Mac Tablet – The Ultimate Device for EMRs?

Great ideas! I hope Steve Jobs is reading this!

Nice article!

Before I start, allow me to disclose my bias. I love Apple products. Having made the switch from Dell almost 6yrs ago now, I have never looked back. Basically, I think the company [excretes] sunshine.

Besides being a mac-ophile, I am also a medical student rounding out his education this year. After 2 years suffering through both Brooklyn area hospital paper records and ridiculous EMR, I can tell you that with some certainty that there is a huge potential market for this product…and this article brilliantly describes the upside.

The only unfortunate bit is the timing. The strengths of this product will undoubtedly have to be weighed against cost. In an industry that is reaching crisis and is increasingly looking to streamline budgets and tighten efficiency, the itablet will have to demonstrate strong data for hospitals and clinics to open their tightly pulled purse strings.

I’ve been involved in EMR’s for almost a decade. As a practicing optometrist and as a software developer and founder of a company that provides unique (SaaS) practice management and EMR solutions to optometrists and ophthalmologists.

I’ve been very underwhelmed with the utility of tablets vs a desktop/laptop for data entry with EMR data. There are lots of data fields that lend themselves well to “point and click” data entry, which tablets excel at. There are also fields which require text entry and/or numerical data entry (the amount will depend greatly on the field of medicine that you’re dealing with). Current tablet technology for UI/data entry is simply not efficient enough either with handwriting recognition or “hunting and pecking” with a stylus over a virtual keyboard.

If Apple can come up with a better way to input custom text, they’ll have a winner. The devices will need to be quite rugged and have long batter life also, but I think those issues can be overcome easier than the UI issues.

I’m not throwing water on the idea, just trying to share my years of experience using and designing EMR’s for my field.

John Warren, OD
jwarren@revolutionehr.com

Just as the iPhone revolutionized the then existing smartphone market, Apple once again has everything it needs to do it again with an EMR device. But this time there is no existing satisfactory alternative as was RIM’s Blackberry prior to iPhone. Thus Apple’s EMR device would be to the “pen and paper” medical practice what Henry Ford’s Model T was to the then existing “horse and buggy” transportation industry.

I believe the challenge for Apple is not software or anything concerning their heavily patented multi-touch technology — not even wireless inductive charging — as all that is the easy, mostly already solved part we know in iPhone. Instead, it all comes down to size, weight and physical design. If the device ends up being too cumbersome or awkward in any respect, it will not pass muster with the medical community no matter how brilliant it is inside.

Being both a Mac fan, and a medical student w/ experience in an ER & private-practice settings, a larger iPhone-style device caught my attention when I first heard of it.

I currently share my workload between a ThinkPad laptop, and an iMac desktop. But I also have a Powerbook that was my mobile workhorse for 6 years. And without a doubt, Apple currently offers the best hardware & software environment, in both desktops & laptops.

The only gap in their product mix I can discern, is a large-enough tablet-style device. Despite the superior quality and ease-of-use of MacBooks, typing is not my preferred data input method during a patient interview or exam. It can slower than handwriting, not to mention impersonal; unless you can touch-type effectively. I know I wouldn’t want my doctor behind a laptop screen, or constantly looking to one side to see what he’s typing.

Not that there aren’t options in the Mac space. I’m referring to Axiotron ModBooks. But while the base ModBook is interesting, it is neither the most aesthetically pleasing device, and is based solely on pen-based input. And while I am smidgen over the ModBook Pro, it is quite an investment when I can design a complete three-station Mac network for the equivalent price. And in fact, that’s one of my current projects.

I am currently designing a Mac-based small office network, for a pair of physicians in private practice. It will handle patient records, billing, and scheduling (via MacPractice software). However, I feel limited when it comes to the choices I can give the physicians when it comes to note-taking. Asking someone who has used pen & paper exclusively for notes for over 10 years to switch to typing is a bit of a stretch. And I’d hate to improve office efficiency, only to ask the physician to add dictation to his workload (not to mention the technical issues of importing dictations to individual patient records), when his current paper-based practice does not require it.

That’s why I am intrigued by the possibility of a tablet-style touchscreen device by Apple. And when I say tablet-style, I specifically do not mean hybrid tablet-laptops. A single flat-panel with efficient touchscreen input is definitely the way to go. This would be unobtrusive during patient encounters, and the ultimate in portability to boot. Given the choice, I don’t see how a physician would deny something that would be equivalent in bulk to a clipboard with a notepad attached, especially when that same device also gives instant access to patient records as well.

Not to say this type of device doesn’t exist in some forms in the Windows world already. But to be honest, from the perspective of designing an entire office network using Macs, and then asking the physician to use Windows… heck I’d rather ask them to go the dictation route. I am a regular Windows user, and I’m flabbergasted on a regular basis by what those machines are capable of doing, and the time wasted in dealing with issues. The result is that Windows-based machines – as core tools in the delivery of service in an EMR system – are less efficient, and therefore less profitable. Not to mention the fact that they are considerably less secure, and it is essential to eliminate such risks while managing confidential patient data.

