[Ed. Note: This post will be part of an ongoing series on the efforts of the Johns Hopkins Internal Medicine program to go mobile. Given that Dr. Misra (iMedicalApps senior editor) is part of this effort, we will be able to share an honest, insider perspective that can help others learn from the Hopkins experience. Not only was this permitted by the Hopkins program leadership, it was embraced, and for that we are grateful. ]

Medical training is currently undergoing a dramatic change. Duty hour reforms, increasing financial and regulatory demands, and a healthcare system at the center of a political battle are among the extraordinary pressures being exerted on the traditional training model.

These pressures require that training programs at all levels – from medical school to the most sub-specialized fellowships – rethink how we do pretty much everything.

Recently, the Johns Hopkins Internal Medicine residency program distributed iPads to its housestaff as part of an effort to do just that. The aims of the program are quite broad – to increase the efficiency of in-hospital care, enhance clinical training of residents, improve patient-physician communication, and more.

The mobile platform is relatively young in terms of its utilization in healthcare and many of the potential applications, benefits, and pitfalls remain to be discovered. As this program continues to grow and evolve, iMedicalApps will continue to share the the insider perspective on the Hopkins experience as part of our shared desire to drive this process forward. In this first installment, we’ll start by addressing the question – why the iPad?

Why the iPad

There are many tablet’s out there that are similar, and in some ways, better than the iPad. In fact, Apple is in a legal dispute with Samsung because they claim the Galaxy tab is a repackaged iPad. And the question certainly came up – why not go with another tablet? Android is arguably a more malleable platform than iOS, many of the tablets are cheaper, and there are many more options.  We’ve had great debates on iMedicalApps in the past about this subject.

Here are a few reasons why we went with the iPad.

The iPad has a head start

When looking to launch a mobile platform, you have to consider your audience. And in any clinical practice, that will include a range of familiarity with consumer technologies, specifically in this case tablets. Among those that were already using tablets, all of them were using iPads. That simple detail confers a number of advantages.

First, with the iPad, we have a group of individuals who are already “embedded” within the our audience. So not only had their use of the device already piqued the interest of others, they also were engaged in this program from the beginning. After launch, these individuals can provide both formal and informal help to colleagues who are less familiar with the device and platform.

Second, in terms of program planning and development, we already had a wealth of experience due to using the iPad in our own institution. These early adopters had already problem-solved a number of issues, found some of the potential efficiencies to be gained, and even identified potential new applications and enhancements.

Third, the launch of the iPad program at the University of Chicago was certainly helpful as their program leadership was quite forthcoming with their own experiences.

The choice Android offers wasn’t all that helpful

Choice is a great thing for the average consumer, but not necessarily for an enterprise. In considering Android as an option, several issues arose that led us to conclude that the iPad was the best choice.  One of the main issues — choosing an Android device involves several extra steps.

First, we would likely order a few different devices, test them out, and then, for practical reasons, probably pick one device. Picking more than one would complicate everything from picking accessories to device management by the IT folks. And if were going to choose a single device in the end, then the value of choice for individual housestaff is ultimately lost anyways.

Another argument could be made that Android potentially offers cost-savings in comparison to the iPad. However, we determined early on that we didn’t need the 3G connectivity nor did we need the 32gb memory. Our application of the device is primarily for in-hospital use where WiFi connectivity is available – this makes the 16gb WiFi iPad the natural choice and very competitive in terms of pricing, roughly $500.00.

What about apps?

Apps are a big part of success of any mobile platform. We’ve talked before about how their absence in the Blackberry and Windows environments are an Achille’s heel for those platforms. However, the difference between iPad and Android apps did not end up being a significant factor in the selection of the iPad as our platform of choice.

Perhaps it was the sense of parity between iPad and Android, given that most major apps are available on both. Additionally, the issue of app compatibility across different Android devices was less of a concern since we would most likely only be dealing with one Android device anyways.

These reasons, among others, were major drivers in our selection of the iPad as the platform of choice in our efforts to go mobile. Please share your thoughts and experiences below as we’d love to hear and learn from other efforts.

The Endogo HD, created by Envisionier Medical Technology, is a portable imaging device (similar to an expensive video camera) that gives clinicians the freedom to share information with patients instantly. With its removable LCD screen, images can be recorded at the point of care.

Once they are captured, the images are instantaneously stored on the device and can even be incorporated into the hospital’s EMR for further storage and collaboration with colleagues. After the patient’s procedure, conversations with the patient and their respective families can happen in a calm manner due to the device’s transportability.

