For Apple fans, MacPractice has been a popular practice management and clinical electronic medical record software for Apple computers.  They often partner with Apple for workshops geared towards medical professionals — as one of our physician editors witnessed while at his local Apple Store.

The iMedicalApps team has previously reported on the MacPractice software and we lamented that there wasn’t a native iPad solution for the software.

At that time, there was a workaround that allowed clinicians to login from an iPad to their Apple computer and view the MacPractice software remotely. Obviously, this isn’t an ideal situation.

That has changed with the upcoming release of Clipboard, a native iPad application that works seamlessly with the desktop software. MacPractice Clipboard streamlines the registration process, saves paper and staff time, and also reduces risk of data-entry errors due to illegible handwriting.

MacPractice’s CEO Mark Hollis explains why the app was created.

“In response to many requests from doctors’ offices to use the iPad for patient registration, we are announcing new Clipboard Apps for the iPad that work in conjunction with MacPractice MD, DDS, DC and 20/20 v. 4.1 desktop practice management and clinical software.”

While doctor’s have frequently requested a native MacPractice app, the task of creating the app has been an interesting challenge for the company. Traditionally, desktop software is designed to take full advantage of the size of a typical computer monitor. With the relative small screen on the iPad, the challenge was designing an app that still provided a quality experience to the user, while not sacrificing any of the functionality of the software.

“Another obstacle to implementing iPad apps as quickly as doctors can use them is simply all of the various security and privacy protocols that MacPractice needs to follow. Patient and medical information is obviously very sensitive, and there are a whole host of guidelines and standards, required by law in many cases, that MacPractice needs to follow to make sure its apps are certified and can be used by medical professionals.”

“Hollis says that most of the issue there is that MacPractice has to build in those standards by itself — Apple doesn’t have an official part of the iOS API, for example, designed to deal with medical certification. “It would be helpful,” says Hollis, if Apple did provide some official code to help deal with those issues. But for now, MacPractice has to make sure its own apps are valid, and that takes time and effort, obviously.”

Currently, the Clipboard app is in beta version. It will be released for MacPractice users soon. We will keep you updated on the status of this app and future developments from MacPractice.

Source: TUAW and MacPractice

Manhatten Research, a pharmaceutical and healthcare market research and services company, recently released a detailed report stating that 56 million people in the US  have accessed their personal medical information through an  electronic health record (EHR) system maintained by their physician.

An additional 41 million people are interested in doing so.

The information was generated from Manhatten Research’s Cybercitizen Health 2011 report. This report is an annual market research study that tries to understand how U.S. consumers use the Internet, digital media, mobile devices and other technologies for health. The study is conducted every Q3.

The current study surveyed more than 8,600 U.S. adults online and on the phone.

“Growth in access of electronic health records by patients has been remarkable in the last year,” said Meredith Ressi, Manhattan Research President. “There’s been strong pent up demand from consumers over the years, but only now has the supply side caught up as a result of the government mandate. This is the beginning of a real shift in care delivery and patient engagement.”

Despite these promising results, there are still numerous Americans who do not currently access their health record online.

“Despite strong growth in EHR adoption and awareness, 140 million consumers report that they have not used and are not interested in accessing medical records from an EHR system maintained by their physician. Compared to consumers who do access their medical data on an EHR, the audience not interested in doing so is older, less educated, and significantly less likely to use the Internet or own sophisticated electronic devices such as smartphones and tablets.”

According to the website, some additional topics covered in the Cybercitizen Health 2011 report include:

• How is the health web evolving and how can marketers leverage emerging online health audiences?
• How does search and website behavior differ across the disease and treatment pathway?
• What role is digital health playing at the point of care for doctors?
• Do consumers want additional support and services from pharmacists and nurses?
• Is social media adoption for health maturing?
• To what degree are mobile devices transforming health seeking behavior?
• How advanced are consumers in terms of recording and sharing their health measurements?
• Which pain points related to digital on-going care represent the strongest opportunity for health stakeholders?

A related study from the company discovered that EHR adoption rates are increasing among physicians, and will likely accelerate as iPads and Android tablets facilitate EHR access for busy doctors on the move throughout the workday.

The Taking the Pulse Report studies how U.S. physicians use the Internet, digital media, mobile devices and other technologies for work-related purposes as well as patient interaction. The study is conducted annually in Q1, surveying more than 2,000 physicians.

Source: Press Release

SAP recently unveiled a yet to be named EMR app that promises to give a unique physician-centric face lift to the traditional EMR interface.  The app, which has been in development the past three months, strives to give a full 360-degree, unified view of a patient’s medical history, medications, X-rays, and vital signs.

The above picture is the dashboard of the EMR app. Through the dashboard, physicians have access to patient records, a list of medicines taken, pictures of X-rays, medical allergies and even a real-time view of vital signs.

“There’s a lot of talk about how a smooth, slick user interface is an important competitive advantage. In healthcare, however, an easy-to-use, powerful UI is mission-critical. While doctors are often very gadget-y, they are also impatient and too busy to deal with a lot of training. An intuitive UI that easily delivers the right information can actually “save lives,” says Korten, a former doctor himself.”

