A few of you might be reading this on your new iPads. The rest of you are probably sick of the speculation and hype that Apple’s new tablet will transform the publishing world, just as the iPhone changed mobile phones and the iPod revolutionized the music industry. But a more relevant question for us is: “Can the iPad change the way we work in the emergency department?”

I sure hope so. Because the nature of emergency medicine – the speed at which we have to work, the interruptions, the need for information, has forced some unfortunate compromises. Many departments are stuck with 20th century paper charting, depriving physicians of easy access to patient data and decision support in the name of efficiency. Other EDs have made the leap to electronic information systems, recasting doctors as glorified clerks, parked in front of computers, engaged in a protracted data entry sessions, while the confused patients look on and wonder what could possibly be so important on that screen. Another option – docs with scribes in tow – is an expensive and awkward band-aid for this fundamental problem of workflow.

The iPad offers a solution. Maybe it won’t happen with this specific iPad release. Maybe it won’t happen this year or next. But I expect emergency physicians will someday be able to wander through their department, moving patient to patient, with a tablet like the iPad tucked under their arms. During encounters, we’ll use iPads to tap on elements of the history or exam in, and enter orders – all very quickly at the bedside. These tablets will help us go over images and lab results with patients, and let us review diagnoses and instructions.
In short, I think the iPad can liberate doctors from the desk-based tyranny of ED information systems and the shortcomings of the paper chart. Here’s why.

The Operating System
You might be wondering– isn’t the iPad just a bigger iPhone with fewer capabilities? After all, it can’t make calls or take photos. Well, you’re missing something: the iPhone, even without a camera or phone, is already a pretty amazing product (Apple markets it as the iPod Touch, and they’ve sold about 30 million of them). Putting this intuitive operating system behind a more powerful processer, bigger battery, and a much larger 9.7 inch screen (which translates to about 8 times the viewable area on an iPhone or iPod Touch), opens up a lot of possibilities.  

But let’s focus on the platform, first. Already Apple’s mobile operating system has apps that help physicians at work – the healthcare section of the app store is popular, and there’s dozens  of apps specifically for emergency medicine (a few favorites include EMRA’s antibiotic guide and WikEM, a physician-edited repository of EM pearls and formulas). Even with the small screen of iPhones and iPod Touches, this operating system has attracted interest from a variety of ED information systems (EDIS) vendors.

Why is this operating system so compelling? For one, these devices just turn on and are ready to use (although you’d expect that with a smartphone; it’s still not standard among computers). With the iPad’s interface, unlike netbooks or laptops, there’s never any searching for files or folders, or wrestling with uninstalls and malware. Navigating and launching apps is easy, and getting new ones through the App store is, too. While Palms and handheld Windows devices have offered programs like notepads, calculators and ePocrates for a decade or more, it’s only when Apple entered the handheld market that these apps became fast and slick enough to completely abandon handbooks and scraps of paper.

But just as importantly, Apple has put forth some elegant design precepts for their apps, and forces developers to stick to them. Instead of multi-tiered menus, apps should have intelligently laid out buttons and easily navigable screens. Selections are optimized for fingers, instead of mice or styli. You move through screens by swiping, instead of clicking tiny scrollbars. You choose options by flicking through a slot-machine-like wheel, instead of drop-down lists. You zoom in and out by pinching with your fingers.

We’ve never seen an EMR based on this elegant interface, though certainly people think it’s desirable (Mandl, Gamble refs). Current ED information systems have evolved haphazardly – the rush to add features and maintain interoperability has left them bloated, slow, and difficult to navigate.

In the past decade, hospital experiments with tablet PCs haven’t taken off, despite obvious benefits of portability (Cockerham ref). The problem was these Windows-based tablets were running similar EMR software as found on desktop PCs, only with a stylus instead of a mouse. These portable systems brought all the frustrations of desktop charting and order entry into a miniaturized (but still heavy, and unnaturally warm) tablet. Bringing cumbersome screens full of menus and checkboxes to the bedside isn’t the solution; the EDIS needs to be reimagined for tablets.

