By: David Ahn, MD

The iPad 2 is upon us, and offers the same experience for stylus input for handwriting and note taking as the original iPad.

This final article in a three part series on handwriting and the iPad brings us to the various apps that developers have created for the clear purpose of translating strokes of the pen or finger to the screen.

My first article was about why the iPad needs better handwriting support, and the second article compared several iPad styluses on the market.

METHODS

To begin, I first created a simulated patient note with traditional pen and paper (below image). I tried to create a sample that utilized a lot of the previously discussed strengths of handwriting, including abbreviations and complex spacing throughout the paper. I then set about making sure I had the most recent updates for the software reviewed (current as of March 5, 2011). I have been using these apps to various degrees over the past 3 months, so I then set about using each app to best recreate the sample note.

This review covers five different note taking apps for the iPad that utilize a stylus pen: PaperDesk LITE, Cocoa Box Designs’ Penultimate, Notes Plus, WritePad, and Penultimate.

The primary criteria for evaluation was how effective the app was able to re-create this traditional paper and pen produced patient note using an iPad stylus pen. Secondary features were also evaluated, and apps received high marks for supporting synchronization services such as DropBox or Google Docs. They all essentially offered multiple pen thickness, colors, printing, and exporting to PDF, so these features were not mentioned.

The apps reviewed fell into three overall approaches when creating the interaction between a stylus and iPad: One to one note taking, handwriting with Zoom feature, and handwriting recognition.  This comprehensive review will compare the apps in each category and discuss the strengths and weaknesses of each approach, as a whole.

The Plain and Simple Approach: Good, But Not Great

The first approach is a very straightforward one that acts exactly the way you’d expect when you think of the iPad as a notepad. The screen is a piece of paper, and your pen or finger is the pen. It’s incredibly simple, but there’s a huge glaring problem with this: you’re writing utensil is just too blunt. It’s near impossible to fit enough writing on the page. This approach might be useful for simple notes, lists, or drawing, but falls flat when you’re trying to write longer notes.

WebSpinner’s PaperDesk LITE (FREE)

PaperDesk LITE is free, and unfortunately, that’s where its strengths end.  The app is too clunky to recommend, unless you insist on not spending money. Because of the limitations of this plain and simple 1:1 approach, there was not enough space to write the note on the screen.

It has a rich feature set which is consistent with all the other apps. It also has the nice touch of allowing you to sync to Google Docs. It’s UI is decent and is overall fairly polished, although it does look a bit simplistic in certain aspects.

Pros:

- Free

Cons:

- Clunky User Interface
- Stylus/finger too thick for screen

iTunes Link

Cocoa Box Designs’ Penultimate ($1.99)

In addition to having the most clever name of the bunch, Penultimate really makes the most of the plain and simple approach. It’s been prominently featured by Apple in TV commercials and in the App Store, and for good reason. Its UI is beautiful and takes after composition books. It’s incredibly simple to use: tap on the pen to write, tap on the eraser to delete. No complicated features, and it works well.

One bonus feature is this app simulates brush strokes, the only one to do so in this comparison review. I say simulates because unlike older tablets for graphics, the iPad does not support pressure-sensitivity. However, Penultimate simulates some pressure-sensitivity based on the speed and direction of your strokes. If you look at the writing sample closely, especially on the boxes around PMH, you can see that there is some variation of thickness.

However, overall, the app suffered from the same problem as PaperDesk, in that the one to one translation of screen to paper did not leave enough room for the thick stylus.

Pros:

- Beautiful User Interface
- Simulates Brush Strokes

Cons:

- Stylus/finger too thick for screen

iTunes Link

The “Zoom Approach”: The Redemption of Blunt-Tipped Styluses

The Zoom Mode is a feature that allows the user to write in a zoomed-in box that then shrinks down the text, leading to the overall result of something much more similar to the fine tip of a pen. To better understand this concept, it’s like shrinking down the writing of a sharpie on a posterboard to the size of a pen on a lined piece of paper. Since you are writing in a “zoomed area”, even though you are writing with a blunt-tipped stylus or finger, the output will still be as fine as a pen.