As can be seen, the developers at SAP have taken great care in designing the layout of the app.  There is even a separate screen that displays a patient’s vitals.

“Doctors can see which indicators are out of normal range (in red), and zoom in and out of the data. The data is sent real-time via Wi-Fi. Indeed, most of the data displayed by 1.0 version of the EMR app is streamed directly from the server, with only small amounts encrypted and cached on the iPad itself, according to Berndt.”

Jan Korten, a solutions manager at SAP, and Thilo Berndt, the product development manager for SAP’s mobile healthcare apps, unveiled the EMR app during an August 31 Webinar. To watch the 1 hour presentation, click here.

For further reading and diagrams of the software architecture from the source, refer to ZDNet.

ClearPractice, makers of the popular iPad electronic health record Nimble — that we reviewed — have now launched Eden Practice. And for all those physicians who are Apple lovers, they are going after you. Eden Practice is being marketed as a comprehensive medical office solution for the Apple Mac, iPad, and iPhone — all connected via the cloud.

The desktop version was made for Safari, and runs four times faster on Safari than accessing the desktop EMR on a Windows computer with Internet Explorer.

Eden Practice will launch in September, and it will have native apps made specifically for the iPhone and iPad


(Nimble is the EMR app for the iPad that is part of the Eden Practice suite that we reviewed). Unfortunately, their iPhone app, aptly called “Fetch”, will be limited to fetching.

As with other iPad EMRs, such as Dr. Chrono, there still isn’t a good EMR solution for inputting patient data and encounters into an iPhone. I understand the 3.5 inch display isn’t conducive to storing a great deal of text, but I’m surprised that EMR developers continue to neglect that physicians would want to dictate and create patient notes on their iPhone.

Nonetheless, the Eden suite looks very exciting. We have a beta copy of Eden and we’ll be publishing a review soon.

For more information on the electronic health record, check out the ClearPractice Eden website.

We featured DrChrono, the first native iPad electronic health record, almost a year ago on iMedicalApps. Since then, they have made huge changes, not only with their software, but their overall business plan.  When they initially launched on the iPad, they didn’t offer a free version of their EHR, had a quirky user interface, and were betting big that physicians would embrace the iPad.

So far, they bet right. Study after study is showing how physicians are enamored with the iPad, and the number of physicians signing up for DrChrono reflects this theme.  DrChrono told iMedicalApps, they have experienced 30% growth per month, and have had 600 health care provider signups in the last 3 days alone.  In our opinion, these significant numbers can be attributed to four things: The iPad’s popularity among physicians, enhanced user interface of the DrChrono EHR, the quest to attain $44,000 in stimulus incentives, and the recent offering of a free version of the DrChrono electronic health record.

Over the last several months, the DrChrono team has been furiously working on a large upgrade, version 8.0, for the iPad.  We were the first to get our hands on the 8.0 beta upgrade, which they plan on releasing in approximately 2 weeks.

In this review, we’ll go over the main features of the DrChrono iPad electronic health record, and touch on the iPhone and Android versions of the EHR.

Overview:

Dr. Chrono has significantly improved their user interface(UI) over the past year, and the 8.0 upgrade brings another refresh to their UI.  They have done a complete overhaul of their desktop and mobile apps (iPad, iPhone and Android).  Comparing the screen shots from our feature of DrChrono last year with the following screen shots of the upcoming update shows how far they have come.

Within the iPad EHR itself, you are able to do full H&Ps, SOAP notes, e-prescribe, perform patient scheduling, use real time medical speech to text, and more.  The DrChrono EHR is aimed at ambulatory practices, with single to multiple practitioners.  You can manage an unlimited number of patients in the paid version of the EHR offering, and there are four tiers of pricing for the iPad electronic health record: Free, $99 per month, $149 per month, and $199 per month.  This pricing structure is based per physician.

Key Features

Medical Speech to Text:

This is a feature DrChrono began offering just over a month ago — and they are the only native iPad EMR with this feature.  The power of this feature cannot be overstated.  Earlier this month, we wrote extensively on how having native speech to text on mobile platforms allows physicians to be truly mobile.  Inputting text on mobile devices can be cumbersome, and speech to text circumvents this issue.

In the new update, DrChrono will enable speech to text for every portion of the History and Physical, as well as the SOAP note, virtually removing the need to input text by hand.  For this feature, DrChrono is partnering with M*Modal, a company that works with hospital systems to provide medical speech to text.

Below is an example a partial chief complaint I dictated using the native real time Speech to Text on DrChrono.

As you can see, not very accurate the first time around.  The DrChrono team informed us speech to text is currently being upgraded with M*Modal, and will be improving in accuracy with future iterations.

However, when I slowed down a bit, and enunciated my words, I found the medical speech to text worked significantly better:

Faxing

In the 8.0 version of DrChrono, physicians will be able to receive patient records that are faxed to them directly on their iPad.  Those of us intimately aware of how the medical world communicates understand how crucial this is.  Often times, hospitals will fax a patient’s discharge papers to their primary care physician, in anticipation of a follow up visit.  Having the ability for these records to be automatically uploaded to the patient’s mobile chart is huge — saving a physician’s supporting staff from having to individually scan these documents.

