A number of recent surveys have indicated that the Apple iPad is the number one choice for healthcare professionals when it comes to choosing a tablet.

This is hardly surprising given the head start the iPad has had compared to its competitors (read more here) and the significant development that has gone into medical apps for the iOS platform.

This article will attempt to help decide which particular iPad is the best choice for a healthcare professional who wants to use it as part of their daily workflow.

The choices available from the Apple Store at the time of writing are as follows:

• iPad 2 3G/Wi-Fi 16GB
• iPad 2 3G/Wi-Fi 32GB
• iPad 2 3G/Wi-Fi 64GB

This article will not consider the color of each device as that is a purely aesthetic choice. When it comes to purchasing an iPad, there are three main considerations, each of which will be addressed in turn:

• Processing hardware
• Storage space
• Connectivity

Processing hardware

As tablets become more powerful, they gain the ability to run more demanding applications. This means that they are generally faster, better at multitasking and will be suitable for future software developments. The iPad 2 was a large hardware upgrade from the original iPad with an enhanced processor, more memory and two cameras amongst other features.

Due to this, the iPad 2 is recommended over the original iPad.

Storage space

The iPad 2 is available in three different sizes, 16GB, 32GB and 64GB. The average app size for iPad apps is often larger than that of iPhone apps. One of the main functions of the iPad for medical professionals is storage and reading of medical literature. It is very easy to store large numbers of PDFs and presentations using apps such as PDF Expert/GoodReader. Apps such as Dropbox store the majority of documents online, however, they still require some local storage in order to display the files.

Another storage aspect worth considering is the rise of eTextbooks. Companies such as Inkling release excellent versions of core texts, though these can take up significant amounts of space– e.g. Inkling’s version of Harissons Principles of Internal Medicine is an amazing resource however it does take 3.4GB of space.

One final consideration when it comes to storage is accessibility. This will be discussed in greater detail below. Essentially, if your hospital or workplace has excellent connectivity, the greater you will be able to rely on cloud based storage services such as Dropbox.

If your hospital has a number of deadspots or you are based in the community then chances are you will want to make greater use of local storage to ensure you have access to all your documents regardless of internet connectivity.

On the basis of this, the 32GB model is regarded as the minimum size for healthcare professionals. The 16GB model does not have enough local storage on it for it to function effectively and users with this model are likely to find themselves running out of space in the future. In an ideal world, the 64GB model with its significant amount of storage would be the ideal choice, however, this does come at a cost. Users who are keen to store lots of documents locally and other media such as videos and photos may find that this model suits their needs better.

Although not strictly medical, this info graphic from gizmodo helps illustrate the different storage sizes available.

Connectivity

The final consideration when purchasing a new iPad is connectivity. All iPads are supplied with Wi-Fi as standard but a Wi-Fi + 3G model is also available. 3G keeps you connected to the internet even when Wi-Fi isn’t available and uses the same signals your mobile phone uses. It’s available without a contract and service is sold separately. Interestingly, Wi-Fi + 3G iPads include a GPS locator which the Wi-Fi only iPads do not.

Connectivity is an integral part of many medical apps which often store information online and download it as and when required. Similarly many iPads are used to input data into EMRs which also require internet connectivity. This is vital and therefore the Wi-Fi + 3G model is recommended for healthcare professionals. There is no need to purchase a contract for 3G data if there is Wi-Fi available, though it is useful to be able to access 3G if required.

Overall Rating

Having considered each of these three main points, it is clear that the iPad recommended for healthcare professionals is the 32GB Wi-Fi + 3G model. The 16GB model is not recommended on the basis of storage whilst the 64GB is not recommended on the basis of cost. 3G connectivity is essential to ensure that internet access is maintained in case there are deadspots in the hospital. The 32GB model should be more than adequate for the majority of users’ needs.

Its no secret that healthcare providers are adopting tablets at a rapid pace – one survey found that over 25% of physicians own a tablet and that was nearly nine months ago.

This trend, both with tablets and smartphones, has generally been bottom-up; physicians, PA’s, NP’s, nurses, and other healthcare providers are buying consumer devices and bringing them into the clinical world.

However, as Eric Yablonka, CIO of University of Chicago Hospitals put it, “This is not ‘nice to have stuff’ anymore, this is life saving stuff now.”

And so we’ve seen institutions across the country move to implement mobile devices on an enterprise level – from the Johns Hopkins and University of Chicago Internal Medicine residency programs to the entire VA healthcare system. However, Kaiser Health News reports that less than 1% of hospitals have fully functional tablet systems and points out how one of our biggest investments in health IT, the HITECH act, may be part of the reason why.

When the iPhone was first released, it transformed the way people interact with mobile devices – they became something better than just mini-computers. However, as pointed out by Jenny Gold, staff writer at Kaiser Health News,

“The most popular systems don’t yet make apps that allow doctors to use electronic medical records on a tablet the way they would on a desktop or laptop. To use a mobile device effectively requires a complete redesign of the way information is presented, Jonathon Mack, director of clinical research and development at the West Wireless Health Institute, says.”

We would first point out that the assertion isn’t entirely accurate – Epic, Allscripts, and Centricity as well as many cloud based EMR vendors like MacPractice and Dr. Chrono do have iPad and in some cases Android apps. That being said, these apps are, in many cases, limited – some allow read-only viewing for example.

What is often true, though, is that for hospitals, accessing these apps requires substantial additional cost. For example, Epic and Allscripts both require a separate licensing agreement for their mobile platforms. As Mr. Mack points out, many hospitals and healthcare systems have just made major investments in their IT infrastructure, a trend which was accelerated by the HITECH act. As he puts it, “When you look at a health system that has bought into an EMR, they’re not ready to turn the boat around and start over.”