Viet Tran’s Notes Plus ($5.99)

This app was the only one that was developed by an individual seller, but provides the best overall performance. As you can see in the image, it very closely re-created the original sample. The writing experience was extremely pleasant and simple. You press and hold down in an area to bring up the Zoom Box. If you don’t want to use the Zoom Mode, you can pinch to zoom in and out and just write directly on the screen. As you can see, the final product of this app is nearly identical to the original sample.

The Zoom Mode was very well-implemented: in the zoom box, when you are nearing the right edge of the box, the left portion of the box shows a preview of where your writing will go next, so you can just continue writing at the left side of the box without having to constantly move around the zoom box. (refer to below picture)

In regards to the feature set, the app provides intelligent stroke recognition that instantly creates linear shapes from your hand-drawn shapes. It also allows you to select groups of text by circling them, which allows you to then then delete or move the text. Try doing that with a pen and paper! Also, it offers the ability to record audio. Notes Plus also syncs smoothly with Google Docs, but it does lack DropBox support, which would have been very nice.

In addition to the lack of DropBox support, several other issues could be improved upon. For one, the undo stroke button was located at the top of the screen and it would have been nice to have one closer to the box where you do the bulk of the writing. Also, when writing in a column near the right edge of the page (ex. The list of medications), the app’s logic kept wanting to advance the writing to the next line. This would be nice in most instances as it allows you to easily start writing on the left margin on the next line, but just doesn’t make sense if you are TRYING to stay on the right margin to create a list.

Overall though, this app is the standout performer of the entire group.

Pros:

- Best use of Zoom Mode
- Folders
- GoogleDocs Syncing
- Low Price

Cons:

- Lack of DropBox Support

iTunes Link

David Ahn, MD

In a previous article, I suggested improved stylus support would help the iPad gain everyday usability in the hospital and work place. The iPad already supports styluses, but the multi touch capacitative technology which makes the screen extremely responsive to human touch also makes it less sensitive to fine-tipped styluses.

As a result, the iPad currently only supports blunt-tipped styluses, much like the tip of a Sharpie marker.

For the time being, many companies sell these thick-tipped styluses that offer basic pen-like interaction for writing and drawing on the iPad. Unfortunately, there are many different form factors and designs that make selecting a stylus difficult, especially when most of these products are only available online.

This comparative review of seven iPad stylus pens will attempt to focus on the handwriting and usability of the various styluses currently available.  The iPad styluses reviewed are: Griffin Stylus, AluPen, BestStylus, Boxwave Styra, Pogo Sketch, Stylus Sock, and Dagi Stylus.

Methods

Gathered below are my thoughts on seven individual styluses, sorted alphabetically, that I’ve gathered over 2-3 months of use. For some objectivity, I ran three primary tests of handwriting that set the foundation of this review.

In the first test (The Light Pressure Test — below picture), I tried to write as quickly and as naturally as I would write, as if I was using a pen. This was by far the most sensitive of the tests.

The second (Hard Pressure Test – below picture) was where I tried to write with more pressure, in effort to improve the detection of the tip. As you can see, the quality of the writing is not particularly impressive in the first two tests, as the thickness required for the iPad to recognize the stylus leads to sloppy writing.

The third test was done using the Zoom Mode feature.  This last test looks remarkably more crisp and impressive thanks to the Zoom Mode feature.  The Zoom Mode feature is one that many of the top-tier notepad applications provide (be on the lookout for my “Handwriting Notepad App Comparison” review in the upcoming weeks).

In this mode, you write in a box at the bottom of the screen that is a zoomed in view of the writing area.  Therefore, you can write large and clearly, and when scaled back down, the handwriting is many times more legible and tightly spaced. While the end result is clean and impressive, it can become a bit clumsy working in Zoom mode.  This last test (Zoom Writing mode — below picture) showcases the writing with each stylus in this mode.