Multimedia

Of course, everyone is well aware of the iPad 2′s HD videocamera and image capturing ability.  The DrChrono update will be taking advantage of the new iPad’s features, and allow physicians to add multimedia, in the form of videos and pictures, to their patient records!  If you look at the above pictures, you’ll see a picture button — enabling physicians to add multimedia via this button.  Again, not just pictures, but full video!

Overall, this is a feature that could be a game changer, and make their electronic health record come to life.  Imagine being able to track a patient’s suspicious skin lesion over time, or being able to consult that lesion with another physician, using DrChrono’s sharing capability.

Sharing capability

DrChrono enables you to share your patient’s chart with physicians who don’t have DrChrono.  You are able to send a document to the physician of interest, and they are able to securely login to DrChrono’s online EHR, and view your patient’s chart — huge for curbsides or formal consults.

Integration with Android and iPhone

DrChrono is available for the iPhone and Android.  The apps allows providers to track patient scheduling, and to pull rudimentary patient information.  The DrChrono team has informed us they are currently working on a Android tablet version of their EHR — for Google Honeycomb operating system.

What I liked:

*We are huge fans of the real time, medical speech to text feature — the ability to use this for every portion of the EHR provides huge utility

*Overall, a simple and easy to use User Interface.  Content is easy to access.

*Multimedia features cannot be overstated, and if properly implemented, adding pictures and videos in conjunction with sharing documents could be a game changer for some physicians.

*Automatic conversion of patient documents from fax to the iPad reduces time spent by support staff, and keeps patient’s chart up to date.

*Ability to customize your own H&P templates — very important for specialists.

What can be improved:

*The menu system for the review of systems and physical exam felt cumbersome at times.  In my experience, Epic’s hospital based EMR does a great job of simplifying these types of menus, and makes them extremely quick to go through (ROS image  of DrChrono shown below).

*iPhone and Android versions of app could be made more comprehensive.  Currently you are able to view patient schedules, and basic information on patients, but with the new medical voice to text feature on the iPad, one would naturally think this feature could be put on the iPhone and Android — creating an extremely mobile, keyboard free, mobile EMR.

*Lack of stylus support.  It’s no secret we are fans of using a stylus on the iPad.  In certain settings, having the ability to write freehand is useful — in the case of interacting with a patient.  Typing on a computer or trying to tap on the iPad’s screen while interacting with a patient can be off-putting.  Having the ability to take rough notes with a stylus that can be transcribed later could improve the overall workflow.  The DrChrono team has informed us they are working on this exact type of utility.

Pricing:

DrChrono now offers a free version of their electronic medical record.  The DrChrono team was adamant in making sure we understood they don’t sell ads or share patient or provider data for the free version of their software.  DrChrono generates revenue by offering upgrades in the form of electronic prescribing and electronic billing solutions.

Conclusion:

The DrChrono electronic health record has come a long way since initial launch a year ago.  They have made significant improvements to their user interface, both on their mobile platforms, and their backend online website.  The new implementation of voice to text is absolutely essential — enabling you to avoid typing on the iPad or having a blue tooth keyboard.

Using the photo and video functionality of the iPad to bolster the patient chart, along with physician sharing, could be one of the main reasons why providers would be inclined to try DrChrono.  Until recently, DrChrono did not have forms for filling out full H&Ps, relying extensively on SOAP notes and custom designed templates.  The full integration of H&P templates is an example of an essential iteration that could make providers who passed on DrChrono initially come back for a second look.

DrChrono continues to improve with each successive version, and their early bet on the iPad has paid huge dividends, allowing the electronic health record company to have many “firsts” in the mobile EHR space — and more importantly, deliver quality software in innovative form factors.

Link to DrChrono Website

Practice Fusion is a free, web-based electronic health record that has seen a rapid rate of adoption over the last two years and, as we reported recently, is currently the largest commercial EHR installation after Kaiser and the Veterans Affairs.

But like all “overnight successes”, the rise of Practice Fusion is not accidental and not without laborious engineering. In fact, important design decisions at its inception have been instrumental in its growth, allowing for rapid iteration of features without incurring heavy development and deployment costs. Matthew Douglass, currently the VP of Product Development, has been through almost the entire history of the company. He was the second person to join the company and continues to lead the engineering process.

In this interview we learn some of the fascinating story of Practice Fusion’s rise, its plans to expand its API (application programming interface) and launch an app store.

We envision that doctors could prescribe an app much like they prescribe a medicine now. – Matthew Douglass

How did you get involved in Practice Fusion?

At the time I was approached by [now CEO] Ryan Howard in 2007, I was working in energy and finance. But, even then, I wanted to do something besides, as I said, “turning millionaires into billionaires”. Ryan had started in 2005 and had just bought a one site EHR that was developed by a family practitioner. I was charged with making it multi-tenant and web-based. Multi-tenant means having all the data stored in a single database, instead of separate for each user. Back then, we worked in coffee shops, communicating electronically. I worked hard for six weeks, including one non-stop 72 hour stretch just before we launched, which has become urban legend around here. Three months later, we went on to the web. That was the beginning of 2008.

How did Practice Fusion initially grow?

