First-year medical students at Stanford received new iPads when they started in August 2010. The school will assess the devices' effectiveness. Photo by Norbert von der Groeben / courtesy Stanford University

Health care embraces the iPad: Doctors jump on new technology

With competition for the Apple product coming, physicians will decide if tablet computers are their mobile device of choice.

By Pamela Lewis Dolan — Posted Feb. 7, 2011

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Lianna Lawson, DO, a family physician in Daleville, Va., spent most of her career using paper charts. When she opened her own practice less than two years ago, she started using a laptop as a way of going electronic without being tied down to a computer terminal. She made it work, but it never felt natural. She longed for the ability to hold the laptop in front of her patients and review their files with them -- but the laptop was too heavy and awkward to do that.

When her electronic medical record vendor, ClearPractice, gave her an iPad in 2010 to pilot-test a tablet version of its EMR system, Dr. Lawson quickly realized that using the device felt natural -- almost like having a paper chart in her hand.

Several industries have taken an interest in the iPad since its Jan. 27, 2010, unveiling, said Brian Reed, chief marketing officer and vice president of products for BoxTone, a mobility management company. But "health care is one that lit up like a neon sign."

No numbers exist for iPad sales specific to health care, but major institutions such as Stanford University School of Medicine in California are handing it out to medical students, and other physicians. These new iPad users, who might have bought the $500 to $800 devices for their personal use, are adapting them to their professional day.

Reed contributes the sweep to the iPad having the right combination of ease of use, size, portability, long-lasting battery power and relatively low cost of adoption. For physicians, that meant adopting a technology that was the next best thing to paper charts, for a price that didn't break the bank.

About 80 more tablet models are expected to come out in the next year to compete with the iPad, with most of them working much like the Apple-produced device -- the ease of touching instead of typing, the capability to download applications, and the ability to "flip" through pages instead of entering long URLs.

Already, according to market-research firm Strategy Analytics, Android-based tablets' overall market share increased to 21.6% in the fourth quarter of 2010, up from a mere 2.3% in the third quarter. The iPad's market share fell to 75.3% from 95.5%.

However, the tablet market is rapidly growing larger -- industry analysts expect nearly 45 million to ship in 2011, more than double 2010's total of 17 million.

If the iPad and other tablets continue to grow within health care, then perhaps a prediction made two decades ago will finally come true -- that the tablet computer will become the technology choice of doctors.

A new tablet for medicine

One of the first tablet devices ever developed was the GRiDPad, created in 1989 by Jeff Hawkins, the man behind the Palm Pilot. Apple also was one of the first in the tablet market developing the Apple Graphic Tablet, used to create pictures that could be transferred to computers, and the Newton, which, at about the same size as the Palm Pilot, was more of a personal digital assistant-sized device than a tablet. The Newton, like the Palm Pilot, was heavily marketed to physicians after its 1993 launch, but it never took off and was discontinued after only five years.

The earlier tablets usually were considered too bulky or heavy and too expensive, with many selling for several thousands of dollars. The companies tried to replicate the feeling of using paper charts by allowing physicians to write on the screen, and then have their scrawl translated by a desktop computer for a permanent record. But the penmanship didn't always translate correctly, and having the record transferred off the tablet didn't allow physicians to have fingertip, mobile access to records.

Laptops and smartphones helped make technology more mobile for physicians. But physicians who have adopted the iPad say it has fulfilled the promise of the tablet computer in health care.

Keith Klein, MD, an internist and nephrologist with Cedars-Sinai Medical Center in Los Angeles, said one of the biggest criticisms about the iPad ended up being one of the things he liked about it -- it was simply an oversized iPhone.

"That's actually saying a lot," said Dr. Klein, who was, and still is, an avid iPhone user. He said the iPad brings the same utility and ease of use that attracted so many physicians to the iPhone. The iPad takes all those features to the next level, making it possible -- and practical -- to adopt it as a clinical tool, he said.

Before Jon King, MD, a general surgeon at Banner Estrella Medical Center in Phoenix, started using his iPad in practice, he routinely would have to leave the exam room to get anatomical drawings or medication lists to review with the patients.

Now, not only can Dr. King increase patient satisfaction by staying in the exam room, but he also can save time in his practice and at the hospital doing rounds. Carrying the iPad is much easier than his previous mobile technology -- a desktop computer wheeled around on a cart during rounds, he said.

The most popular applications physicians used on the iPhone were drug reference tools and e-prescribing systems. But the iPhone's usefulness was limited, because there was only so much you could do and see with a three-inch screen.

Because the iPad screen is larger, for some physicians the device simply makes it easier to see things. With a flip of the fingers, the screen size can be made larger -- or smaller.

"The iPad brings you back to the patient's bedside," Steven K. Libutti, MD, a surgeon and oncologist who is director of the Montefiore-Einstein Center for Cancer Care in New York.

