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Tablet computers in the hospital
By Charlotte Huff
At the University of Chicago Medical Center, the internal medicine residents frequently felt torn between their two responsibilities: unceasing patient needs and ongoing educational training requirements.
It's a common dilemma. But educational leaders at the Chicago facility found a way to help boost resident efficiency: tablet computers. In the fall of 2010, residency program leaders purchased 115 iPads, one for every internal medicine resident.
Photo by Thinkstock.
Now more work can be done in real time, rather than getting stacked up at the end of the day, said Bhakti Patel, MD, a chief resident at the University of Chicago Medical Center. Residents can enter patient orders directly into their own iPads as they round with their attending physicians, rather than waiting until rounds wrap up and then hunting down a computer. As a result, she said: “When they're done with post-call rounds, they are able to do the work that requires them to be at the bedside, such as talking to the patient.”
University of Chicago Medical Center was one of the nation's first residency programs to purchase tablet computers for all of its internal medicine residents, according to Dr. Patel. But purchasing trends indicate that the Chicago program may only be on the leading edge of a significant shift.
Last fall, Stanford University School of Medicine announced a pilot project to provide an iPad for each first-year medical student. And early this year, 30% of doctors surveyed by New York City-based Manhattan Research reported that they had already purchased an iPad. An additional 28% planned to do so within the next six months, according to the survey of 2,041 practicing physicians. (The survey also asked physicians about their use of tablet computers besides iPads, but a spokeswoman would only say usage was lower, declining to release specific numbers.)
Doctors and information technology experts say there are a number of logistical issues to work out, as the tablet computer becomes a more common sight protruding from a doctor's white coat. Along with patient privacy and infection control worries, the software products and screen displays are still evolving to fully meet hospitalists' needs, such as integration with electronic health record systems.
Still, no one interviewed questioned the technology's potential to reboot not only patient care, but also the doctor-patient relationship. Viewing, and then sharing, a computed tomography (CT) scan image is as easy as pulling it up on a tablet and then leaning across the bedside, said John Halamka, MD, an emergency physician and chief information officer at Beth Israel Deaconess Medical Center. “It invites the patient and the doctor to share data and images together,” Dr. Halamka said. “Have you walked into a hospital ward and noticed the number of doctors sitting in front of computers instead of being in patient rooms?”
Vineet Arora, FACP, associate program director of internal medicine residency at the University of Chicago, also has noticed some teaching benefits. After rounds, she frequently compiles interesting studies and articles for teaching purposes. With the help of the iPad, she can now quickly pull them up to show residents the next day. Then she can forward along the documents immediately with an e-mail blast.
At Beth Israel, the doctors started purchasing the iPads themselves, a trend that has only accelerated with the release of the iPad 2, Dr. Halamka said. As of one May afternoon, 600 iPads and 1600 iPhones were connected to Beth Israel's network, said the emergency physician, who is a bit bullish on Apple's tablet.
“It turns out that the most appropriate device for a clinician weighs under a pound, is easy to disinfect, fits in a white coat pocket, has a battery life of 10 hours and can be dropped five feet onto carpet without significant damage,” he said. (They've performed the five-foot test.) At this point, the iPad is the tablet that best meets those specifications, he said.
Scot Rolly, MD, a hospitalist in Owensboro, Kentucky, isn't nearly as convinced. Dr. Rolly, who practices at Owensboro Medical Health System, said that his hospitalist group started a pilot trial late last year. It was great not to have to constantly search for a desk computer, given that the nurses frequently need them for their documentation, he said.
But he no longer uses the iPads, which the hospitalists were sharing. It was difficult to fit one into his white coat pocket and the device was heavy to carry along with his stethoscope and other papers, he said. The tablet also only worked well on the hospital's network, so he couldn't use it at home.
“I think it's just early—I think the infancy part of this (technology) is the issue,” he said. “Implementation has certainly not matched with the imagination.”
As new tablet computers are introduced, their size and software will affect physician satisfaction, said Russ Cucina, MD, a hospitalist and medical director of information technology at UCSF Medical Center. “I think the market competition is going to decide for us: What is the ideal size of the clinical tablet?”