We initially charged $50 per month per doctor. Then we decreased it to just $50 for support and training. By the time we went to the web, we were free. This led to rapid growth. We started rapidly signing up physicians. Our very first web user, by chance, was also in San Francisco. With the passage of HITECH act in Feb 2009 [which provided financial incentives for physicians adopting EHRs], we started to get interest from investors. The first were a large Bay Area angel group called the Band of Angels. Later Mark Benioff [CEO of Salesforce] invested. We recently completed a series A round from a venture capital firm [7.2m, 11/24/09, Morgenthaler Ventures]. We don’t do direct sales, meaning door-to-door. Most of our customers find us online. The majority of our users are in California, New York, Florida and Texas.

How did you settle on free as the price?

We found that primary care practices were quite price sensitive, as their real income had stagnated for more than 20 years. We decreased our price until we got to free. We are committed to keeping it free. We feel there are enough other participants in the health care IT ecosystem who can subsidize the EHR, such as device makers, labs, billers, pharmacies, etc. Doctors should not have to pay.

How about advertising revenue?

Ads are a large part of our revenue.

Talk about your implementation

The original EHR was written by a physician, Robert Rowley, who is now the Chief Medical Officer. Our multi-tenant database, where all patients around the country are stored in a single database, has allowed us to scale smoothly by allowing us to release new versions of the software while keeping everybody on the same version. Our architecture also allowed us to easily add a patient portal [Patient Fusion]. Initially we were adding 5-6/day users a week, now we are adding as much as 350 users or about 40-50 practices per day. We have surpassed 60,000 registered users. Just two months ago we were adding 250/users a day, so the rate of growth is accelerating quickly, and we feel that with HITECH incentives in 2011, this may push it higher. We are planning for even greater acceleration.

How many engineers do you have at Practice Fusion ?

We have a total of 53 employees, 17 are engineers and we are hiring 6 more, thanks to the stimulus.

What are your continuing challenges?

A lot of what we do is integration, tying together other systems and suppliers. This does not always show up as an explicit feature. For example, seeing a Labcorp result requires getting a file, parsing it, displaying and storing it. And every single lab is different. e-Prescription integration, such as with Surescripts, and determining formulary eligibility can be very complicated behind the scenes. But because our system is multi-tenant and web-based, we just have to do it one time and all our customers get the update simultaneously.

Tell us about the Practice Fusion Developer Challenge

Last spring, Matthew Holt and Indu [Subaiya, of the Health 2.0 Conference] approached us about posting a Developer Challenge at the Health 2.0 meeting in July. We decided within a week, and launched within 3 weeks. [The Health 2.0 Developer Challenge is supported by HHS but run by Health 2.0]

For our Developer Challenge, we discussed it and decided to go with a limited API emphasizing ways to get real time data into Practice Fusion. We felt that getting the physician real-time measurements [e.g. blood pressure, etc] could be really valuable – instead of requiring the physician or practice to enter all the clinical information. We were very surprised when 35 developers submitted projects, more than any other challenge.

Of the 35 submissions, 25 had to do with medical devices and data transfer. This tells us that there is a market for this connectivity. The winner [Team Critical Systems] was a great example of hacking – a simple bathroom scale was hacked to read the LCD display and the result is transferred directly into Practice Fusion.

Any surprises among the submissions ?

I was surprised that 10 of the submissions did not even submit their own data, but rather co-opted the API to present unstructured data, for example turning a patient intake form into a rudimentary data entry API, e.g. patient submitted “mood” data. This [type of observation] will drive our API strategy. Other types of structured data we had not anticipated such as reporting diagnoses or clinical workflow.

How did you decide on your Challenge ?

There are a lot of medical device manufacturers which already transfer measurements to their own servers. However, this data is isolated. It does not take too much work for them to use an API to transfer this data to patients’ records and allow clinical decisions to be made from this information. This is what could be revolutionary. We already have a dozen companies lined up to work on our API

What future directions are you anticipating for your API ?

We are planning on extending the API enough to allow a limited interface. The first will be scheduling, problem list and medication manager. As with everything else, we will listen to the market. Extending the API has to be carefully done not to disturb published APIs. Developing an API does take away resources from other efforts, but we feel it is important.

What are your mobile plans ?

We will shortly have a Practice Fusion interface which will work on smartphones. It will have limited functionality, giving you the ability to view patients and the schedule. The extension of the API will probably have the same capabilities. We will be bringing our mobile interface, including iOS, Android, and RIM, hopefully in first half of 2011. This will work across all mobile devices with web enabled browsers. We are planning on native apps, depending on marketplace.

The Practice Fusion app store

The biggest enhancement will be a Practice Fusion app store. This is not yet announced although I have a rough date. The idea is that the doctor will have access to all the application within the Practice Fuson network . The app store concept is a way to unify the apps, downloading may occur elsewhere. We put the application as something the doctor can prescribe. The instructions to download the application may be sent to the patient via email.

This is a way for making applications work for you. The buyer could be the doctor, patient, payor, etc. It will be a place where developers can showcase their apps. The apps will be attached to a user’s account but could also be used on other devices, such as a communicating smartphone app.