As a result, healthcare providers are very reliant on workarounds to shoehorn tablets into existing infrastructure. For example, apps like Citrix or VMWare enable access to virtual Windows environments on the iPad or Android tablets, allowing access to fully functional EMR’s, radiology viewers, and so on.

In my own experience, while this method works, it just turns these devices into laptops without the keyboard. Windows is designed for computers and laptops; Microsofts release of Windows Phone and abandonment of Windows Mobile is a testament to that.

Despite these obstacles, healthcare providers like Kate Franko, a physician assistant highlighted in the article, are still finding utility for tablets to improve efficiency, patient communication, and more. While there are many issues to be addressed – cost, security, infection control, and so on – tablets are likely to be an increasingly common feature on medical wards and it’s only a matter of time before the IT infrastructure is forced to catch up.

As we discussed in the first of this two part series, mobile devices are already entering the world of the surgeon. Currently, it is mostly downloadable apps that promise to help surgeons with the informational portions of their tasks, such as tracking the cases they have done, e.g. Surgichart or helping in the consent process, e.g. Surgery Risk

While apps that are dedicated to the technical aspects of surgery, such as the excellent AO Surgery Reference, are becoming available, in the future we will see the iPad (or its brethren) actually in the operating room. Why ? Because the iPad has many characteristics that make it a great an advanced surgical instrument.

First is its small size. Every modern operating room has stacks of electronic equipment hanging from the ceiling or in large cabinets for patient monitoring and controlling in-field devices. Since the iPad already supports a bevy of standard wireless communication protocols, many of these large boxes’ functions could likely be off-loaded to an iPad with clever engineering. One immediate advantage would be that the iPad could be brought directly into the operative field in a small sterile bag where the touch interface makes it possible to change settings even using gloved hands. This means that the surgeon or assistant could manipulate the controls rather than asking the room staff to make every little change. The long battery life means that an iPad can make it through even a long surgical day without needing a recharge (at least not before the surgeons do !)

Even more intriguing are the possibilities for user interfaces that incorporate the built-in sensors in the iPad, specifically the accelerometer and gyroscope. These sensors have made the iPod Touch a massive success in the mobile gaming world by allowing players to interact with games by turning and twisting their devices. Could they also lead to new types of assistive surgical instruments ? Read below as we explore these ideas.

[Ed. This article, and the first part of this series, is co-published in the Journal of Surgical Radiology]

Communication

The most basic and fundamental function of mobile devices is communication. In the surgical realm, this often means sharing visual information since intraoperative observations are critical to understanding surgical options and prognosis. But this can even be extended to the preoperative setting, where the ability to quickly consult with a colleague about physical findings could help guide surgical planning. The built-in FaceTime videoconferencing feature in the iPad 2 and iPhone 4 is as simple as it gets. In fact, this is exactly what Armstrong et al showed could be one use of FaceTime, in a brief report describing its use in sharing the appearance of pre- and post-operative wounds, where two surgeons discussed the appearance of an extremity and whether surgery is indicated, as seen in the image below. If the Wi-Fi network is encrypted, the communication is likely in fact HIPAA compliant.

Sharing intraoperative images with patients and other professionals is also a feature of SurgiCharts, as our recent review showed while eGoWorks is an iOS app for sharing endoscopic images stored using Envisionier’s web-based endoscopic image server by the same name. For more robust video sharing, JEMS offers a system where multiple mobile clients can view the same video stream (image below). The stream is encrypted and mobile clients are available for both iOS Android devices. A video server is required, which can take in up to four different video inputs. This means that the same surgical procedure can be viewed in multiple locations, even in different cities, making it potentially a great tool for teaching.

Intraoperative visualization

While the iPad could be used to view a remote surgery, it may be put to even better use in the immediate operative field. One use could be to follow the patient’s vital signs. The AirStrip platform already allows for live remote monitoring of fetal heart tracings and is already deployed in multiple hospitals. Now also available is remote monitoring of vital signs, such as EKG tracing, blood pressure and oxygen saturation. While this is mostly the responsibility of the anesthesiologist, in cardiac procedures especially, the surgeon is also acutely interested in heart electrical activity and blood pressures. Thus, large and expensive plasma screens are often hung from the ceiling in cardiac operating rooms. An iPad in the operative field running AirStrip may be a far more economical alternative.

Another interesting possibility is to use an iPad as a microscope. Surgeons are used to using “loupes”, eyeglasses with built in magnification, when working on small objects such as nerves and vessels. Other times, large and expensive floor microscopes are brought sterile-wrapped into the operative field. However, there may be times when an inexpensive video microscope may be all that is needed. One university project, “CellScope” demonstrated the feasibility of attaching a magnifier to a cell phone camera to make an inexpensive 45x microscope that can be used in rural settings or less developed countries. Instead of using the built-in camera, if the image sensor was a the tip of a thin extension tube, such as seen below, it could be brought into the field and the video transmitted wirelessly to a nearby iPad. This would then function as the surgeon’s eyes, allowing her to peer into poorly lit body cavities and magnifying small objects.

Intraoperative measurement

The accelerometer inside many smartphones is sensitive to changes in position, such as rotating the device between portrait and landscape. It can also allow for software to be written to allow the device function as a sort of “level” to determine when objects are parallel to each other or to the ground, as demonstrated by the popular iPhone app “iHandy”. This capability is exploited by the “Scoliogauge” app to help orthopedic surgeons measure extent of spine curvature in scoliosis. By having the patient bend forward and placing the iPhone on their back, the angle of trunk rotation can be measured. This rotation corresponds to the degree of curvature in scoliosis. You can read more about this in our recent interview with the orthopedic surgeon and app developer Matt Ockendon.