Dr. Cucina, who has tested a variety of tablets, tried out a Samsung Galaxy Tab this spring because he liked the easier portability of the seven-inch screen. He predicted that, just as Android-based devices have proliferated in the smart phone market, different types of tablets will multiply and provide increasing competition for the iPad.
Meanwhile, the current generation of tablets is somewhat hampered by software limitations, specifically how the tablet's software interacts with a facility's electronic health record, Dr. Cucina said. Electronic health record software was designed for at least a 17-inch screen, not the 11-inch screens that are more typical with tablet computers, Dr. Cucina said. On the smaller screens, all of the information is there, but it's difficult to read. Plus, the various electronic health record functions might be designed more with a mouse in mind, not a touchscreen, making it more difficult to enter information accurately, he said.
Software vendors have begun to introduce some solutions, Dr. Cucina said. As one example, he cited a tablet product called Epic Canto, developed by the electronic health record vendor (see sidebar). It's not a “shrunken version of Epic,” he said, but rather has redesigned functions to make it more tablet friendly.
Sterility and security
One of the biggest selling points of the tablets—portability—also triggers some concerns: sterility and security.
Keeping the tablets clean isn't easy, as the devices weren't designed to be waterproof, Dr. Cucina said. “I doubt that people are going to want to swab alcohol all over their $700 iPad.” But Dr. Halamka reported that several physician colleagues regularly clean their iPads with alcohol wipes. Henry Feldman, ACP Member, a hospitalist at Beth Israel, said he's cleaned his tablet five to 10 times daily without a problem.
As these devices advance, it would be helpful if they're designed to ease cleaning, said Steven Gordon, FACP, president of the Society for Healthcare Epidemiology of America and chair of the infectious disease department at the Cleveland Clinic. In the meantime, though, the optimal solution mirrors the recommendation for stethoscopes and other potentially germ-carrying devices, he said. “Hand hygiene. That would be my main kryptonite in terms of this potential issue.”
With security as well, part of the solution is tech-related and the rest is human behavior, Dr. Cucina said. Passwords and encryption provide protection, but don't inoculate against other more traditional privacy breaches. “If you are sitting in a Starbucks and looking at medical records on your tablet, it's your responsibility to make sure that no one is looking over your shoulder,” he said.
At the University of Chicago, every tablet is insured and various layers of security protection have been installed, including lockup if the tablet stands idle, lengthy passwords, and the ability to lock or wipe the computer tablet clean remotely if it's lost or stolen, Dr. Patel said.
As of this spring, two iPads had been stolen by brute force, such as while a resident was reading on the train, she said. The residents know they are responsible for replacing the device if it's lost due to their own negligence.
Initially some of the patients thought that the iPads, which the residents carry in a case slung over the shoulder, was a purse, Dr. Patel said. (The cases allow the residents to keep their hands free.) But they soon learned to appreciate the new technology.
Now doctor and patient can bend their heads together over the screen to look at radiology images or check other lab results, Dr. Patel said. If a patient has a question, such as a cancer patient who wants to know his latest white cell count, the answer is only a few keystrokes away. “It makes patients feel like they are participating more in their care,” she said.
Apps for hospitalists
Tech-savvy physicians have access to an expanding array of medical applications. A few starting points:
- A variety of ACP products are available for tablet computers, including the Medical Knowledge Self-Assessment Program (MKSAP 15), PIER, Annals of Internal Medicine, and clinical guidelines.
- Epic Canto: The popular electronic health record vendor has developed software specifically designed for the iPad.
- Epocrates Essentials: Provides drug and disease resources.
- New England Journal of Medicine Image Challenge: The journal's image challenge allows doctors to use photos to test their diagnostic skills.
- Unbound Medicine: Provides a variety of mobile applications, including the Merck Manual and Medicine Central, which includes numerous features, such as the 5-Minute Clinical Consult and drug-related resources.
- VisualDX Mobile: Pairs clinical information with thousands of medical images, including those that show disease progression.
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