Transforming healthcare requires more than giving iPads to doctors

Credit: Levent Konuk

Apple's new iPad mini is expected to be a huge hit with doctors. A small survey conducted earlier this year by Epocrates, which makes medical references apps for mobile devices, found that one-third of physicians were planning to buy one -- before Apple had even announced it. The reason according to 90% of respondents is the smaller form factor that's almost tailor-made for standard lab coat pockets.

That isn't surprising when you consider that many surveys healthcare professionals illustrate that medicine is going mobile faster than virtually any other industry. Many of those same surveys also show a distinct preference for Apple's iOS platform and the iPad. The following is just a small sample of what's going on with mobile technology in healthcare:

  • A study by Vitera Healthcare Solutions showed the iOS devices the most commonly used mobile devices among healthcare workers with 60% using iPhones, 45% using iPads, and 38% using Android phones.
  • A large study of physicians by QuantiaMD, an online community for physicians, delivered similar results with 80% reporting that they owned a mobile device with the iPhone being the most common device owned by doctors (59%) followed by the iPad (28%) and an Android phone (21%).
  • Manhattan research found that tablet use, predominantly iPad use, among U.S. physicians had doubled in one year with 62% of doctors reporting that they regularly use a tablet in some professional context -- half of them in point of care situations involving patients.
  • Aruba Networks examined the adoption of BYOD policies and personal devices used by healthcare workers, including doctors and nurses. It found BYOD support at 85% of its healthcare customers participating in the survey and that the iPad was most commonly used personal device -- 83% of respondents reported iPad use. Personal iPhones and/or iPod touches were used in 65% of the organizations surveyed.
  • Health guide and journal publisher Lippincott Williams & Wilkins found that 71% of nurses used a smartphone on the job.

Most commonly, healthcare providers are looking to mobile technology for ways to streamline care and documentation workflows, deliver better and more engaged patient interactions, and to provide instant easy access to medical references and calculation tools.

But there's a multimillion-dollar question that needs to be asked here: do iPads and related mobile technologies actually meet those needs and expectations?

According to two papers presented at last week's American Medical Informatics Association symposium in Chicago, the answer is a qualified no.

Both papers looked specifically at the iPad and the expectations that physicians have of it in hospital settings. The first study was sparked by a demand for iPads among emergency physicians at two hospitals operated by Fairview Health services in the Minneapolis-St. Paul area, and focused on why doctors are so enamored of Apple's tablet. The second study looked at the perceived advantages of the iPad and how and how well they integrated into clinical workflows at New York's Columbia University Medical Center.

The Minnesota paper started was born out of an ultimatum issued by the emergency physicians at both Fairview hospitals. The ER docs told Fairview's IT leaders flat out that they wouldn't even consider using a new EMR (electronic medical records) system unless it could be accessed via an iPad. The move was ballsy and effective.

The idea that physicians would take such a forceful approach intrigued researchers at the University of Minnesota. A research team led by Akhil Rao, a University of Minnesota graduate student at the time, found that the intense focus on the iPad likely resulted from personal experience with the iPad outside the hospital. In speaking with 14 of the 22 doctors that made the demand, Rao noted that 85% already owned iPads.

Based on that personal experience, they felt that the iPad would be the easiest and most efficient way to integrate the new EMR into their workflow. Given that the average patient interaction for these emergency physicians was only eight minutes, efficiency and the ability to directly interact with patients rather than focusing on a PC -- logging in, locating the appropriate records, and typing notes or orders -- was a top priority.

The physicians also felt that the iPad would be a good fit for other reasons, most notably infection control. Unlike a PC, the iPad doesn't have any moving parts like hard drives or fans that suck in or blow out warm air that can be a breeding ground for germs. They also argued that the iPad should easier to disinfect because it's a single surface rather than a PC with cords, keyboards, and various nooks and crannies. This advantage was handily debunked by Fairview, which found no evidence to support the claims that the iPad lower the chance of infections.

