By: Ankur Gupta, MS1 & Iltifat Husain, MS4

This past week yielded a surprisingly impressive release of quality free and paid medical apps for both the iPhone and iPad. Those in cardiology have a couple app releases that should make them very excited, but this list also contains many apps that primary care and other specialists should be interested in as well.

CathSource

An up-to-date reference for cardiac catheterization and angiography. Contains videos, images, and overviews on a variety of topics pertinent to specialists and trainees in cardiovascular conditions.

Also includes detailed videos and descriptions of key cardiac pathology that can be seen on catheterization.  Although aimed at specialists, could be used a reference tool for students or residents who are rotating through the CCU or other cardiology rotations.

Devices: iPhone, iPod Touch, iPad
Price: $3.99

iTunes Link: CathSource

3M Littmann Sound Builder

Students and practicing clinicians can use this app to improve their auscultation skills through 14 lessons based on key heart sounds. Includes text, 3D cardiac animation, dynamic waveforms, and a virtual manequin along with the lessons. Potentially a great educational app for students and residents learning heart auscultations — best part, it’s free.

Devices: iPhone, iPod Touch, iPad
Price: Free

iTunes Link: 3M Littmann Sound Builder

ASE Pocket Guidelines

This app, developed by the American Society of Echocardiograpy (ASE) provides mobile access to charts from its guidelines.

Devices: iPhone, iPod Touch, iPad
Price: $9.99

iTunes Link: ASE Pocket Guidelines

iVCLv2.0 – Cardiac

We reviewed the free app, iVCL, just the other week — and the developers continue to impress us. This current app is a 3D virtual fluoroscopy simulator, and allows you to learn how to orient yourself when trying to view key cardiac anatomy.

Devices: iPhone, iPod Touch
Price: $2.99

iTunes Link: iVCLv2.0 – Cardiac

CMR Atlas

A mobile atlas for cardiac disease visualized by cardiac MRI. Pins on each image show information on anatomy, MR sequences, and disease specific MR information.  Although images aren’t crisp, the app is currently free and worth a try.

Devices: iPad
Price: Free

iTunes Link: CMR Atlas

3D Tooth R

This app offers users a 3D look at the anatomy of human teeth. Those in dental school, or those who are practicing nerve blocks might find the clinical anatomy useful. Overall though, it appears too rudimentary for serious use by students in graduate school.

Devices: iPad
Price: $0.99

iTunes Link: 3D Tooth R

Textbooks: Clinical Anesthesiology ; Current Diagnosis and Treatment in Family Medicine

Two significant McGraw Hill textbooks from MedHand, customized for mobile form for both the iPhone and the iPad.

Clinical Anesthesia provides basic principles and clinical considerations in the anesthetic management of patients. Includes information on equipment, pharmacology, regional anesthesia, pathophysiology, pain management, anesthetic management, and critical care.

Current Diagnosis and Treatment in Family Medicine, as the title describes, is focused for primary care, and covers medical information ranging from pediatric to geriatric care.

Devices: iPhone, iPod Touch, iPad

iTunes Link: Clinical Anesthesiology
Price: $79.99

iTunes Link: Current Diagnosis & Treatment in Family Medicine
Price: $74.99

OsiriX HD

Companion app to OsiriX – an interactive visualization program for MacOS designed for the display and analysis of medical images. Supports many common imaging modalities, and can be a huge advancement in teleradiology. Designed to work seamlessly with OsiriX, but does not require it. We have covered this app extensively before on iMedicalApps.

Devices: iPhone, iPod Touch, iPad
Price: $29.99
iTunes Link: OsiriX HD

Exporting Patient Imaging to the iPad

[Editor's Note: Felasfa Wodajo, senior editor at iMedicalApps, had the following article published in the Journal of Surgical Radiology.  This is Part 2 of a two part series, in Part 1 we wrote on the general uses of the iPad in the Operating Room.]

As previously mentioned, one use of the iPad in the OR is to bring patient imaging studies to surgery. But, how does one copy computed tomography (CT) or magnetic resonance imaging (MRI) images from a patient’s CD ROM to the iPad? I have found a very useful method involving two terrific and freely available resources; OsiriX and Dropbox.