The same concept has been used to help guide surgeons planning reconstructive eyelid surgery as reported by Mezzana et al, who used an iPhone intraoperatively to ensure that eye lids are parallel during oculoplastic surgery, as seen below.

The app is called Laser Level and it is was originally designed for home decorators to determine when wall hangings are perfectly level. The app overlays two “laser” lines in real-time onto the camera image which turn green when they are parallel, as seen in the image above. The authors reported they were able to get both 100% interobserver reliability as well as “perfect alignment of the lateral canthal position after surgery verified by manual level assessment” in all nine of their patients.

Intraoperative “navigation” refers to a group of technologies that are used to assist surgeons in locating deep anatomic structures or accurately placing implants inside patients. In orthopedics, navigation has been shown to increase the accuracy of placement of knee replacement prostheses. However, one consistent complaint among surgeons has been the inconvenience of assembling the  required transmitters and registering them onto the display sensors while in the operating room. Now Brainlabs, in partnership with implant maker Smith & Nephew, has developed a system that uses an iPod Touch to replace almost the entire device.

As can be seen in the image above, the reflectors and the user interface are incorporated into the iPod Touch which is inside a case and brought sterile into the field. The alignment of the implant is read directly off the screen. The device is awaiting FDA approval in the USA  and a demo is available in the iTunes App Store.

Augmented Reality in the Operating Room

Object recognition software is becoming increasingly sophisticated, even on mobile devices. A great example is the remarkable iPhone application MagicPlan that can almost “magically” draw the floor plan of a room by using the iPhone camera to determine the distance to each corner in a room. The user points the iPhone camera at each corner in a room and the app draws green lines, which are approved the user. Once all the corners are registered, the floor plan, with actual distances, is shown.

This type of technology is termed “augmented reality” and generally defined as the practice of combining or superimposing computer generated data onto live-obtained images. Familiar examples include televised football where a virtual first down line is superimposed onto the field or televised soccer where advertisements seem to be displayed on the walls enclosing the playing field.

The medical uses for augmented reality are just being explored. One app currently available measures the angle between bones on an xray. The app is called Hallux and it is specifically designed to guide surgeons planning reconstructive foot surgery.

In this case, the software combines readings from the iPhone accelerometer and the user determined positions of the bones, using the on-screen alignment guide, to read the angle between the first two metatarsal foot bones. You can read more about it  at our more detailed app review.

Much of surgery has to do with imagining deeper structures, such as organs and bones. Sophisticated image processing techniques make it possible to render three dimensional images, even color coded by organ. These types of images can be invaluable for identifying pathology and planning complex surgery.

The above rendering was produced by Dr. Maki Sugimoto a hepatobiliary surgeon who is pioneering methods of incorporating advanced imaging techniques and surgery. In this example, he uses an overhead projector to overlay the 3d image onto the actual patient during surgery, as seen below. In order to align the images, he uses anatomic landmarks, such as the navel and the iliac crests. to properly align and scale the image.

His group reported their findings in seven surgeries including three cholecystectomies, two gastrectomies and two colectomies. They found that live image registration helped the surgeon locate small objects and tumors introperatively that would otherwise have been difficult to find, and potentially helped avoid intraoperative injury.

An even more useful and convenient method of combining real and computer generated images during surgery, I propose, would be if this “overlay” image could be displayed on an iPad. In this concept, the three dimensional image would be manipulated in real time by pointing the iPad at different portions of the body, giving the sense of being able to peer inside the body. A method of simulating a live three-dimensional view on the iPad was demonstrated by the Engineering Human-Computer Interaction Research Group in France (below).

By using the iPad’s accelerometer, different aspects of a computer-generated 3D object are displayed as the iPad is tilted (video). This can simulate the familiar stereoscopic 3D image display which relies on polarizing glasses, without the glasses. The group even demonstrated how using the front-facing camera and face detection algorithms, the same 3D experience can even simulated when the user looks at the iPad from different angles. A demo version of the software is available for download in the iTunes App Store.

Going further, perhaps the remarkable technology developed by Microsoft for its Kinect could be incorporated into surgery. The Kinect was developed as a gaming tool to allow players to interact with objects on the screen by moving their own bodies. It works by projecting a dense yet invisible mesh of infrared dots into a room and, by rapidly reading the reflection of the infrared light, it can track the movement of people.The image below is from source Matt Cutt’s blog.

The Kinect has already been “hacked” to work inside an operating room by allowing a surgeon to manipulate the display of CT & MRI images from across the room, hands-free.

From there, it is not hard to imagine the same technology being used to track the movement of a surgeon’s hands or instruments. What could be a great leap forward would be to combine the position of the surgeon’s instruments with live-registered three dimensional anatomy images and thus simulate the instruments inside the body. A Kinect-like device could “watch” the surgeon’s hands and instruments outside the body while the iPad is pointed at different parts of the patient to virtually peer inside and show the instruments.

Conclusion

The iPad has the potential be a game changer in surgery because of its small size, built in sensors and wireless networking capabilities. The only restriction is the imagination of future surgical innovators. Even if the above predictions fail to materialize, it is safe to say what the future holds is only barely imagined today.

References

Armstrong, D. G., Giovinco, N., Mills, J. L., & Rogers, L. C. (2011). FaceTime for Physicians: Using Real Time Mobile Phone-Based Videoconferencing to Augment Diagnosis and Care in Telemedicine Eplasty, 11, e23.

Mezzana, P., Scarinci, F., & Marabottini, N. (2011). Augmented Reality in Oculoplastic Surgery: First iPhone Application. Plastic and Reconstructive Surgery, 127(3), 57e–58e.