One interesting point that the ER doctors made in their case for the iPad went beyond any technical or medical advantage. They argued that iPad had an innate ability to project an air of confidence and assurance to patients. They felt that the iPad would make them and their hospitals look more cutting edge and effective to patients than a desktop or notebook PC.

That the iPad alone would inspire greater confidence might be a dubious claim, but a related argument -- that the iPad improves doctor-patient communication -- has been pretty well documented. The iPad and other tablet devices allow doctors to illustrate illnesses, injuries, and treatment options to patients in a way that verbal descriptions or even static medical diagrams or brochures can't equal. In fact, Rao told MobiHealthNews that "the patient-physician interaction was paramount [and] of great importance to them."

While Rao's research highlighted the perceived advantages that the iPad among physicians, it was a pre-implementation study and didn't focus on the ultimate results -- with the exception of the infection control idea. It does, however, indicate that healthcare's rapid incorporation of consumer devices like the iPad and its adoption of BYOD stems from personal technology use and ownership -- just as consumerization trends do in virtually every other industry.

In contrast to the Minnesota paper, the study conducted at Columbia University tracked the use of the iPad in a hospital setting after implementation. The study, which included 62 residents at Columbia University Medical Center, found that the iPad didn't deliver on expectations of added efficiency, patient interactions, or workflow transformations.

Overall, the study found that residents didn't use the iPad that broadly as a clinical tool. Only 18% reported using the iPad in clinical contexts. Those who did use it in such situations did so primarily to review patient documentation and lab results. iPad use in handing off patients to other physicians or departments was even less frequent than overall clinical use with only 12.5% of staff using it in such situations.

The iPad was considered most helpful when performing hospital rounds.  Ninety percent of the residents used the iPad when on rounds with attending physicians, a time when residents can't conveniently leave a patient to access a PC. Dr. Colin Walsh, a Columbia internist and postdoctoral fellow, noted that rounds are "the time physicians are truly mobile."

Most of the residents used the iPad as a reference source when working with patients. That's on par with other surveys of doctors and nurses including a recent survey` of 3,700 physicians by QuantiaMD. That survey found various reference activities to be the most common use of mobile technology in clinical healthcare settings with drug/treatment guides being the most common reference material accessed by of doctors.

Ultimately, the study's most surprising conclusion is that the iPad didn't reduce the amount of paperwork or replace it at any point in the residency workflow. Despite initial assumptions, the study found that the iPad didn't provide residents more time with patients or attending physicians. After six months, Walsh noted that "the reality is, they’re spending a lot of time interacting with the electronic health record."

Both the University of Minnesota and Columbia papers note that the EMR systems used in the hospitals didn't offer a native iOS app when their research was conducted. Both sets of hospitals relied on a Citrix virtual desktop for access to the EMR from an iPad -- an approach that is largely seen as a stopgap measure in other industries to offer some mobile access to back end systems until a native app or web interface can be developed. It's important to note that the Epic EMR suite used by Fairview now includes a native iPad app.

Unlike other industries, however, Citrix and other virtual desktop solutions are much more common in healthcare and they are often used as a primary solution for desktop PCs as well as for laptops and mobile devices. The reason for their widespread use in medicine is that they offer a greater degree of security -- and thus easier compliance with privacy laws -- than desktop apps. A Citrix session ensures that no patient data is ever stored on a PC's local hard drive (or on mobile device like an iPad).

The overall message of both studies as well as earlier surveys is that the iPad and other devices are empowering physicians in certain ways -- the immediate access of information being the most common and most important -- but that a true transformation of medical workflows requires much more than just handing doctors iPads or other device and/or allowing personal devices to connect to a hospital or practice's network. Like leveraging the mobile and BYOD trends in other industries, it requires a partnership between the professionals using technology and the IT staff or contractors that manage and support it. Some hospitals have made that intense investment and reaped big rewards as a result -- Nemours Children's Health System is one excellent example. Ottawa Hospital in Canada and RehabCare of Missouri are two other great stories of what is possible when physicians and IT leaders come together to plan and develop a healthcare transformation. 

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