By: David Ahn, MD

The iPad and the tablet market continue to make significant headway into the medical and business markets. In a previous article I wrote about the unique features of the iPad, I briefly mentioned that it was sorely missing the ability for fine-tip stylus recognition.

Currently, the iPad’s capacitive touch screen beautifully recognizes the touch of a human finger, but is poorly suited for the fine tip of a stylus. As a result, styluses designed for the iPad are all thick-tipped, and writing/drawing with them are akin to using a blunt Sharpie marker. However, the practice of medicine often requires the grace of a pen, and would benefit from improved stylus support in future generations of iPads and tablets.

Doctors and Handwriting: A Bad Combo?

An obvious stereotype for physicians — we are known for having poor penmanship.  In addition to the simple fact that we do indeed have horrible handwriting, it’s also because handwriting plays a key role in our practice: prescription pads, patient encounter documentation, medical-legal paperwork, and more. While replacing handwriting with text will improve the readability of many doctor’s notes, I still think there are significant tradeoffs with eliminating the option for fine-tip writing.

Handwriting Can Be More Easy to Read Than Type

Just to be clear, I dislike interpreting the hieroglyphics of a physician as much as anyone else, but in certain respects, a handwritten note can be more readable than a text note. For example, typed notes often have a density of excess information that includes blocks of text that lack focus and clarity. For example, in a typed HPI (history of present illness), it can be hard to sort through pertinent positives and negatives because the nature of typing lends to more information, complete sentences and prose rather than simple abbreviations and pertinent phrases.

Even beyond the shear difference in quantity of words/letters used, there is a clarity that handwriting provides with spacing and distribution of words on a page. Many handwritten patient notes use multiple columns and complex organization of text with random boxes of text (e.g. medication list being listed in a small box on the right), which require more effort to reproduce on a typed note. This is often why typed notes can span over 2-3 pieces of paper, where a handwritten note will rarely go over one sheet.

Drawing and “Marking Up” content provides utility

At our hospital, since we have paper charts, we have two choices when writing progress notes: printing out typed notes or handwriting notes on printed rounds reports. One benefit to handwriting on printed rounds reports is it allows for circling pertinent lab results and fully integrating personalized, subjective notes with the objective data on the report.

In addition, certain specialties benefit significantly from drawings or symbols. One example would be cardiologists who often like to diagram which heart vessels have blockages or have had stents placed. Another example would be when describing skin lesions or documenting reflexes, it can help to illustrate with traditional stick figures.

Handwriting is Personal and Unique to Each User

Think about a signature: it is a personal, handwritten identifier that holds significance in our society. When it comes to medication prescriptions and medical-legal forms (ex: medical disability paperwork), physicians are often required to handwrite their recommendations and signature. In a more general example, when sending a thank-you card, there is a humanness that is more appropriately conveyed with a pen rather than a keyboard. The unique nature of each person’s handwriting speaks as to the genuine authorship, and this can go a long way with the various responsibilities of a physician — such as more “personalized” discharge instructions for a patient.

Conclusion

Apple CEO Steve Jobs has previously said in an interview that a stylus is only required in a poorly-designed product, saying “if you see a stylus, they blew it.” I see where Mr. Jobs is coming from and agree with his sentiment that the majority of a well-designed user interface should not require a stylus. Furthermore, I much prefer typing to handwriting in most situations. I can type significantly faster than I can write. I struggle to read the poor handwriting of some of my peers.

However, at times, the pen is almost as integral to a physician’s practice as a stethoscope, and I eagerly hope for this feature in the next generation of iPads and other tablets. What about you? Do you think the iPad’s lack of fine-tip stylus support is a big deal? Share your thoughts about this in the comments.

Note: Over the next several weeks, I will be reviewing several of my favorite styluses and notepad apps for the iPad/iPhone. If you have any that you’d like to recommend, feel free to let me know in the comments as well.

In July our report of the Stanford School of Medicine giving iPads to all incoming medical students captured a great deal of attention – the story alone received tens of thousands of views.

Recently, the School of Medicine highlighted how students have been using their iPads – commenting on how frequently they are being used, textbook capabilities, and even on how certain applications are being used.