Image overlay navigation by markerless surface registration in gastrointestinal, hepatobiliary and pancreatic surgery. Sugimoto, et al. J Hepatobiliary Pancreas Sci. 2010 Sep;17(5):629-36. Epub 2009 Oct 2.

How do you implement the iPad in the hospital setting for patient care and properly distribute it to a large group of physicians — all at once?

The University of Chicago’s Internal Medicine residency program tried this last year, and came up with a great blueprint for others to see.

Chicago’s Medicine residency garnered national headlines this past year with their use of the iPad for patient care. They have some great resources on their website that are public, showing how they have tackled many of the concerns of implementing a tablet based tool in the clinical setting.

The topics range from using the electronic health record Epic on the iPad — to Security, infection control, iPad accessories, purchasing apps, and more.  The various manuals are focused on the internal medicine residency program’s implementation of the iPad, and while some aspects are focused on the medical education use, the manuals can be extrapolated by hospitals or other medical educators trying to implement an iPad based curriculum or iPad based patient care scenario.

Topics featured in the manual: (Links to manuals are at end of the summary)

Using an EMR with the iPad:

• The manual shows how to use Citrix, a virtual desktop app, for using an electronic health record. In the University of Chicago’s case, their house EMR is Epic.
• For those wondering how Epic works and functions using Citrix, the manual does a great job of breaking this relationship down, even showing you how you can find local printers.
• Some of the advantages they have found using the iPad and Epic: Can address patient issues while in conference, ability to discharge patient’s on rounds, patient education.

Security:

• Gives the appropriate steps the internal medicine program has identified in case the iPad is stolen. You are not allowed to store any patient information locally on the device. This makes obvious sense, the iPad should only be accessing patient data on the cloud.

Infection control:

• They give specific instructions on how to clean the iPad with specific solutions, such as Cavicide spray, and have given screen protectors as well.
• They recommend not using the iPad in isolation rooms.

Basic Features:

• Imagine taking 30 or so random people off the street, and telling them they will use the iPad for work. That’s basically what happens when a residency program, or hospital system starts implementing the iPad in a clinical workflow. Because of this, many of the so called “obvious features” aren’t so obvious. The manual does a fantastic job of showing what the basic features are of the iPad, and how to use them.

How to handle the rollout of the iPad, and manage multiple iPads:

• There is also another manual called “iPad & Administration”.  It has some great content in it as well, and is aimed at the leaders who are in charge of deploying multiple iPads.  Some of the features: How to manage all the iPads and the rollout, how to track the devices, and some key accessories such as an iPad stylus and various iPad cases.  The residency program uses Mobile Iron, software that enables them to track the iPads, and more importantly, manage apps in bulks on the devices.

References:

U of Chicago iPad initiative website

iPad Manual by Bhakti Patel, MD [PDF File]

iPad & Administration: By: Maria Jacobson, Bhakti Patel, MD [PDF File]

In a nod to the reality of rapid physician adoption of tablets and smartphones, the CIO of the VA system recently stated that the VA must find a way to accommodate  iPads at a  conference on federal information technology.

According to Baker, the fact is that 100,000 residents rotate through the VA each year and “they’re all carrying mobile devices”. In order for them to do their jobs, they want to be able to access resources on the internet.

In an article published at nextgov.com, CIO Roger Baker said

I’ve told my folks I don’t want to say ‘no’ to those devices anymore…I want to know how I say yes

The key, according to Baker, is security. While the iPad can be secured, proper protocols need to be developed. Otherwise, the device can be likened to a “huge unencrypted USB stick with no pin”. In order to facilitate development of security protocols, a pilot program has been launched giving out iPads to select employees in situations where security is looser.

In an easy to understand analogy, he proposed

If it won’t go on a device where you’re willing to put all your banking information, your pins, your passwords, [then] don’t put veterans’ information on it.

As we have published on this site before, there are ways to secure your iOS device adequately for medical use (“How to secure your iPhone or iPad for medical use“). The issues are not always technological, often it is a question of policies and habits of the users. A positive contribution by a large scale institution like the VA can only help to instill good habits and a better understanding of security in future doctors.

For anyone interested in mobile health, the pace of new developments, partnerships, and innovations is dizzying. In this series, we pore through the latest in the mobile health world and pick a few articles that we think are interesting and convey important developments. Be sure to let us know what you think by adding your comments to this post !

GenerationOne Selected by Cincinnati Children’s Hospital Medical Center for Mobile Health Pilot with Teen Asthmatics
From PR Newswire

GenerationOne and the Cincinnati Children’s Hospital Medical Center have conducted a pilot study testing the efficacy of using mobile phones to improve the treatment of teenagers with asthma.

Adherence to treatment regimens is a particularly challenging issue in treating asthma. To help with this, researchers sent personalized reminders and messages to participants’ cell phones. Positive results of this pilot study will hopefully lead to bigger and more thorough trials.

Mobile Alliance for Maternal Action (MAMA)
From Council on Foreign Relations
Secretary of State Hilary Clinton announced the latest addition to mHealth in developing countries. The Mobile Alliance for Maternal Action (MAMA) will seek to use mobile phones to provide personalized health information for pregnant mothers in Bangladesh, India, and South Africa. The official site for MAMA has more information on the initiative and its goals. This article also highlights various other mHealth initiatives in developing countries such as TulaSalud in Guatemala, MoTeCH in Ghana, and a program for Lady Health Workers in Pakistan.

