log their medication administrations. It’s often ironic when electronic health record systems don’t take into account the user interfaces they are designed for.

In the evolving world of medicine, where the transition to mobile is happening quickly, the disconnect between software and hardware could not be more apparent.  While it might seem impractical for a vendor to produce the hardware, a closer partnership between vendor and hardware is necessary, yet rarely occurs.

4. Apple Specializes in Uniformity and Simplicity

Apple’s critics accuse the company of sacrificing customizability and certain higher-level functionality in exchange for uniformity and simplicity. In this way, such people use the condescending term “walled garden” to describe Apple products because they excel beautifully in what they do well, but with a degree of limitations.

Whether or not you agree with this, such a “walled garden” approach is surprisingly appropriate in the health care industry. Electronic medical records are, by definition, very tightly controlled and limited in terms of customizability as they must accommodate employees of various technological expertise throughout an entire health care system and protect the privacy of patient data.

5. Maybe Apple itself should jump into health information technology

EMR’s and medical computing is a billion dollar industry. For any corporation, the potential profit must be massive in order for it to fund the research and development required to produce a highly-polished product. Hot off the heels of the success of the iDevices, Apple’s profits are at an all-time high, and experts postulate whether the company can continue its exponential rise.

In response, Apple has fixed its sight on expanding its market from the consumer to the business world, with increased focus on security, stability, and allowing companies to produce their own in-house apps. Health care is a billion dollar industry, and making a significant entry into the EMR field could prove to be immensely profitable, even when compared with Apple’s already staggering success.

Conclusion

The thought of an “Apple designed” EMR and computer setup is incredibly intriguing. Next time you walk into your local Apple store, observe the well-designed workflow of greeters, roaming salespeople with modified credit-card swiping iPod touches, “geniuses” taking care of and fixing pc’s through walk-in and scheduled appointments, and educators leading training sessions. Does it require much imagination to visualize a similar “Apple-designed” medical workflow with corresponding software and technology?

Iltifat Husain contributed to this post

In part one of this series, we reviewed the Blio business model and how Blio has strategically catered to the needs of book publishers as well as readers. In this post, we will review what we know about the technology and functionality of Blio Reader and how it might enhance digital textbooks to move closer towards their potential as a interactive teaching tools.

Excerpt from part 1 of this series:

Blio reader is a fascinating digital publication platform which appears poised to grow rapidly across multiple devices. Since medical textbooks are such a prime target for digital publishing, one can almost guarantee that Blio reader will be how a significant proportion of tomorrow’s medical students and health professionals will be reading.

Layout preservation

Blio’s preferred submission format from publishers is PDF (Adobe’s “portable document format”). As readers are aware, this text document format precisely specifies the exact layout of columns and pages as well as the type and images. This immediately differentiates Blio reader content from Kindle or iPad iBooks where the original pagination is lost. For volumes where layout is important, such as anatomy and pathology atlases, preserving the published layout will allow for a rich, colorful book-like experience. However, the trade off is that reading multi-column text on small screens (such as an iPhone or Android phone) will be require repeatedly panning left and right as the Blio reader will not re-flow the text to accommodate smaller screen widths .

In initial demos, it appears that the Blio reader software displays the text as images, rather than rendering the type using computer fonts. However, clicking on a text region allows the underlying text to be selected, which can then be copied and pasted. The software will allow for bookmarking, highlighting as well as note taking within the text. Interestingly, the user can paste a locally stored image or text (such as a hyperlink) directly into the notes, opening the door to using Blio reader as a powerful research tool.

Enhanced text

Using the software development kit (SDK), publishers can further “enhance” the text. Video files can be be embedded directly into the text, as long as the file size is reasonable. Larger files can be streamed from the internet. Publishers can also add quizzes, either in-line within the text or separately. However, the big caveat with these enhancements is that any additions to the layout will necessitate re-flowing the text and revising the book pagination and index. The additional costs associated with these changes means that, except for large sellers, older volumes will probably be offered un-enhanced for the time being.

Social media integration, presumably sharing on Facebook or Twitter, is also promised. Digital rights management (DRM) settings will be chosen by the publisher, the default will allow for viewing the document on up to five devices. This number, as well as user printing permission, can be set individually for each text by publishers.