The first, Osirix, may already be familiar to many readers of this journal. For those not yet acquainted, OsiriX is a free, open source DICOM (digital imaging and communication in medicine) viewer written for the Macintosh. I find it easily superior to just about every built-in reader bundled with patients’ CD-ROMs and routinely use it to view patients’ DICOM data. It is an indispensable part of my practice. In addition to basic features, such as measuring distance and angle, modifying window and level, zooming and panning, OsiriX has some features usually available only on expensive imaging workstations, such as 2D  & 3D  image reconstruction, and fusion of PET & CT studies. While the iPhone version of OsiriX will run on the iPad, I still find transferring DICOM files between the desktop and mobile applications unwieldy. Therefore, I will describe a simple method that uses Dropbox to export selected images to the iPad.

Dropbox is a multi-platform file-syncing utility.  This terrific service has a web component and native applications for Macintosh, Windows, Linux, iPhone and iPad. It is able to rapidly synchronize files across multiple devices through file-level trickery in which it determines only those portions of the files that are changed.

Sample Workflow

My workflow is as follows (see above screenshots):

1. Insert patient’s CD ROM in computer and open with OsiriX
2. Identify key images of interest
3. Export images as JPEGs into Dropbox folder on computer
4. View images using Dropbox app on iPad

I also use the Apple iPad camera adapter to quickly transfer intraoperative photos to my iPad.  For the curious family member, these photos can really enliven the post-op waiting room conversation!

One glaring omission on the iPad is a method to organize images into albums that would be preserved even when the iPad is synchronized with iPhoto. The apps available for organizing photos on the iPad, such as PhotoSort, appear to duplicate the images rather than manipulate the native photo album. We can only hope Apple will provide this function in future updates of the iPad OS.

iPad on the Wards

Dr. Henry Feldman of Beth Israel Deaconess hospital in Boston shared with iMedicalApps.com his experience using the iPad as his primary computing device for a week as an attending.

One instance where the iPad really shone, he wrote, was its “nearly seamless experience” in accessing his hospital’s wireless networks. “The secure wireless network handoff was amazing. As I roved around it was seamless … and the best example is that I would use the elevator ride to catch up on news/tech websites, and every time the elevator doors would open it would reconnect and download some more prior to the door closing.”

The soft keyboard of the iPad, he found, was adequate for the bulk of his documentation needs on the wards. He brought his Bluetooth keyboard and iPad stand to the hospital but found both “sat on the shelf for one week, unused.” He used desktop computers for complex compositions such as admission notes and discharge summaries, but felt “this had less to do with the keyboard than being able to see multiple web pages at once.” Orders and discharge plans did not require an external keyboard although, “after one beefy paragraph the screen keyboard does feel a tad clunky.” Despite this enthusiastic report of iPad usage from an experienced physician, we should remember that Beth Israel has a sophisticated web interface for all their major clinical applications, making the transition to using an iPad fairly seamless. Personally, I also find a bluetooth keyboard much faster for typing longer documents.

When asked about security concerns with the iPad, especially if one is left behind inadvertently, Dr. Feldman pointed out that as with everything web-based, nothing is stored on the device. The iPad (like an iPhone) can be “remote-wiped,” meaning all the data and settings on the device can be erased remotely. Note that this requires a MobileMe subscription ($99 per year). Each of the applications in the hospital has a username/password, and network communication for most of the applications occurs over an encrypted (SSL) connection. These measures, Dr. Feldman suggested, already exceed the security that almost any institution places on paper charts. He also mentioned a strategy for the lock screen which I have since adopted. This involves replacing the iPad’s default background with an image including one’s name, cell and pager numbers, for device return information if the iPad were to fall into friendly hands.

Conclusion

The iPad clearly has the potential to be very useful in the hospital and in the operating theater. Medicine is, by its nature, a mobile occupation and a powerful and flexible computing device will almost certainly play some role in our future everyday practices. There is still much to be learned and undoubtedly we will see the introduction of other devices with different strengths and weaknesses. In my practice, using the resources described above, I have been able to maintain a portable image repository of my patients that has been very useful in the operating room, office, and in hallway discussions with colleagues.