Healthcare providers eye 3G tech for the next leap in telemedicine
From livemint.com
The hope for telemedicine and wireless networks to address basic health needs in developing countries is gaining momentum. This article examines the potential for growing 3G networks in India that could lower the costs for remote video consultations – a cost that has deterred private companies from investing in this market. Mobile phones and networks could potentially revolutionize access to physicians for communities with limited medical infrastructure.

Medtronic sees big value in iPads
From Financial Times
Leading medical technology company Medtronic looks to maximize the potential of the iPad in its marketing interactions with physicians and to improve the functionality of its medical products. Sales representatives can use interactive charts and visuals in their meetings with physicians, allowing for a more collaborative approach to device sales. More importantly, as Medtronic looks to develop apps that integrate their products with mobile devices, users will have access to “understandable, useful data that patients can access on their tablet computers, allowing them to better manage their health.”

The Chicago Sun Times is reporting on examples of how Apple’s iPad has been adopted by doctors and hospitals in their region.

In this article by health reporter Monifa Thomas, the examples and quotes paint a picture of enthusiastic adoption, that spreads rapidly once the tablet device appears and doctors find that it can be useful for their daily activities.

Examples include a plastic surgeon who uses the iPad to demonstrate to patients what they might look like after breast reconstructive surgery, an emergency room doctor showing patients radiographs of their injuries (photo) and Loyola University Medical Center which has given iPads to all of its orthopedic residents as part of a pilot program.

In at least one hospital, being able to access the hospital electronic health record (EHR) via the iPad was the critical factor.

Once doctors there learned that they could access the hospital’s electronic medical records with the iPad, “it went through here like wildfire,” said Dr. Richard Watson, an emergency room physician at MetroSouth.

The article notes that since patient information is not stored on the device, security and privacy are less of a concern. Check out the original article at: iPad functionality just what doctor ordered

via Cult of Mac

Dell’s recently released tablet, the “Streak”, was actually designed with the medical community in mind.

Jamie Coffin, vice president of Dell Healthcare and Life Sciences, says Dell thought about the form factor of the device in relation to a lab coat – along with other types of functionality the device delivers such as front and back facing cameras and video conferencing.

The key though is Dell’s planned integration with their established health care software.  They want the Streak to be used to access electronic medical records and other patient data via secure networks.

We’ve documented before how Dell has close partnerships with electronic medical record companies, but it’s obvious Dell is hoping for a more intimate relationship with the health care sector after they spent $3.9 billion late last year acquiring Perot Systems, a technology services provider. Almost half of Perot Systems revenue comes from the health care industry and the main driver for Dell’s acquisition was to be a player in the 2009 Recovery Act’s stimulus reimbursements for the adoption of electronic health records.

Dell made sure to take a few knocks at Apple’s iPad when mentioning the Streak and health care – saying the iPad does not provide enough “functionality” for health care professionals and the iPhone 4 is too small for physicians to use with patients.

The Streak’s screen size is 5 inches, smaller than the 9.7 inches offered by the iPad, and larger than the 3.5 inches offered by the iPhone. The tablet is actually designed to work as a phone as well – albeit an over sized one.

Features that make it appealing for the medical community:

*Syncing with Dell’s existing health care software systems

*Long battery life: Some reviews estimate 10 hours on one full charge. Battery is also removable, allowing for easy replacement when used for extended periods

*Front facing and back facing cameras: Ability to video conference – we have mentioned how medical video conferencing (telemedicine) is a hotly debated topic in regards to physician reimbursement.

*Ability to work as a phone (3G Cellular Network): The key here is the ability to use the device to access off site patient data when not connected to Wi-Fi – such as in a mobile health care setting or in clinics without Wi-Fi networks.

*Relatively inexpensive when compared to other health care tablets: The Streak costs $549.99, or $299.99 with a 2-year contract from AT&T.

Features that don’t make it so appealing:

*800 by 480 LCD screen: Although a relatively good screen resolution, the iPad boasts 1024 by 768

*Price:  Even though the Streak is still relatively inexpensive compared to health care tablets, it’s one third the size of the iPad yet costs more than a standard iPad, and only $80 less than a 3G iPad.

*Form factor: Although it’s definitely bigger than an iPhone, it’s significantly smaller than an iPad. When viewing medical imaging and electronic health records, real estate on the screen is a must and this size might be too small.  It could be argued the 5 inch screen barely makes the device a tablet in the first place.

Final Thoughts:

The Streak tablet phone runs on the Android platform and will link to patient information stored in databases using an app on the phone. Dell expects to start testing the tablet with physicians later this year.

This tablet by Dell is definitely different than other traditional health care tablets. Not only is it smaller, but also significantly less expensive. The ability to connect to the internet using a 3G carrier is crucial for off site access of patient data or for home health purposes. The tablet also had a relatively long battery life and if Dell can properly implement it with their currently health care software infrastructure there is a chance it could gain wide acceptance in the medical community.

One of the biggest questions this implementation by Dell raises – Since they are running the Android OS, and the EMR functionality will be provided by an app on the device, will other Android phones be able to access the same information via the App?  Or will the App somehow be exclusive to the Dell Streak?  This is  a question that will surely be raised as the tablet undergoes further testing in the health care field, especially for those that might be a fan of Dell’s health care infrastructure, but not their hardware.

The following is a hands on video review of the Dell Streak:

Story Source: Reuters via Gizmodo
Other Sources: Wall Street Journal, Engadget

One of the issues we’ve discussed previously is that, when it comes to iPhone and iPad acceptance in healthcare, compatibility with the more traditional enterprise solutions could turn out to be a problem for large scale adoption of iOS 4 devices.

There was a fair amount of concern that the iPhone and iPad, as consumer electronics, would lack the necessary business-oriented features to ever be widely adopted by corporate America, let alone healthcare.