The school has also collected some preliminary data that quantitates how many of the 91 students who were given iPads are actually using them – or if they are using them at all.

Brian Tobin, the school’s instructional technology manager has stated students are customizing their usage of the iPad based on how it helps them to study:

“Everyone is doing their own thing,” said Tobin “Some students are learning on it really well. Others have decided that laptops are still the best option. Some still use paper. And others use some mix of all three.”

Tobin also commented on how students are being encouraged to go paperless. The push is to get students to replace traditional texts with e-books – to take traditional note taking methods and make them electronic. The school is encouraging students to use the iPad when in the cadaver lab, from viewing anatomy to viewing pathology slides.

For note taking the school has put iAnnotate, a popular annotation app we have reviewed in the past, on each iPad. Students have found the drawing and highlighting tools within the app helpful in gross anatomy and are using it for traditional note taking as well.

Preliminary data shows 68 of the 91 students are using the iPad exclusively for note taking. Eight students are sticking exclusively to their laptops – eight are using traditional paper and pencil handwriting – and the rest are using a combination of tools for note taking. Overall though, no one has replaced their study tools with just the iPad.

Only some of the medical textbooks are available digitally – and the school hopes this will change as more medical texts become available electronically. McGraw Hill, one of the leading publishers of medical textbooks, already has partnerships in place with e-book developers for the iPad and hopefully a greater demand in medical texts will only help facilitate the conversion of these texts.

The news of more than 70% of the students using their iPads exclusively for note taking should be welcome knowledge to educators who might be thinking of implementing similar programs at their undergraduate universities and graduate schools. This also shows a relatively high level of technical competency displayed by the medical school class – something educators should take note of with the “Facebook and twitter” generation.

As the year progresses, the school will be conducting regular surveys to see how students are using their iPads.

If a Stanford Medical Student would like to write on our website about their own personal experiences with using the iPad for medical education don’t hesitate to contact us: http://www.imedicalapps.com/contact/

Source: Stanford School of Medicine

Update: Per reader requests, we’ve made direct links to the pictures in this article now, so they should show up full screen with only one click now

If you have an iPad, iAnnotate PDF is almost a must have application for healthcare professionals and students. I’ll explain the almost part later.

No matter where you are in your career in medicine, you’re reading PDF files constantly – it’s what keeps your evidence based clinical skills up to date. And as we all know, PDF files aren’t exactly optimized for the iPhone or other mobile devices. Rather, the two column appearance that dominates journal layouts is displayed horribly on mobile devices.

When the iPad was first released, I was looking forward to a host of medical applications, but unfortunately, most developers have been slow to convert their medical apps to the iPad format. I’ve documented the show transition in prior posts. But PDF viewing apps such as Papers, GoodReader, and now iAnnotate have not disappointed – and were quickly released with the iPad in mind.

With the iPad’s larger real estate, I knew viewing PDF files would be significantly easier, but I didn’t know how much I could do with them until I tried iAnnotate PDF. This app allows you to annotate in ways you couldn’t even do if you had a paper version of literature with pens and highlighters. However, it does have some flaws that we’ll get into later in the review. 

Annotation functionality:

I was going to list the different types of annotation you can do with this app, but you almost have to ask yourself what this application can’t do. All the annotating is done with your fingers and keyboard, and in true Apple form, the capacitive touch screen is extremely accurate and is a huge asset for this application.

Key annotation features [Picture is shown for each feature]:

*Highlighting: This is done with ease by dragging your finger across text.  I was pleasantly surprised by how smooth this feature is.

*Hand Writing: As you can see by the writing skills showcased, you probably want to use a Pogo stick – stylus for the iPad – if you really want to use this feature.  Handwriting on the iPad’s screen is fun, but using your fingers to write a short note is difficult and too cumbersome without a stylus like accessory.

*Comments: This feature is done extremely well. You can put a comment box anywhere on the PDF, and once you’re done, you can collapse the comment box, or you can choose to leave it open.  The collapsing feature prevents clutter within your PDF, while also giving you the ability to recall key notes.