We envision that doctors could prescribe an app much like they prescribe a medicine now. Right now all a doctor can do is write an order [CPOE] or hand out a pamphlet. But, there are a lot of things in between appointments where a patient can report back to the doctor – maybe compliance with a medication or nutrition plan. A weight monitoring app for a patient trying to lose weight can directly enter weights into their record. Simple alerts can signal patient compliance, or can even provide feedback to the patient herself.

[As mentioned in yesterday's review of Nimble, ClearPractice has been in business long before last month's release of Nimble, its iPad EMR. In this interview, we learn from Joel Andersen & Dr. Doerr how the founding principles of ClearPractice still drive its current evolution.]

Dr. Doer, please tell us a little about your background, and the start of ClearPractice

I am a practicing internist and in 1996, I had an epiphany while in an exam room, that medicine was an art not a science. I thought there should be some consumer reports for doctors to help them make decision. So, I, wrote a drug reference for myself. This grew to 140 pages by 1998. I recruited a pharmacist to help edit it and started to share it with partners.

When I told this to my brother John, the investor, he told me to write a business plan. I co-founded the company in 1999. We hired more pharmacists and the document eventually became 5000 pages. We indexed it by diagnosis codes in order to help find information faster. Using this guide, in1999 United Healthcare told our group that we were one of top two in the country in terms of cost-effectiveness. This led to the development of our data driven company servicing Medicare Advantage plans.

What were the goals of ClearPractice ?

[TD]
We feel like we’ve been ahead of our time for some years. We feel that EHRs should render decision support and better outcomes. So far, reimbursement has been so focussed on meeting bullet points that the resulting care has not been as focussed on outcomes. The current ARRA incentive may be turning the direction.

We are interested in “point of thought decision support”. I’ll give you an anecdote. Cox-2 inhibitors were studied in a 2000 study named “CLASS” in which the Cox-2 inhibitor, Celebrex, was compared to NSAIDS over a six month period. Eight thousand patients were randomized and it was published in JAMA. However, the cohort actually continued to be followed and by 12 months the benefits had disappeared. Still pharma decided to target subset of patients with GI sensitivities and used direct to consumer advertising and by 2007, Cox-2 inhibitors were 60% of all NSAID prescriptions.

The information [showing no benefit] was actually available on the FDA website. We had it in our prescribing guide. We feel if all docs had ready access to this type of information, it would help them make their own best decisions.

Why do you think adoption of EHRs is still slow smong small physician groups ?

[TD]
There are a lot of reasons for poor adoption. One reality is that EHR systems slow down busy doctors. HITECH only solves the economic problems. But, what value does it bring the doctor ?
[JA]
We know 70-80% of docs practice in groups of 10 or less, and most don’t use an EHR. Complex pricing is an issue, we have straightforward pricing. We have to look at implementation methodology, doctors can’t shut down their practice and do training. The principles for the company include: easy to evaluate, easy to implement, and easy to use. We can’t expect docs to need a consultant to evaluate an EHR. Most EHRs will not even let you see the product. I vowed when I came back to the EMR industry, that docs would know exactly what they’re getting into. Our implementation method is called “RAD” – rapid adoption & deployment. Doctors and staff can perform self training, and can continue to train after installation.

Dr. Doerr, your brother was recently quoted as saying “‘With the right software that is cloud-based, the iPad is going to be transformational in healthcare.” What makes you believe that the iPad could sustain an EHR ?

I think the iPad could be transformational in healthcare due to its usability. For example, I’m in a 70 man group which evaluated EHRs and chose NexGen. I’m leaving the group so I can use Nimble. For me to use NexGen, I have to use Citrix to access it. In fact at home, I have a computer just to dedicated to Citrix. With Nimble, I can log into it in 10 seconds and “talk” my note into it. The advantage of the iPad is portability, usability and navigation. We were forced to rethink the EHR interface.

What was the nature of your collaboration with Apple ?

[JA]
We were at a board meeting of a parent company in April when John Doerr said I want ClearPractice to dedicate 3-4 developers to making an iPad app. After that, we went out to Cupertino 3-4 times, that is Tom, Subba [Subbarao Siddabattula, Founder and CTO] and myself.
[TD]
I initially thought the iPad was going to be a toy but John & Suba saw the vision right away. That’s how John is. For example, in 1994 John was quoted saying unconnected computers would be worthless. This was in 1994.

We did the demo for 6-8 Apple execs, but initially they did not seem to be very excited – until they heard the app was actually written in [the iPad's native programming language] Objective C. Actually, it is now one of the most robust apps for iOS, per Apple. After that demo, they got excited, and they assisted us in UI development. They will do this for other developers also. We had several meetings with the head UI evangelist at Apple. That’s where we made unbelievable breakthroughs in UI simplification. He helped us get it down to 3 buttons, he sliced and diced it not knowing anything about EHRs. What you are seeing now is actually the 4th version. Currently Tyler Stone runs healthcare vertical in Apple, he really knows the EHR industry.

Will we see Nimble in an iPad ad someday ?

[JA] I hope to see it !

Could the App store make HIT software more modular ?