However, a recent article in the Wall Street Journal suggests that Apple may be making major inroads when it comes to adoption as a business-wide mobile solution and this time with the blessing of corporate IT.

The vast majority of electronic medical records run on Microsoft Windows-based and Exchange-based operating systems and servers. Additionally, the traditional stalwarts of mobile enterprise solutions – Blackberry and laptops running Windows – were tried and true products when it came to the ability of IT departments to maintain secure, centrally controlled networks for their companies. However, according to the WSJ,

Businesses are behaving differently with the iPad, in large part because the new device is starting out as more of a known quantity from a technical standpoint. The iPad runs the same operating software as the iPhone, which has been enhanced with a number of business-friendly features.

Some of these enhancements include the ability to internally distribute apps via a corporate network, thus bypassing the App Store, as well as improved techniques for securely connecting to a corporate network. Healthcare is traditionally a late-adopter of non-healthcare technology (i.e. everything but the latest and greatest imaging and procedure modalities).

So the note in the article regarding testing being conducted at Kaiser Permanente’s tech lab in California is particularly exciting. Kaiser is working with the iPad for viewing medical imaging, working with an unspecified EMR, and more. All in all, these developments bode well for the adoption of the iPhone and iPad as a mainstream, IT-blessed mobile healthcare solution.

When Apple’s retail stores reopened yesterday at 5pm, they had a shiny new item sitting on their shelves – the iPad 3G.  At iMedicalApps, we’ve certainly been excited about the iPad, not only because its a great device that could work for clinicians, but also because it is hopefully just the leading edge of a new generation of tablets that will finally free healthcare providers from paper charts and computer stations.

For the most part, the 3G iPad is no different than the non-3G iPad in terms of hardware. So the question is, is the 3G premium worth it? With going rates of $630 for the 16GB device, up to $830GB for the 64GB device, it definitely carries a substantial premium over its non-3G sibling. In addition, the unlimited data plan from AT&T will run another $30/month. My first impression – not yet, but it will be. Here’s why.

Reason 1: Electronic Health Records

The greatest promise of the iPad and the coming generation of healthcare tablets is putting the electronic health record – patient records, decision support tools, safety stops, billing, etc – in the hands of healthcare providers at all times. As healthcare evolves to respond to our current challenges, the flexibility to put tools into the hands of clinicians will be crucial. At Johns Hopkins, my home institution, the Elder House Call Program is an excellent example of an innovative response to a patient-care challenge that would benefit from a 3G enabled device like the iPad. The gist of this program is that a team of physicians, nurses, and other professionals provide in-home care to elderly patients who lack the mobility to get such care on their own. A similar program exists in Pediatrics here.

From some of my peers who have participated this program, it is an incredible experience, an opportunity to provide care for the person rather than the disease. A 3G iPad here could enrich the encounter in so many ways – videos uploaded by PT to the EHR to document mobility one week, reviewed by the physician who visits the next week ; access to online patient education modules for teaching patients about whatever topic comes up ;  the ability to actually review radiology and labs face-to-face ;  and so much more. There are similar opportunities in many other areas – rural/remote care, care of indigent populations, and so on. In addition, if healthcare peripherals are developed for the iPad (blood pressure cuffs, weight scales, maybe even portable ultrasound), the opportunities to provide care anywhere/anytime get bigger.

So why not yet? The reason is simple – electronic health record platforms out there are still maturing and building the capabilities that would allow them to take advantage of truly mobile healthcare. Some of the more rigid, cumbersome systems will take some time. More flexible systems with a “plug-in” based infrastructure, as Dr. Wodajo described previously, may be ready sooner. But the fact is that current EHR’s are designed for hospitals and clinics with workstations. But they are certainly on their way to embracing mobile healthcare.

Reason 2: High-Powered Apps

Apps are another cornerstone of mobile healthcare, as evidenced by the success of the iPhone in healthcare. The ability for developers and clinicians to fill niche requirements quickly with a targeted app has turned the iPhone into the “peripheral brain” of many clinicians, putting incredible amounts of information at their fingertips. And many developers are embracing the mission of evidence-based healthcare, trying to put decision-support tools and practice guidelines into the hands of clinicians. Take the app CORE – Clinical ORthopedic Exam – from Clinically Relevant Technologies. This app provides instruction on common physical exam techniques, including sensitivity/specificity and follow-up testing information. Videos of the techniques are linked in the app but stored on YouTube.

Any comprehensive resource that includes lots of videos compromises device memory if stored locally, so many developers opt to store on a platform like YouTube. This also allows them to readily add to that database of video as needs arise. As cloud storage of content in these high-powered apps is likely to grow, having a 3G-enabled tablet lowers the oft-cited disadvantage of such storage. Take a patient education app that includes lots of videos, like Blausen Human Atlas (above). In our home-visit scenario, I can now access high-resolution video that helps me explain a cholecystectomy to the elderly woman who I think has gall stones. And as the needs arises, developers can augment these resources without worry about compromising device memory.

So why not yet? Frankly, the iPad app store isn’t there yet. Many apps which we think would be perfect for the iPad are not yet available in iPad optimized forms, and therefore resolution is poor when trying to use the iPad. But they are coming.

So in the end, 3G will be a big plus for the iPad some day soon. But its not quite there yet.

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

Lexi, a medical information provider for 30 years, is making news by releasing an iPad-compatible version of its comprehensive drug and disease database. This is notable not only because of the depth of its databases but also because it’s beating other medical players to the iPad door – including Medscape, Epocrates and Evidence Central – all of whom have iPhone apps in the market but have not yet released iPad versions.