*Lines: You can use the ruler tab to form straight lines. This can be useful to highlight key tables, graphs, or paragraphs.  Or for making random boxes just for fun, as I’ve shown below.

*Underlining and Crossing out: There isn’t really a need for the crossing out feature if you’re reviewing literature, but the underlying feature is definitely useful. Again, I got the same reaction with this feature as I did with highlighting – it’s extremely easy and smooth to do.  Just drag your finger across the text you want to underline [below picture is in portrait mode]

There are other things this app can do as well, but these are the main features I found useful when reading medical literature on this app. If you want to see other features explained in more detail view the video we have attached at the end of this post.

Transferring Files onto and from your iPad:

The achilles heel of this application is clearly transferring files. The developers offer a program you can download onto your computer that enables you to sync to your iPad with your computer via your Wi-Fi connection. But, if you have a hospital issued laptop with extra layers of security, the application might not work – it didn’t for me. If you don’t have the extra layers of security, you should be able to get your PDF files into the application with ease. I had to use another laptop to do this, but even then, there were a few PDF files that the iAnnotate PDF app wasn’t able to upload [almost all the files were uploaded easily].

The developers actually have a pretty robust forums section on their website that is useful in guiding you with file transferring issues. However, you shouldn’t have to spend half an hour or more trying to figure out how to get PDF files onto your iPad – you could have read a few clinical guideline PDFs in that time.  Another way to get files into the app is to view them in safari or your mail, where an option to view the file in iAnnotate pops up.

We e-mailed the developers about the connectivity issues we were having, and they have assured us that better file transfer options are coming very soon.

What I liked:

*Extremely powerful annotation features: Highlighting, Underlining, Crossing out, Comments, and more.  Each of these features is done really well, and is fun to use.
*Ability to have more than one PDF file opened at a time, the “tab” feature – similar to using a web browser. This feature is great if you’re trying to read multiple PDF files at the same time or are referencing information in multiple files simultaneously.
*You can customize how the toolbar is displayed, and the toolbar is displayed in both portrait and landscape mode.

What I didn’t like:

*Transferring files can be an issue – as mentioned above.
*No clear method on how to move annotated files back onto your computer.  We’ve been told updates will resolve this.

Conclusion:

Once the developers of iAnnotate PDF figure out alternate methods to upload PDF files into the app, this will become a must have application for medical professionals. The type of annotating you can do with this app is actually fun – and makes reading medical literature that can sometimes be bland a bit more exciting. Per the iTunes description, the app is currently on sale for a limited time at $6.99, and at this price, the iMedicalApps team definitely recommends it – even with the issues that can arise for some users.

Links: iAnnotate PDF website, iAnnotate on iTunes

Note: We’ll be reviewing other PDF viewers (Papers and Goodreader) for the iPad soon, so stay tuned.

Video of the App in action[developers video]:

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

Fits in your white Coat:

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

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

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

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

Fast enough for Healthcare Point of Care Use

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

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

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

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

The Apple iPad is set to launch, and right now, most of the early reviews of the product have been positive.  The NY Times has a fantastic piece looking at the iPad from two angles – An everyday user verse a more technically inclined user, and both have differing opinions on the eventual success of the iPad.

But what about a medical professional or a medical student.  From the reviews I’ve read so far, the screen is gorgeous and easy to read, further giving traction to the idea of medical e-books or radiology viewing on the iPad.  We’ve also made clear that handwriting software for the iPad is a necessity if broad implementation in the medical field is a goal.

We’ll be getting our hands on an iPad soon so we can show you how some of our favorite iPhone medical apps perform on the new platform.

Until then, we’d like to hear from you.  Will you be buying the iPad, why or why not? What additional features do you want to see on the iPad – and do you think it can help with medical education or enhance the patient physician relationship?