“With high-definition video and still-image capture capabilities in a compact, portable setup, Endogo HD allows a physician to share and review exam findings with the patient or family immediately following the exam, at the patient’s bedside or in a waiting room. A resident can also share captures with the attending physician, which may reduce the need for repeat procedures. With the Endogo HD, OR imaging capabilities can now be available throughout the facility, wherever a procedure is performed. The combination of data acquisition, storage, management and the synchronization of patient folders in an easy-to-use Web application makes it possible to send an image or video over a secured connection to a referring doctor outside the facility.”

As can be seen, the storing and sharing capabilities of the Endogo HD make it a welcome addition to a hospital’s commitment to patient care. eGoWorks is the online data storage and collaborative software that is natively compatible with the Endogo HD. It incorporates the recorded data within an existing hospital’s EMR system– another benefit of the device.

“We are excited about endogo HD because it truly underscores Cook’s commitment to physicians and their patients,” said Jean-Marc Creissel, global leader of Cook’s Urology business unit. “The technology simplifies the process of storing and sharing medical images. The benefits around care, ease of use and potential cost savings are significant because this technology streamlines how physicians interact with each other, their patients and external facilities.”

Source: Cook Medical

Advantech has designed an infotainment terminal that takes the best ideas from tablet computers and medical devices and combines them into a very powerful and useful product. As with many things, this device builds on the accomplishments of its predecessors.

In this case, the success of the iPad has created demand for small form-factor computers. The HIT-W121 then, while it does not have the most awe-inspiring name, is the natural progression of the tablet market. This small lapse in name creativity is completely overshadowed by the plethora of attributes and attachments that are possible on this device.

The tablet has the following features (non-exhaustive list):

• 2MP front-facing webcam for video conferencing and taking pictures
• RFID Reader chip is installed for tagging and tracking
• Wifi access of b/g/n standards for internet and hospital server access
• Intel Atom dual-core process for improved performance
• 3 mm thick slim fanless design makes it easy to handleHigh quality, 11.6″ display with a 16:9 viewing angle
• Easy to clean touch panel, IP54 compliant
• Accessory items that can be added include – Handset/ Smart card reader/ Barcode Scanner/ MSR
• VESA 75 mm standard mounting holes for a myriad of mounting demands
• Various ports/connectors including USB, and coaxial cable allow for even more uses
• Instant function key access via programmable touch hotkeys on front panel
• ITE & medical dual certificates provide full application coverage

Advantech seems to have addressed nearly every conceivable hospital scenario. The HIT-W121 is even certified to endure various extreme and environmental conditions!  With the realization that tablet computing is not a fad and is here to stay, Advantech is trying to capitalize on this market and produce a product that is both relevant and functional in the hospital setting.

The infotainment terminal can be ordered from the company’s website in a variety of colors and finishes.

Source: Digitalsignagetoday

The HTC Flyer promises to be the perfect medical tablet: it supports a fine-tip stylus and is small enough at 7 inches to comfortably carry around in a white coat. The recently reviewed BlackBerry PlayBook impressed with its size (also 7 inches), but ultimately suffered from its lack of third party apps. The HTC Flyer offers the potential of the growing Android marketplace and its many medical apps, so I was thrilled to purchase one for review. One of the two tablets earned a permanent spot in my white coat. Read on to find out which one and why.

Beautiful Android Home Screen

Operating System: Powerful, Multitasking

For the Flyer’s operating system, HTC took Android OS 2.3 (aka Gingerbread), which was not intended for tablets, and customized it to support the larger screen of a tablet. Since other new Android tablets (eg. Samsung Galaxy Tab) run Android 3.1, the Flyer is running a version that is essentially 2 iterations behind. On the upside, though, HTC did an excellent job customizing the OS, and the Flyer functions quite effectively on the larger screen.

Quick-Launch Apps from the Lock Screen By Dragging Its Icon to the Ring

One unique feature of the OS that I appreciated for hospital use is that one can launch one of 4 user-specified apps directly from the launch screen by dragging the selected app on the lock screen to the “unlock ring” at the bottom. This cuts out some extra steps for quick tasks like referencing the dosing for a medication through Epocrates. Also, the operating system is quite beautiful, with flashy animations for the weather and a large flip-style clock. Another benefit of Android is that it allows for various other applications/widgets to be running on the home screens, which provides a welcome level of complexity above the iPad’s simplified iOS homescreen icon launcher.