[JA]
There are limitations to the App store for enterprise software. It is not always predictable in terms of timing, of when the app will be released. And, the health IT is incredibly proprietary. We were even reluctant to put the software as a free trial until we realized that doctors can try it out themselves. However, we adopted Apple’s methadology of releasing the software at announcement so docs can see it for themselves right away.

Talk about Lumeris a bit

[TD]
Lumeris is actually one of three companies that were initially founded by physicians in five states. The others are ClearPractice and Essence, a Medicare Advantage part D insurance company. Lumeris grew out of our learning from Medicare Advantage.

We believe that payors should be collaborative with physicians, and that they have reciprocal responsibilities. This is detailed in a whitepaper on our website. Lumeris incorporates a rules engine to guide prescriptions and other orders. It is a shared risk contract with the physician group and receive 80% of share-back from the savings. So far, in Medicare Advantage, this is working nicely. Now, other payors are becoming interested in this type of relationship. One of the Blues is a customer.

In November, we are piloting real time communication between payor through Lumeris and ClearPractice. We feel
that the EHR has information that the payor does not have, and we want to accelerate the free flow of information.
Payers will have to be more transparent and there will be more pricing visibility. ClearPractice is well positioned due to its relationships with payers and Lumeris will be in the forefront of this change.

Why do you think clinical decision support has not yet reached its potential

[TD]
Clinical decision support is hard to do well. When suggesting alternative treatments, the burden is on the author to provide every bit of pertinent information. The doctor needs to be able to see all possibilities one click away, a lot of companies have not done that. There is this myth of the all-knowing doctor, that’s why we need a team approach.

What are your plans for the browser based application ?

[JA]
We believe 90% of users will use Nimble alone

How has the initial response been to Nimble ?

[JA]
There was a lot of initial excitement from early iPad adopters and Apple enthusiasts. But after that waned, the excitement stayed with others. We built it in 5 months, but other releases are coming, with exciting new features
[TD]
One of the nice things about the iPad community is that users tend to be more sophisticated, it’s a nice place to be. We set out to have the whole app on the iPad, not just the mobile version. The true value of EHR is when clinical decision support can be used at point of thought.

[Editors note: Be sure to check tomorrow for our interview with ClearPractice co-founder Dr. Tom Doerr and president Joel Anderson]

Lately, it seems almost anything medical regarding Apple’s iPad generates immediate interest. Nimble, the new iPad electronic health record (EHR) by Clear Practice, has been no exception. In the few short weeks since its release, this application has rapidly generated interest across medical blogs, mainstream press and, most importantly, from doctors themselves.

Most prominently, the coverage included a lengthy piece last month in the New York Times, which apparently resulted in a dramatic spike of physician interest. Other coverage has included prominent medical bloggers (here, and here) and other press coverage, listed here.

One reason why the heightened interest in Nimble may be justified is that the application, although written natively for the iPad operating system, is actually the front end for a mature and feature complete web-based EHR named ClearPractice that has been in use for more than a decade. As such, it already includes features such as practice management, e-prescribing, patient portal, and coding and billing that doctors expect from an EHR. In addition, ClearPractice and thus Nimble includes a rich body of patient education material and physician oriented evidence based information on diseases. It is the ready availability of these comprehensive features in a truly mobile device that might justify the description of the iPad, in co-founder Dr. Doerr’s words, as potentially “transformational in healthcare”.

User Interface

The first notable innovation of Nimble precedes its first use, namely it allows a physician to download and explore a fully-functional trial EHR from the App store. This might seems trivial in the world of non-medical software, but the current reality is that a doctor who wants to check out an EHR will generally have to schedule a visit or at least a web demo with a sales representative in order to have the features explained to them. Having seen the lost look on many physicians’ faces as they are taken through such vendor demonstrations, this simplicity alone may catalyze Nimble’s future success.

Once the user is logged in, the home page of Nimble is very clearly laid out as a grid of large tiles. As can be seen in the video demo below, the user can rearrange these tiles to suit their work flow. Where appropriate, the tiles are badged with the number of items requiring attention, such as “44″ laboratories to review or “12″ messages. A persistent button in the top left of the screen produces a pop-over menu with navigation quick links.

In the design of the application, the developers have been disciplined in utilizing the native user interface (UI) elements of the iPad. As will be discussed in the interview, the folks at Apple actually helped in refining the user interface and the attention to detail – this clearly shows in the released product. This also means that navigating inside an otherwise sprawling application is actually very intuitive and quickly familiar to any iPad user.

Documentation

Once inside a patient’s chart, a separate pop-over menu offers context-dependent links to relevant portions of the patient’s chart, depending on the current open document. As with other EHRs, entry of the patient’s history or exam is driven by templates. A large number of templates are available and physicians can, of course, customize them to their needs. Drilling down to select items within templates is done via cascading columns, which are fairly easy to navigate using the touch interface. The narrative text is displayed below as it is assembled from the various selections. Voice memos can also be directly added in many fields.

Images can also be used to enhance the physical exam or history, based on medical illustrations to which the physician can add arrows and text. While this is a very promising feature, it is currently implemented a bit awkwardly. The stock images are too detailed to allow simple annotation and entering text is more difficult than necessary.