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

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

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

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

1) Stylus

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

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

2) Medical Grade Case

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

3) Battery Case

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

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

4) External Camera and Video recording adapters

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

5) VGA / AV out adapter

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

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

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

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

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

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

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

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

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

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

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

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

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

When I first entered the clinical world, physician order entry and electronic medical records were just concepts to me. As I learned how to navigate the hospital, diagnose everything from the mundane to the incredibly rare (my first patient was a baby with an idiopathic subdural venous thrombosis), and figure out how to treat the sick, I also had to learn how to use those two systems as a prerequisite to doing everything else. The four hours of class didn’t seem to cut it, so I probably spent at least a month trying to get my bearings on how to manage these IT systems. So for anyone who is already familiar with some form of healthcare technology, in this case a tablet, I suspect the adoption cost is far higher than just the price tag. You may be surprised how highly some medical students and residents weigh the notion of learning a new system in their career decisions. And because of what seems to be a particularly high barrier to adopting new information technology in healthcare, anyone interested in whether the iPad will succeed in healthcare should first ask who the competition is.

One member of the healthcare tablet family is Motion Computing and it’s tablet, the C5. The C5 has many things that a physician, nurse, pharmacist, and many other healthcare providers would want. First and foremost, its a rugged piece of equipment. It’s designed to be capable for taking a hit on the floor or being cleaned with disinfectants. If you’ve seen the sheer number of hand sanitizer dispensers in a hospital, you know how important that latter capability is. It also has a barcode scanner and RFID reader. This feature would be incredibly helpful for nurses who need to verify patient identity before dispensing a medication or confirm a medication they are about to administer is the correct one. In addition, it has built-in microphone and camera, the latter of which would be very helpful in areas such as wound management or patient identification. As for the microphone, if the Speak Anywhere technology is as good as Motion Computing claims, it would allow physicians to dictate patient notes without a peripheral microphone (though I suspect its not that good). Also, these machines are  Windows and stylus based. While this isn’t necessarily a functional strength, it does reduce some short-term barriers to adoption by increasing the likelihood of compatibility with established EMR’s. And if you’re going to be working with patient information in a HIPAA world, security is crucial. That’s why data security solutions for tablets like the C5, specifically those using Intel processors, are another crucial advantage that established vendors like Motion Computing have.

All of that being said, there is certainly a reason tablets like the C5 have not achieved widespread adoption already. For example, the C5 weighs in at over 3lbs, not that heavy, but more than twice as much as the 1.5lb iPad. In addition, it’s battery life is pretty weak in comparison with the iPad, 4 hours vs. 10 hours (per manufacturers reports).  To me – this means I’d have to lug the C5 around all day, stopping probably twice on the average day to charge up. And while the fact that it can run Windows 7 is key for compatibility and widespread adoption, there is a reason the iPhone has been so incredibly successful. Its user-interface and enormous developer community make it a far more versatile and easier to use medium than a Windows-based product can be. Finally, the $2,000+ price tag on the C5 makes it a large investment for even a suburban dermatology practice, let alone cash-strapped hospitals and private primary care practices.

So is the healthcare tablet market ripe for an iPad sweep or do the entrenched players already have the market cornered? Frankly, I can’t predict the future. On the one hand, the C5 has most of the features I’d want in a tablet. However, it also has a few things I don’t want, especially an eye-popping price-tag. And while the iPad really wallops the C5 on those weaknesses, it doesn’t come close to approaching its strengths. Honestly, I don’t think either tablet really fits the bill for what healthcare needs. But I’m excited Apple has entered this market, not because I think the iPad will become the dominant tablet, but because I want to see this fight. Apple’s record of innovation are likely to spur unprecedented competition in the healthcare tablet arena – and that kind of competition is almost always good for the consumer.

It was only a matter of time before partnerships between medical textbook publishers and the iPad development community emerged. One key partnership the Wall Street Journal just announced is between ScrollMotion (app developer) and McGraw-Hill’s Education division, with the purpose of developing e-books for the iPad.  And why does this matter? Because if you’re a medical professional, you most certainly have read or own a medical text from McGraw-Hill.