And while the cost of this software is very much an open question, the hardware cost – $500 for a basic iPad – ought to be pretty attractive for administrators. This is not only cheaper than most desktops PCs with monitors, but should be easier to support and maintain.

The Form Factor
The iPad weighs about a pound and a half. It’s half an inch thick, and couldn’t cover up a standard sheet of paper. So, while its big glossy screen has understandably rejuvenated the prospects of the publishing world, it shouldn’t be too cumbersome to carry around. Maybe moving with the iPad can’t be as straightforward as shoving an iPhone in your pocket, but it ought to be preferable to walking back and forth between patients and desktop EMRs, or toting a clipboard with a T-sheet.

And already, a host of accessories has sprung up to augment the iPad, just as with the iPod and iPhone before it.  There are already shock-resistant cases and grip sleeves with shoulder slings. There are even waterproof cases (some that look suspiciously like zip-loc bags). I don’t doubt there’’ soon be cases with extra battery power, giving a boost to the iPad’s non-swappable battery (said to last 10 hours while displaying video, perhaps less if constantly accessing a network). As part of a group that thinks nothing of wearing stethoscopes around our necks, I think docs will find a way to comfortably carry an iPad.

Next Steps
I doubt we’ll see a fully integrated and comprehensive ED information system spring forth on the iPad this year. Instead, I think administrators warm up to the device’s potential with already existent apps that provide different aspects of a comprehensive system. First, perhaps, the department will buy some iPads for patient education apps which, given the device’s screen and multimedia capabilities, can make efficient teaching tools. Then, maybe, an investment in a radiology app that interfaces with your hospital’s PACS, or an app with discharge instruction templates and prescription writers that, through Bluetooth or network connections, prints to your nearest location.

ED-specific apps might be implemented next, like a tracking board to monitor patients’ bed status or vitals. I expect Dragon and other voice transcription software to enter the marketplace, either with a standalone app that can export transcriptions to charts, or with integration in a vendor’s system.

Eventually, I expect a vendor will release an app that does it all, seamlessly interfacing with the enterprise, offering charting, computerized order entry, bed tracking, results review, and admission and discharge pathways.  It won’t look like any system we’ve seen for desktop PCs. That’s why I think it’ll change the way we work.

Trailblazers: a few health care Apps that are already leading the way

Epic’s Haiku
For hospitals and clinics with the latest version of Epic and a Haiku license, Haiku lets authorized clinical users on iPhone and iPod Touch (and now, iPad) securely access hospital patient lists, test results, notes and schedules.

Airstrip
A suite of apps (including the only FDA-approved iPhone and iPod touch medical app) that provide HIPAA-compliant access to lab results and streaming data, including vitals, telemetry waveforms, fetal rhythms for OB, patient census and more. The app is free but hospitals have to buy Airstrip equipment and use compatible monitoring devices.

eDr. Rx
A standalone browser-based e-prescribing solution, already available on smartphones and now on the iPad. Departments sign up for a subscription to send new prescriptions to local pharmacies. Features include the option of integrating prescription data with the medical record.

coActiv EXAM-PACS for iPad
Enables secure DICOM querying of a hospital’s PACS, bringing a patient’s radiology images to the touch-screen iPad where they can be reviewed or mailed as JPGs.

Allscripts Remote
Optimized for iPhone or iPod Touch, this app can log into compatible electronic health records remotely, checking vitals, patient summaries, contact info, and enabling e-prescribing.

Cited Works
Mandl, Kenneth D., Kohane, Isaac S. No Small Change for the Health Information Economy. N Engl J Med 2009 360: 1278-1281

Gamble, KH. Wireless Tech Trends 2010. Healthc Inform. 2010 Feb;27(2):24, 26-7.

Cockerham, M. Use of a tablet personal computer to enhance patient care on multidisciplinary rounds. American journal of health-system pharmacy. 2009, vol. 66, no21, pp. 1909-1911

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