Because of the ease of use and affordability of the device, several EMR vendors are hoping to cash in on the tablet trend as many physicians go after incentive money tied to meaningful use through a program in which the federal government pays up to $44,000 per doctor over five years for certified EMR use in Medicare, or $63,750 per doctor for Medicaid.

And because many of the EMR programs used by small practices are cloud-based, all that is needed is an Internet connection. (Tablet computers allow Internet access either through Wi-Fi or by paying a small monthly fee for cell-network access.) Several EMR vendors also are developing applications that make access to the EMR as simple as touching the icon on the home screen of the tablet.

Even though using a cloud-based EMR means that no patient data are actually stored on the device, organizations still need to ensure that the devices are secure, and that has caused many hospitals to worry about the implications of widespread adoption.

"While everyone is enamored about the devices, they need to make sure that they first do no harm," Reed said. "And 'first do no harm' in IT is make sure you can secure and manage it."

He said this means having device management policies and procedures in place such as encrypting data, having pass codes and passwords, and enforcing compliance.

Staying power

Despite its usefulness, most physicians say the iPad never could overtake the desktop computer completely. Some physicians report that heavy word processing or information input is not very efficient on the iPad due to the touch-screen keyboard, which many say is too small for anything more than a few notes.

Reed said he expects smartphones to last -- and not just as phones -- because their small size makes them more practical for some situations than a tablet. "The physician isn't going to carry the iPad into the opera that night, but his BlackBerry will be in his pocket."

Stanford also is looking at potential downsides to using tablet computers while it assesses their usefulness. Each member of the 2010 incoming class received a school-issued iPad. Michael Halaas, chief technology officer in Stanford's Information Resources & Technology Dept., said school administrators didn't know how students would use iPads, but the school will analyze how the devices helped students meet objectives for the year, or how they may have impeded them. Stanford also will decide whether to continue the program for the next class. Halaas said it is inevitable that the technology will trickle down to the entire Stanford Medical Center.

"There hasn't been an overall, institutional 'Let's all use the iPad' initiative in the clinical care cycle, but it is certainly cropping up," he said.

The Dept. of Orthopaedic Surgery and Rehabilitation at Loyola University Health System in Chicago started giving iPads to its 25 residents in summer 2010 as a way of digitizing its medical library. Micah Sinclair, MD, a fourth-year orthopedic resident at Loyola, said the residents found many new uses, including having them in the operating room to refer to the technique guides for surgical implants. The iPads were so popular that many attending physicians starting using them, as well as tablets using the Android operating system. Physicians now can use them to access the hospital EMR.

Virginia family physician Dr. Lawson refers to a "zone of comfort" many doctors need to accept new technology. "For physicians, many of us are traditionalists and are slow to change. The nice thing about the iPad is that if you have a physician who has been practicing for 20 or 30 years and is used to paper charts, the iPad can give them a similar feeling of having a chart in hand."

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iPad alternatives

Apple's iPad has reinvigorated the formerly dormant tablet computer market. Competitors are gearing up with their own tablet products, many of which will become available in early 2011.

Product Company OS
Galaxy Tab Samsung Android
Xoom Motorola Android
Streak 7 Dell Android
G-SlateLG T-mobile Android
Playbook RIM BlackBerry
Via Tablet Vizio Android
Multiple models Acer Android

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How many are using the iPad?

In October 2010, the Healthcare Information and Management Systems Society hosted a webinar on iPads, which attracted nearly 1,000 participants. More than 70% represented hospitals or health care organizations, and 15% represented executives and physicians. Of all the respondents:

  • 25% plan to use an iPad immediately
  • 70% plan to use iPad within a year

Source: BoxTone Mobile Service Management and HIMSS survey, October 2010

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Purchase of iPads for health care ramping up

iPad use in health care often starts with a physician buying one for personal use and then discovering health care applications. But larger-scale efforts are under way to use iPads in the health care system:

  • Kaweah Delta Health Care District in Visalia, Calif., owns more than 70 iPads, and more than 60 doctors use their own. They are used to look at x-rays and electrocardiogram results, and for home health care workers to access monitoring programs. It plans to have more than 300 iPads in use within a few months.
  • The Orthopaedic Surgery and Rehabilitation Dept. at Loyola University Medical Center in Illinois purchased iPads for all residents, and it later expanded the program to include attending physicians. They are using iPads to access drug reference guides and electronic medical records. Some surgeons are using them in the operating room to access reference tools.
  • Georgetown University in Washington, D.C., handed out iPads to all its surgeons, who are using them in the operating room and the hospital wards to access up-to-date patient information such as lab data, CT scans and x-rays.
  • Stanford School of Medicine in California started a pilot program of giving iPads to all incoming students. Students can use them however they wish, and the school will determine the iPad's usefulness as an educational tool.
  • RehabCare, which operates skilled nursing facilities in 43 states, deployed iPads throughout its system for use at point-of-care.

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