McGraw-Hill is the publisher of Harrison’s Internal Medicine, Schwartz’s Principles of Surgery, the Case-File series and many more medical texts.  They acquired Apple and Lange Inc in 2007, further expanding their vast medical library.  Many of us know of McGraw-Hill via Access Medicine, the online portal to their large collection of medical texts that is available in almost every academic institution in the country.

Many pundits feel the iPad’s use of an LED screen verse E-ink (think Kindle) will dissuade readers from purchasing the iPad for reading purposes.  The principle argument is the LED screen will cause more eye strain after prolonged use, but the medical community should embrace e-books on the iPad because we read textbooks in a different way than traditional readers.

Medical books are not often read cover to cover, instead key chapters are often referenced when needed.  Although the majority of medical professionals, myself included, will attest to reading Harrison’s frequently, it’s doubtful that any of us have read the massive text with the purpose of reading it front to back.  Also, could you imagine seeing key anatomic figures, pathologic pictures, and diagrams in E-ink text?  The dull black and gray colors would look awful.  On the iPad’s 9.7 inch 1024 x 768 pixel display, these full-color diagrams and figures would be far more aesthetically pleasing.  Viewing detailed anatomic figures would be especially useful, highlighted in one of our recent medical app reviews.

It should be noted that a flagship McGraw-Hill book, Harrison’s Manual of Medicine, is already in the App Store via other third party developers.  But we haven’t been impressed with the conversion of this medical text to mobile form, mainly because of the limited size.  Pictures and diagrams cannot be fully appreciated on the iPhone’s 3.5 inch screen.

Since the iPad’s iBook store will be competing directly with the Kindle, we can assume the pricing of these books will be similar.  Surprisingly, the Kindle does not have many of the McGraw-Hill flagship textbooks I mentioned above.  The limiting display factors that E-ink causes could be a reason these texts are not available.  However, McGraw-Hill does have many medical study guides in e-book form, such as the Case-Files series.  The Case-File e-books for the Kindle are priced at almost 40% discounts from the original text.  Although such a high discount is not likely, many of the medical reference texts available for the Kindle are discounted by approximately 20%.

This type of savings, along with the ability to search and review massive text books on a great display, should have the medical community excited about the prospects of e-books on the iPad.  Now if the developers can somehow add the ability to highlight and annotate using the rumored handwriting keyboard….but that might be too much to ask.

Ever tried using your iPhone medical apps with gloves?  Doesn’t work too well.  Although, if you’ve got gloves on you probably shouldn’t be using your iPhone anyways.  The iPad is being touted by many, including us, as a device that could be used with patients at the point of care.  Translation:  Could be used in hospital rooms and procedure rooms that require you to be gloved up.

Since the iPad has a capacitive touch screen your gloves won’t work, and that plastic stylus from your old Palm PDA won’t work either.  There’s a solution to this, the Pogo Sketch, featured in the picture.

The Pogo Sketch becomes an extension of your fingers and works on a capacitive touch screen.  No longer making the iPad or your iPhone inoperable when you have gloves on.  But what if you have to type information on the iPad or the iPhone?  Since your gloved fingers won’t work, using a stylus to peck each letter on the pop up keyboard would be a huge ordeal.

To counter this, iPhone OS version 3.2, the operating system that will be running on the iPad, is rumored to have support for a “handwriting keyboard”, via Engadget.

….and, most interestingly, prototype support for a “handwriting keyboard.” Maybe we’ll see some stylus action on this thing after all.

The above revelation would be significant for the medical community, especially for health care providers who need the ability to write text efficiently with gloved hands or while standing up.  I can imagine myself using this capability to type short notes or even prescriptions for patients while in a standing position in the hospital room.  The alternative would be to use the external keyboard connected to the iPad, definitely more cumbersome, and this would require you to sit down and have desk space.  And as most know, desk space isn’t exactly present in a hospital room.

I’m assuming Apple will not reserve this type of functionality for just the iPad, and will bring it to the iPhone and iPod Touch devices as well.  If they want to make waves in healthcare IT, they would be wise to.