Other minor issues include the presence of two context sensitive menus which can be a bit confusing. There is one on the top right for navigation and second one on the upper left inside the chart. Since there is a persistent quick navigation link on the top left, is the top right button necessary? Also, requiring the user to log-in every time is disruptive, especially without iOS 4.2 multitasking. Perhaps a standard 4 digit screen lock for short durations away, say five minutes, would be adequate security.

For physicians and other medical professionals who are fans of Apple, MacPractice has been the go to electronic medical record for many.  Because of this, it has been surprising MacPractice has not offered a native iPad solution to their EMR.  To be clear, MacPractice has offered a jerry rigged iPad solution – via a VNC interface.

Having to use a VNC interface to access your electronic medical record is not ideal – essentially, you have to use a VNC app on your iPad that allows you to view what MacPractice looks like on your desktop computer – enabling you to control your desktop. You know the situation is not ideal when the MacPractice website has to have a “Tips and Tricks” section for those trying to use the MacPractice iPad VNC Interface.

As an anecdotal example, at a MacPractice demo I saw at my local Apple Store earlier in the year, many of the medical professionals in attendance who use MacPractice were voicing their issues with a VNC interface to the MacPractice representatives on hand – it appeared to be their number one concern.  Needless to say, MacPractice has finally brought an iPad interface that does not require linking to your desktop computer – and I’m sure health care professionals with iPads who use the EMR are breathing a collective sign of relief.

In addition to the iPad interface, MacPractice has also included ePrescribing within the iPad as well – working in a similar fashion to how ePrescribing performs on the native desktop EMR interface.

The following are just a few of the benefits MacPractice is touting with their iPad EMR interface:

Among the capabilities that come along with the new MacPractice iPad Interface with ePrescribe: doctors can create new patient records in MacPractice from the iPad and post procedures and diagnosis from outside the office or in an exam room, daily practice activity reports can be reviewed easily from outside the office, reminders and notes may be sent between the office staff and the doctor, and email may be sent to patients and referring providers. MacPractice users can also see their office schedule as well as patient photos and demographic information. In addition, doctors and assistants may now review and record patient vital statistics and chronic diagnoses, and review prescription history and allergies when seeing a patient, all on an iPad.

Further Details: MacPractice Press Release

With all the talk of the adoption towards electronic medical records (EMR) and questions about software choices – people tend to forget the hardware needed to run such records.  Dell is trying their best to create as many partnerships as possible with EMR vendors and physicians hoping to adopt EMRs. Apple has also tried to foster these relationships, but compared to Dell its efforts have been significantly weaker.

Just recently Dell teamed up with Practice Fusion, an EMR vendor for small practices famous for marketing themselves as the fastest growing free electronic health record company – and are offering deep discounts through this partnership.

The partnership with Practice Fusion is by no means the first relationship with an EMR vendor for Dell.  They have over 20 partnerships with electronic health vendors, ranging from Allscripts to Athena Health.  Dell even has a dedicated number and email address for those who are interested in buying hardware for electronic health records: 1-866-Dell-EMR and Dell_EMR@Dell.com.

So exactly how deep are these discounts?

For the Practice Fusion partnership, Dell has listed the discounts on their website, and our assumption is these discounts are similar to what providers will find with other electronic health record systems for small practice. Even if the electronic health record vendor you are interested in does not have an existing relationship with Dell, you can most likely get this discount by calling the above number or using the above e-mail contact.

Practice Fusion actually has a page where they give you a list of “suggested hardware” – the suggestions are based on how large your practice is.

Most of the above configurations make sense, but the Limix digital cameras are probably not the best way to use your cash.  The following are the discounts being offered by dell:

As you can see, they are naming their products as “EMR laptop” – not with their actual name.  The “EMR Laptop” is actually a Vostro v13 lapop, while the EMR tablet is actually a Latitude XT.  The discount on the laptop is only $164, but the “EMR tablet” has a whopping $1,408.00 discount.  So, to be fair, Dell has definitely stretched this discount out.  The base Latitude XT tablet costs $2,423, and while the “EMR tablet” has higher specs (processor, hard drive, etc) – the base model with a few extra features would provide sufficient computing.

Nevertheless, with the type of specs being offered in the special “EMR tablet”, you are still getting a pretty significant discount.  Oh, and no where do you see specs for clinic specific use, such as special medical grade casing or related items.

Physicians are set to receive $18,000 of the $44,000 in ARRA reimbursements for electronic medical record adoption in the first year of use – but only if their medical record software meets “meaningful use” – metrics that are currently still being finalized.  If you dish out over $2,000 for a tablet, you’ve already eaten over 10% of the reimbursement fund for the first year – and you still have to pay for the actual software and other necessary hardware tools.

It’s these steep prices that make the iPad actually compelling when it comes to using tablets in practice.  Obviously, you’re missing certain levels of functionality that an iPad does not have and the above full featured Dell tablet does – but a recent electronic health record vendor we interviewed is actually designing exclusively for the iPad.  It’ll be interesting to see if others will follow suit or if we’ll see prices for tablets fall for physicians hoping to adopt EMR technology.