Dr. Sam Friedman, a radiologist and chief technical officer and medical director of nuclear medicine at Pitts Radiology, has done an in depth review of the iPad’s potential for viewing medical imaging in the Imaging & Radiation Oncology Journal.

He looked at five different medical apps: eFilm Mobile, OsiriX, iClarity, MIMvista, and ResolutionMD.

His overall conclusion after using the five radiology viewing medical apps viewing apps was:

The ultimate question is whether the iPad will be useful as a radiology viewer. After much fooling around, I can honestly answer “Maybe” or even “Probably.” With today’s software, the iPad can be a very basic–but very portable–viewer. If that’s as far as we get, I likely wouldn’t go out and buy one just for that purpose. But I think we’re at the very beginning of something revolutionary.

His favorite app out of these five appeared to be ResolutionMD from Calgary Scientific. It’s no coincidence this is also the only app currently approved by Health Canada (our version of the FDA) for diagnostic imaging use by Canadian physicians.

One of our editors, Felasfa Wodajo, a bone and soft tissue tumor surgeon, had similar findings as Dr. Friedman when he reviewed OsiriX for the iPhone last year.

Dr. Friendman’s fantastic review inspires a great deal of hope for the iPad being used to view radiology images – but is also notable for pointing out the lack of iPad radiology viewing apps customized for the iPhone. All the apps used in his review are made to be run on the iPhone’s native screen – not the iPad.

Also, a special thanks to Dr. Friedman for mentioning us in the bibliography for his journal article.

Source: Imaging & Radiation Oncology via Medgadget

[picture from iMedicalApps review of OsiriX on the iPhone]

Apple has made it clear that current iPhone apps will run on the iPad.  For many of the medical apps we’ve reviewed, its welcome news, but it won’t make the user experience of these apps any different.  However, there are a few medical apps currently on the iPhone whose user experience should be greatly enhanced by the iPad’s 9.7 inch 1024 x 768 pixel display.

The following are the top 5 medical apps we’re excited to see in action on the iPad.  This list is focused for health care professionals, and stay tuned for another list for medical students. Of note: These apps will only be great on the iPad if the developers port them over – basically, if the developers make a custom version of the app for the iPad.

(1) Blausen Human Atlas – When I think of the iPad in medicine, this app embodies one area in which the iPad could shine.  The Blausen Human Atlas includes 3D figures of human anatomy, an expansive medical glossary, over 1,000 still images, and a library of videos explaining common medical conditions like GERD and osteoarthritis.

Basically, everything in this app is designed with the goal of improving patient-physician communication. A provider who is trying to explain cholecystitis to a patient could access videos that explain the disease, still images to clarify any confusing points, and even 3D figures of GI anatomy to explain the corrective surgery.  The app performs admirably on the iPhone’s 3.5 inch display, but on a display more than twice this size – the iPad’s – it should shine.

Links: Blausen Human Atlas App Review
[iTunes Link]

The torrent of clinical information being made available on smartphones does not seem to be showing any signs of slowing.  Merge Healthcare just announced March 1 an iPhone OS app, available for the iPad, that connects seamlessly with their eFilm workstation to make available patients’ studies as quickly as they are accessioned by the radiology technician. Many hospitals already use the eFilm Workstation for their radiologists to view studies stored on their hospital PACS (Picture Archiving and Communication System). What this announcement means is that a physician who works at that hospital can also now immediately view those high resolution images on their iPad.

While other imaging applications for the iPad and iPhone exist, such as Osirix which we reviewed previously, the advantage here is that the communication between the PACS server and the the mobile device is maintained transparently and securely by servers at Merge. I can attest that connecting Osirix to an imaging server is challenging, mostly due to the arcane requirements of the DICOM standard’s “Query & Retreive” method of communication.  In exchange for this simplicity, however, the app owner is charged a $24.99 monthly subscription fee, in addition to the $9.99 purchase price.  Merge also notes that this app is not intended for diagnostic use, and seemingly to reinforce this status, they have left out any measurement tools such as distance and radio-density, available on the Osirix app.