It’s been suggested that the premium price on Apple devices would be a burden to the healthcare system burdened by high costs. However, a true cost-benefit analysis (taking into account the cost of IT, security, and stability issues, and of course, ease of use & efficiency) might yield a different picture. It might suggest the increased capital investment costs would be justified by long-term savings in labor (IT man-hours, with associated loss of productivity), and increased efficiencies elsewhere.

To give you a comparison, I’ll take my two laptops. My Mac is PowerBook G4 from 2001. My PC is a ThinkPad from 2008. I regularly used my PowerBook through the end of 2007, when I got ThinkPad to handle a large volume of VOIP/video-conferencing, as well as to eliminate a couple of issues integrating into a PC-based network w/ a large volume of streaming based on WMP. In the six years that my Mac was my principle machine, I had less than five instances where the system had an error that required a reboot – that’ less than once per year. And the majority of these occurred in earlier versions of Apple’s OS X. With later versions, stability of the system is exemplary. On the other hand, in the year and a half that I’ve been using my Windows XP Professional on my ThinkPad notebook, I have had so many system-based problems that I lost count pretty early on. On top of that, we have the less intuitive functioning of Windows, which detracts from efficiency. And lastly, and more importantly, there were my experiences with setting up the laptops with my school’s IT department, which required institutional-class virus protection for any PC. And that’s just to access the network. I’m not talking about machines involved heavily in network-related tasks, or critical services. With the Macs, they didn’t require anything… nothing… at all. I know every computer system has some level of vulnerability, and certainly Macs have their share. But it’s a stark contrast.

Lastly, the migration to Macs for users with considerable Windows experience might be unsettling. But a device that has the ease of use of an iPhone-style interface should eliminate these concerns. And if such a device is the right size, and allows efficient EMR input during patient encounters, it’ll definitely be at the top of my list. I have high hopes for something to develop in the very near future.

There are 2 main barriers to entry for a Mac tablet at the point of care in health care (especially in hospitals).

The first barrier relates to the device itself. To be used at the point of care, a device must be water resistant. Because of the inevitable fluids found around patients, any point of care device must be water resistant. The device must resist the ingress of splashed fluids, as opposed to surviving a drop into a toilet.

Next, the tablet must be made of materials that withstand the effects of the harsh disinfectants. Devices at the point of care (in hospitals especially, but also in ambulatory settings) must be wiped down with disinfectants to reduce the risk of spreading infections. Common plastics turn brittle and break after repeated exposure to these chemicals. And if such devices are not water resistant, they risk being damaged by disinfectant wipes.

Any point of care tablet must be ruggedized to withstand repeated drops from 4 feet onto linoleum covered concrete.

These three requirements are met by the Intel clinical tablet reference design. Yet this reference design has met with limited success in the market for two additional reasons: weight and battery life. Existing tablets must be light weight enough to be carried for a 12 hour shift. They also need sufficient battery capacity to provide a full shift’s continuous use. (These two limitations are why tablets are deployed on computers on wheels, rather than carried and used like, you know, tablet computers.)

And don’t forget commercial ganged charging stations. Connecting each device into its own wall wart plugged into an outlet is a nonstarter — there’s not enough room in already crowded central stations.

The other major barrier to adoption is application software. For a computing device to be truly nurse carried for any length of time, it has to be smaller than conventional tablets, and it should probably fit in a lab coat pocket. And remember that the average age of nurses is over 50 years — cramming a 1280×1024 or even 1024×768 display onto a small tablet is a losing proposition.

EMR vendors design their user interfaces for full sized displays deployed on desktops or computers on wheels. A number of interesting devices in the past (the OQO and Emano Tec for example) have languished because no one was willing to redesign user interfaces for smaller devices.

Sadly, Apple has almost no foot print in hospitals, or even physician offices. To get IT departments to support another platform with another operating system, a really compelling solution will be needed. Apple could put this off, if they were willing to put in a little extra effort.

As Rob notes in a comment above, a product that meets health care market requirements would also be attractive to other vertical markets – manufacturing, field service, construction, logistics. It is interesting to note that companies like Symbol approached health care *after* penetrating these other verticals. To succeed in health care they had to include resistance to disinfectants.

Apple is going in the right direction with healthcare applicaiton and hardware. Physicians and other providers like PAs want something that they can hold in their hand and throw into their white coats for mobility. In my opinion, Apple would certainly do better by spending the research dollars and effort into beefing up the medically related functionality accessed on their iphones instead.

Hey, it is already here. I run MacPractice EMR in my office, and use an axiotron modbook (a macbook that has been turned into a tablet by axiotron) tablet as my EMR connection while seeing patients. It runs very well. I can run MacSpeech dictate native on the tablet with a bluetooth headset, and do point and click entry, dictation entry, and drawing entry for images (or for entering hand written notes.) Even if Apple does eventually put out a tablet, I may stay with the modbook and native OS X if the new tablet runs a scaled down version of OS X. It really works quite well. I isn’t cheap though….. I dont’ know of anyone else running this, but it works very well for me!