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

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

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

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

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

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

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

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

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

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

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

Storm clouds continue to gather in the Apple-Adobe feud over Flash and recent reports suggest it could get even worse. Reports are surfacing that they Department of Justice and Federal Trade Commission are in discussions over opening an inquiry into the recent changes to the iPhone OS developer license agreement. As we discussed previously, these changes basically kill Flash on the iPhone OS, thus including both the iPhone and iPad. We’ve talked previously about our excitement over the numerous emerging web-based electronic health records such as CareCloud and Practice Fusion. With news from Adobe of plans to include a “Packager for iPhone” in the latest development kit, we were definitely excited that these electronic health records would be ready to go on the iPad. But it looks like those dreams have ended.

As the folks over at PC World are quick to point out, we are right now in the “rumor” stage that an inquiry – not a full scale investigation – may occur. Even so, Apple’s legal team is certainly revving up for a fight. But, at least when it comes to medicine, this is a fight they may be better of losing.

As Steve Jobs continues to rage against the Adobe machine, Google and the associated Android are very publicly embracing Flash and will be including Flash support in Android 2.2. This will allow access to everything from news content to the most inane of internet games, which some may argue is also important to medical professionals who are also regular people outside of the clinic and hospital. What is indisputable though is that many low-cost or even free web-baesd electronic health records will now be accessible via Android devices. Meanwhile, iPhone and iPad users will have to wait for healthcare IT vendors, whose EHR’s are generally either Windows or Flash-based, to develop apps specifically for them. And as the race for electronic health record adoption continues in light of the stimulus funds available for it, time is not on Apple’s side.

As physicians, especially those in smaller practices, look to adopt EHR’s, they will also look to adopt new devices on which to run them. Android devices will have an obvious advantage with web-based electronic health records thanks to Apple’s scuffle over Flash. What’s also interesting to note is the numerous emerging tablets that will also run Android. Glancing at the CES 2010 review of 10 tablets worth noting, by PC World, the majority will run Android. And with prices as low as $200 (if Freescale does in fact deliver on this promise), there will be a lot of choice in terms of cost as well. So for the physician looking to adopt a tablet, there will be a variety of choices to fit his or her needs.

Web-based EHR’s certainly carry a smaller market share than major players like Epic, Allscripts, and so on. They are, however, a dynamic platform with a lot of potential especially, from a cost and simplicity perspective, for the smaller physician practices. And as physicians deploy these systems and look for devices on which to run them, Android-devices are, for the most part, now the only game in town.

The iPad has been out for almost a month and we now have the first electronic medical record app customized to take advantage of its features. The Dr. Chrono EMR app is the first of its kind to hit the scenes. Technically, MacPractice has already put their electronic medical record on the iPad, but you need a VNC connection, and they don’t have a customized iPad app yet.

The Dr. Chrono EMR app enables you to sync your iPad with the online practice management platform provided on the Dr. Chrono website. The electronic health record produced by Dr. Chrono is intended for smaller practices, similar to the model Epocrates is takings with it EHR. On initial impressions, the app definitely has potential, but you can tell there are kinks that need to be worked out.

One of those kinks happens when you’re trying to open up the app. When you try to open up the app from landscape mode, you get a blank screen and the app closes out abruptly and you’re back on the home screen of your iPad. In order to open the app, you need to be in portait mode – which shouldn’t be a necessary requirement when using an application.

Once opened, you have three options. Buy the app, request a free trial, or you can view the application with sample data containing fake patients. These samples definitely give hints of impressive features the application possesses, such as dictation within the patient file to optimized billing and coding.

Once we get our hands on an actual review application we’ll let you know.  Until then, we’ve included some screen shots of this EHR app doing a soap note, scheduling a follow up, and more.

One of the most important apps for healthcare providers might not be a medical app after all, rather a business app, called Citrix Receiver for iPad.  This app allows your to have secure access to virtual desktops, applications, and data – those of you who have accessed your hospitals electronic health record when off campus are using this type of software. Hospital systems can use the Citrix app to access their own servers and desktops, as shown in the above video, and display key information on their iPad.  The data can be accessed as long as you have a Wi-Fi or a 3G connection, allowing you to become mobile.

This app is one of the main reasons a Visalia, California hospital is ordering 100 iPads for its healthcare providers.  The hospital system, The Kaweah Delta Health Care District, will use the iPads to view radiology images, ECG results, and other key results. They feel the iPad will be especially useful for their mobile healthcare workers, such as hospice and home health nurses.  The above video also shows uses for the device within the hospital setting.

Nick Volosin, director of technical services, and the one in charge of implementing the iPads, makes it clear the iPad isn’t being used because of the “wow factor”.  Rather, it makes fiscal and functional sense.  The iPad’s battery is significantly longer than many of the laptops currently under use, and with the Citrix virtual desktop software, it can perform the key functions required for healthcare use.

He goes on to make the fiscal argument for the iPad: From a cost standpoint its significantly cheaper than other touch screen medical tablets, that can cost up to $3,000.

Battery life, cost, and ability to have a virtual desktop on the iPad appear to be the 3 key drivers of iPad implementation in healthcare right now.  Many in healthcare will be watching this deployment of more than 100 iPads in the medical field and taking note.

Check out the following links for the rest of the story.

Sources: MacWorld, Network World