The evolution of mobile computing will help redefine the competitive landscape for point-of-care clinical information solutions. Lexi, a name not commonly heard among the most familiar iPhone medical information apps, has been selling its products to hospitals and physicians since 1978. A look at its website shows that it has a complex, multiple-tiered pricing structure, allowing individuals and institutions to choose which subset of its many databases they want to license. It has also made these databases available on multiple smartphone platforms. In an era where Medscape and Epocrates are offering substantial amounts of information for free, it may be understandable that many medical students and residents have not yet downloaded Lexi’s applications, although their hospital librarians may be quite familiar with them.

The release of Lexi’s iPad app now gives us a chance to see what they have to offer. Put succinctly – a lot. For the purposes of this review, we were given access to “Lexi Comp”, a comprehensive package of all the Lexi databases which normally would cost $285/year to subscribe. As can be seen by the accompanying screenshot of the setup process, the menu of downloadable databases is quite impressive.

The list of downloadable databases in the comprehensive package includes drug databases, including information on pill identification, dosages and contraindications, which would be familiar to users of Epocrates and Medscape. However, Lexi goes further by making available databases of pediatric drugs and dosages as well as of IV medication compatibility. The latter is actually quite useful for inpatient care, although most physicians are unaware of the juggling often performed by nurses and pharmacists in coordinating the administration of simultaneously prescribed IV drugs. The pill identification module has a nice feature where pill characteristics, such as color and shape can be added individually, narrowing the pool of possibilities with each selection.

Adult and pediatric patient information modules are designed as concise handouts to give to patients and families being prescribed the medications. This can be greatly valuable for a busy practice, especially for patients who would otherwise “google” every medication they are prescribed, obtaining information of varying quality and possibly affecting compliance.

The comprehensive package also includes clinical information culled from Harrison’s Textbook of Medicine in the form of brief disease monographs, useful for quick review when confronted with an unfamiliar entity. These summaries overlap somewhat between the Harrison’s database and the adult and pediatric “5 Minute Clinical Consult” databases. Both of these allow for user generated text to be appended in a “notes” section at the end. An incomplete list of ICD9 codes is also included.

There are also databases of oral diseases and manuals of periodontal conditions as well as databases in Spanish. Among the more impressive databases is a comprehensive list of household products including those used in the  bathroom and in the yard, listing  active ingredients, what do to in case of ingestion and as well as manufacturers’ contact information.

What I liked about this application

• The breadth and depth of the available databases is amazing, I would imagine most individual physicians would only need a small portion of the available databases.
• The iPad app was easy to download and provision with the desired databases.

What I didn’t like as much or would like to see in future releases

 
• Aside from the four items in the navigation bar at the bottom, there was no structure to the application itself to make discovery of the information more intuitive. In particular, the home screen accessed with the first “library” tab was simply a long list of the downloaded libraries.  Thus, it is evident that the application is merely a portal to a long list of disparate information and misses an opportunity to add value in of itself.
• As the app was undoubtedly ported from the iPhone, many of the screens retained the one column format required by the small screen of the iPhone and thus look awkward on the iPad. I  have also noticed
  that this is common to other apps ported to the iPad. Perhaps this is an opportunity for the application designers to imagine a new two or three column navigation tool that more efficiently exposes the rich seams of information hidden in the many databases.
• The inability (yet ?) to print directly from the iPad means that patient information sheets may not be as convenient to give to patients as would be hoped.
• Finally, Lexi Comp suffers the same issue as other mobile or point-of-care clinical information applications, namely that the physician interacts most intensively with the patient and the electronic health record (EHR) during the all-too-brief patient visit. Requiring the physician to interact with yet a third entity (e.g. Lexi) is less likely to succeed than solutions which incorporate clinical information solutions embedded within EHRs, presumably through partnerships. Currently Lexi offers EHR data integration for drug interactions, expanding this to disease and patient information could add great value.

Conclusion
The Lexi Comp application brings together an amazing wealth of clinical information. It has the capacity to help physicians make better decisions and to provide their patients with useful information about medications they have been prescribed. The application serves as a subscription portal to the numerous component databases, which have been presumably refined over the over 30 year life of the company. I would hope that as EHR penetration into office practices increases, more partnerships are created in the future to integrate patient management and clinical information into streamlined applications.

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This is part two of a two part series focused on the iPhone 4.0 Operating System (OS) recently announced by Apple.

Enterprise and Security:

One of the key updates in iPhone OS 4.0 are related to enterprise – the Blackberry’s forte. The upgrade in enterprise will be instrumental in the iPad and iPhone platforms penetration into large health care business, such as hospitals or hospital systems. Here, the new features are aimed at pleasing the healthcare IT department by simplifying mass iPhone/iPad deployment and enhancing data security and Microsoft Exchange integration.

In contrast to small ambulatory clinics, large hospital systems may have to deploy hundreds or thousands of devices at a time. iPhone OS 4.0 will allow wireless device provisioning, so the IT department can be sure all users’ iPhones start with the same setup. Devices can be remotely locked or wiped, in the case of loss or theft.

For example, if a healthcare provider loses their iPad, you can quickly locate it using GPS. If it’s apparent the iPad has been stolen and is off the hospital campus, the IT department can erase all the data on the iPad remotely – preventing patient data from falling into the wrong hands.

In terms of data security, now all application data can be encrypted. Before, only email messages, calendars, and contacts could be encrypted. And, now one iPhone or iPad can by synced with multiple Microsoft Exchange accounts, this is especially nice since the new Mail app will have a unified mailbox that allows all messages to be viewed simultaneously, instead of the user having to switch screens between multiple email accounts.