Android’s implementation of multi-tasking is effective and powerful. Programs will continue to run in the background unless you intentionally kill the process. You can alternate between open apps through a notifications/settings panel that can be flicked down from the top of the screen, which is just slightly more complex than its BlackBerry and Apple competitors.

Left to Right: HTC Flyer, BlackBerry Playbook, Apple iPad 2

Hardware/Specifications: Chubby and Less Professional

After owning the BlackBerry PlayBook and iPad 2 for several months, I can’t help but describe the Flyer’s overall feel as cheaper than its counterparts. What immediately stands out is the two-toned back surface (white and grey) that awkwardly bulges at the bottom. The white color is concerning for showing marks/scuffs, although it does at least fit the white color scheme of most hospitals. Overall, it simply does not have the same professional, sleek look of the PlayBook and iPad.

The Flyer (Right) is Slightly Thicker Than the PlayBook (Left)

Now that Apple’s bombshell has finally been dropped and the world has met the iPad, its finally time to begin separating fact from fiction. Will the iPad boast the same outstanding user interface as the iPhone and iPod Touch? Yes. Will the iPad solve world hunger? Probably not. Will the iPad be a useful tool in medicine, perhaps even transform the way healthcare is delivered or electronic medical records organized? The jury is still out on that one but, admittedly, I am skeptical. Here are a few of the reasons why.

1) For a healthcare provider’s day-to-day use, the iPad doesn’t do anything better than an iPhone or a laptop/desktop.

In considering whether to invest in an iPad, my question is simple – how does this device help me do my job better? The iPhone answered this question by enabling me to put a wealth of medical resources into a small mobile format. In certain health systems, I can even check on new labs or radiology reports from anywhere in the hospital via my iPhone. I’m less convinced the iPad offers similar benefits, at least beyond the iPhone or iPod Touch. Improved graphics or a higher resolution screen don’t really matter much for reading text or looking at numbers. And when it comes to looking at CT, MRI, Echo, or other kinds of imaging where resolution does matter, I’m going to use the 25’’ high-resolution monitors that are available in the hospital. While I agree that this would all be much “cooler” on the iPad (it’d be fun to scroll through a high resolution CT on a larger screen in the cafeteria), the fact is that specialists, such as radiologists, are the ones who really degree of resolution and their screens are already better than the iPad. The iPad certainly does it all, but I have yet to see how it’s a significant improvement over the iPhone in this type of day to day use.

2) Big hurdles face development of peripherals for more advanced healthcare functions

The mobility of the iPad certainly offers some opportunities for the more procedural tasks of hospital care. For example, there would certainly be value to a peripheral that measured blood pressure, heart rate, and other vital signs and then uploaded them to the inpatient electronic medical record. Or for a peripheral adapter that allowed connection to fiber optic cameras or ultrasounds, allowing me to view or record the images from my iPad to the electronic medical record. These are all intriguing possibilities. However, the big obstacle here are the entrenched powers currently in control. Medical devices are a big money game, and companies like Stryker, who make a number of such devices, including fiberoptic cameras, will likely not want to cede the user interface of their platforms to Apple, let alone standardize connectivity options with other device manufacturers.

3) Safety

I mean this in two ways. First, patient safety. Infection control is a paramount concern in hospitals today. You don’t want to know the number of protective layers I had to wear at the height of H1N1 (or the cost of this extra protection). If the iPad is going to do more than be an EMR portal for writing patients notes and reading their records, then it has to be strong enough to withstand disinfection procedures. Second, property safety. Desktops are hard to steal, laptops are easier, and an iPad would be a breeze. If patient information is stored or accessible on the iPad, the hospital’s lawyers will demand a pretty high level of security.

With that said, Apple has had discussions with with Epic, a major electronic medical record developer, on iPhone OS integration. I’m sure the parties involved in these discussions have thought about the potential the iPad has for EMR use. And I do think there is potential in healthcare, particularly in niches where tablets are already used (such as emergency medical services). There is a case to be made that this is the first tablet that’s easy and fun to use and it will succeed where prior tablets have failed. And while we at iMedicalApps have some differing opinions about the possibilities of the iPad, we’re excited to see what happens once developers start making medical apps for the iPad.

And by the way, while the iPad is certainly the coolest kid on the block, at least one competitor (Freescale) may offer customized tablets running open-source operating systems like Android for as little as $200.