The company has announced a testing partnership for their mobile platform with Massachusetts General Hospital, perhaps to bring forth more features. The eFilm Mobile app is available for download now in the App store. Separately, Merge recently announced a merger with AMICAS, another medical imaging technology vendor for $248m in cash, to form one of the largest providers in that arena.

Also announced recently is AirStrip Technologies Radiology viewer. This is part of their AirStrip OBSERVER suite and thus will presumably be deployed similar to the other AirStrip apps, meaning it is  installed and licensed by the hospital and provided free to physicians. Without hands-on experience, we cannot say how each application works but the two companies’ strategies are clearly distinct. Merge is offering the mobile app to enhance their workstation software while AirStrip Technologies is depending on the hospital to do the work of integrating their product into the hospital and pay for it.

For specialties who rely extensively on imaging, such as orthopedics, the seamless ability for physicians to view patient studies on a smartphone is a potentially very helpful development.

One problem that has plagued physicians in specialties where imaging is important is how to describe a patient’s imaging findings to a colleague. Certainly, the radiologist’s report is helpful but sometimes it’s not enough. Particularly for surgeons and interventional radiologists, imaging findings are like a road map to a procedure. If you’ve ever given driving directions to an out of towner, you’ve seen the look of confusion overcoming their face as you desperately pile on landmarks hoping they don’t get lost. But, if you are a physician, how do you communicate the subtleties of abnormal anatomy without pictures?  This review will discuss how this application helps put a legitimate image viewer in the palm of your hand via the iPhone Operating System.

The Osirix iPhone app can actually help. This well-written application brings a small and easy to use DICOM viewer to the iPhone. DICOM is the standard file format used for almost all forms of radiology imaging, including CT, MRI and nuclear medicine.The Osirix iPhone app ($19.99) is a good companion to the OsiriX desktop application (http://www.osirix-viewer.com/). For those not familiar with this remarkable piece of software, it’s a free & open-source DICOM viewer developed specifically for Mac OS X by a group of radiologists. The desktop application is now over 5 years old and is a mature, feature filled imaging workstation. It’s a rope of rescue from the minimalist and poorly designed viewers included on imaging CD ROMs brought in by the majority of patients these days.

The Osirix iPhone app can download images from the OsiriX desktop application over a wireless network. If you have access to your institution’s PACS server, it can even interface directly to the PACS using the DICOM Query & Retrieve (“Q&R”) protocol. Once the images are on the iPhone, you can scroll through them, change the windowing (soft tissue, bone, lung, etc.), make measurements, and even quantify Hounsefield (radiodensity) units!

What I liked about this app:

• ability to zoom, pan and change windowing as well as make measurements
• once image files are on the phone, good performance
• the iPhone Osirix viewer is immediately recognized by the desktop app, if on the same wireless network
• the help instructions are well-written and available from the top level tab-bar

What I didn’t like:

• the price tag might dissuade a few people from trying the application
• performing a query & retrieve over the internet from the OsiriX desktop application is very slow, making it almost mandatory to transfer images over a local wireless network
• if the DICOM server is behind a router (which is usually the case in a small office), the patient study list will be visible but the images cannot be accessed. While this is probably a limitation of the DICOM Q&R protocol, it is especially unfortunate now that we have powerful mobile DICOM viewers available.

What I’d like to see in future updates:

• using a single button for pan vs. zoom vs. window is a bit confusing, the three functions should be separated
• a subset of the amazing 2d (and 3d?) image reconstruction features available on the desktop application
• if feasible, a work-around to the DICOM Q&R protocol, giving the ability to access images behind a router (analogous to the “Back to my Mac” feature of OS X)

Conclusion:

The OsiriX iphone app is a very useful medical application that shows the flexibility and power of the iPhone platform. The app was even highlighted in one of Apple’s television commercials. More importantly though, when speaking to another physician, we can actually look at patient’s images now, instead of drawing lines and circles on the nearest piece of paper.

[itunes]

[website]

Dr. Wodajo is our newest contributor to the iMedical Apps team and we feel privileged to have him on board. He provides a surgeons perspective, along with an extensive clinical background.