Other features

The addition to the iPhone OS that could possibly have the largest effect on the health of the platform is “iAd” advertising. Although this feature most likely will not effect medical applications, this truly innovative technology allows a small banner ad to be periodically displayed at the bottom of the screen, and responds to a user click by expanding to fill the whole screen. At that point, the ad producer can display animation, video, interactive games and even polls, providing a compelling, almost cinematic advertising experience. At any time, the user can tap a small “x” at the top to resume the suspended application. The infrastructure for iAd is integrated directly into the operating system (and patented). Apple will host and sell ad inventory, no doubt fortified by their recent acquisition of the mobile ad agency Quattro.

The importance of this for the iPhone OS, however, is that advertising revenue will be split 60:40 with the developer. While the future success of the iPhone OS platform will depend on Apple continuing to refine the software and hardware, it’s critical that Apple attract developers to continue writing applications for the iPhone OS.

There have now been 85 million iPhone OS devices sold, giving Apple a potentially massive audience for mobile advertising.  If the iAd platform is successful, the increased competition should lead to higher quality medical and healthcare applications – and hopefully cheaper ones as well.

Conclusion

Apple billed version 4 of its iPhone OS as the “the biggest and most exciting iPhone software update yet.” The consumer and enterprise features appear to address the most frequently cited shortcomings of the operating system, while recognizing mobile devices’ needs to preserve CPU and memory resources as well as battery life. The 4.0 update is currently only available to developers.  iPhone users will be able to upgrade this summer, while iPad users will have to wait it out until Fall 2010.

We can’t stress how important the enterprise and security features are for the viability of the iPhone OS in the healthcare setting.  Consumers can feel more assured their personal data will be protected – and mobile health industry leaders should take these signs as a serious attempt by Apple to court them.

ltifat Husain contributed to this post

If you dream of pulling out your shiny iPad from your white coat to look up medical information via an app, similar to what you do on your iPhone, you might think: surely, my iPhone medical apps must look better on my iPad.  You should know the following before entertaining those thoughts.

Will the iPad fit in your white coat? check.  Is the iPad fast enough for this type of healthcare point of care use? check. Will your iPhone medical apps run on the iPad? Check. Do the iPhone medical apps you have translate their user experience over to the iPad? Not really.

In our recent hands on review of the iPad, we were definitely excited with the iPad’s potential, especially for the medical community.  With that said, there have been two huge disappointments with the device.

One – from a visual perspective, the iPhone medical app user experience does not translate well to the iPad.  Two – there are just a handful of legitimate medical apps for the iPad right now.

iPhone medical apps within the iPad

When Apple announced all existing apps running on the iPhone Operating System would function smoothly on the iPad, many of us in the healthcare field assumed the user experience of these apps would be replicated on the iPad – possibly even enhanced by the significantly larger screen.  This didn’t come to fruition, and here’s why.

If you look at the below screen shots, you’ll see an example of how Epocrates and the Blausen human atlas will currently look when you load them on your iPad.

Notice how they take up the same amount of real estate on your iPad as the size of your iPhone.  There is an option to take up the full screen of the iPad, by tapping the “2x” button in the bottom right corner (notice larger epocrates look), but this just doubles the pixels, and causing a blurring and pixilation effect.  The iPhone is set to a resolution of 480 by 320, while the iPad is set to 1024 by 768, which is why this effect is so pronounced.

Marc-Emile Plourde, one of the creators of the popular iPhone medical app, Md on Call, says developers can approach customizing their apps to the iPad in three methods:  Don’t do anything about it (not a good option), create a completely new app designed for the iPad, or update an existing app so it runs on both the iPad and iPhone platforms.

The advantage of the third option is users who’ve already bought the app for their iPhone won’t have to pay for it again on their iPad.  Marc-Emile says many developers are opting to go with the second option, creating a new app that has the same features, in an effort to increase revenues.  Marc-Emile decided to go with the third option.  MD on Call, below, has already been customized for the iPad, and is free of charge for those who have purchased it on the iPhone already.

Lack of medical apps customized for the iPad:

Another iPhone medical app that has been updated with this third option is the popular app, Medical Spanish.  Ameir Al-Zoubi, the developer of this app, says timing and access are key reasons why we do not see more medical apps customized for the iPad.  Developers have had access to the iPad SDK (software development kit) and the iPad simulator since January 27th, but very few developers have had access to the actual device until its release. [screen shots of the Medical Spanish app, customized for the iPad:]

Ameir says many developers have been hesitant to release iPad customized updates of their apps until they have been able to test out their app on the actual device itself.  This is a sentiment shared by Marc-Emile and other developers I’ve contacted as well.

The below chart from Distimo shows how the medical apps category is only ahead of the Finance, Navigation, and Weather categories when it comes to iPad applications.  More notable, however, is the explosion of games for the iPad.  This isn’t a huge surprise since the games category has always been the most popular and usually yields the highest revenues for developers.

What we can expect in the future and what this means for now:

Currently, Epocrates, Blausen Human Atlas, and many more iPhone medical apps are in the process of updating their apps so they take advantage of the iPad – We’ve been told by these developers that the iPad customized version of their apps should take anywhere from a week to a month.

Time appears to be the biggest factor in this transition.  Many developers feel it’s better to wait and make sure their app runs flawlessly on the iPad, verse rushing out an iPad customized version filled with bugs and other errors.  Until then, we’re hoping the top 5 iPhone apps we want to see customized for the iPad get updated soon (the Papers app has been converted already).

If you want to use your iPad in clinic as a reference tool, for medical education, or for patient education, you might want to hold off on your purchase for now.  At the end of the day, the App Store is what makes the iPad stand out, and it’ll take time for apps, especially medical ones, to catch up to the hardware.