iPad: A Tablet Computing Renaissance in Healthcare?

December 2010

By Jim B-Reay
Principal, Aspen Advisors

While tablet computers have been used to support healthcare providers for many years, there have been limitations to the platform that have kept tablets from making a lasting impression (beyond the demo, of course). Apple's new iPad may change that, offering providers a platform with both usable technology and a high "want" factor. This paper will examine the iPad platform in terms of form factor, usability, and current and future compatibility options for EMR software.

Healthcare has been a prime target for the tablet PC industry with visions of clinicians scribbling notes on tablets where charts once were. Companies were formed to “ruggedize” tablet PCs for clinical use, and they were (and are) ubiquitous at trade shows. But total sales for tablet computers in 2009 was estimated by IDC at under 2 million units – less than one percent of the total PC sales, and the number has remained at this level for several years. Clearly, the tablet PC isn’t taking healthcare by storm, but why?

I was recently at a hospital site and found that in their ED, they had tethered their fleet of tablets to stands, attached keyboards and mice, and were treating them as expensive laptops. This is after they invested thousands of dollars in tablet-compatible software, charging stations, and user training. The tablet form factor had simply failed in this context. At another site, the hospital simply pulled their tablets off the floor and replaced them with laptops. These examples are not the exception; there are numerous other examples like these across the nation.

The Original Tablets: What Went Wrong?

In the case of the models used in the above examples, the tablet hardware and operating system (OS) itself were flawed because battery life was a mere two to three hours and required as long for a full recharge. The devices were also heavy, expensive, and easily damaged.

The end-user experience was also an issue; the software was essentially the same as the desktop software, originally designed for a mouse and keyboard and not intuitively responsive to the pen input of the tablet. Handwriting recognition applications were spotty for most clinicians (have you tried to read a handwritten prescription recently?), and often application software simply didn’t support handwriting recognition, causing clinicians to “type” by pecking one letter at a time on an on-screen keyboard with a stylus.

So while both the hardware and the software user experience of tablet PCs may not have lived up to user expectations, it appears we’re on the cusp of a tablet computing renaissance with the release of Apple’s iPad, and it’s happening from the ground up.

Enter the iPad

Much as physician adoption of the iPhone and similar Android smart phones led to the development of phone-based e-prescribing and results viewing tools (from Epic, Allscripts, and others), we are already seeing that voluntary physician adoption of the iPad is pushing the industry to respond to this new modality, and adoption is occurring at a rapid pace. Apple reported that over 8 million iPads had been sold since its release in April 2010, with no slowing of demand. Bernstein Research proposed that the iPad has the fastest adoption rate of any consumer electronics device, including the DVD player and iPhone.

And the healthcare information technology (HIT) vendors are responding. Less than six months after the launch of the iPad, Epic released their Canto application for the iPad, allowing for chart review and e-prescribing. Allscripts released Remote, a VPN-based front end to their EMR. Citrix has released a client for the iPad allowing for delivery of the desktop application to the iPad.

Let’s look at the iPad from a healthcare perspective.

The Good

Solid-State Instant-On: The iPad turns on and is usable within seconds, loading data from flash memory rather than a hard drive. Compare that to the 1+ minute start up cycles of most tablet PCs.

Battery Life and Charge Cycles: Real world tests show that the iPad can be used for over 10 hours with Wi-Fi active, which is long enough for a full shift. Charging to 80 percent takes about two hours, and a full charge is in four hours. That means that the iPad has a 2.5:1 work time to charge time compared to the 1:1 charge to work time for a PC-based tablet.

Screen Resolution: The iPad screen has a standard XGA resolution (1024x768), which is compatible with most PC applications (via Citrix).
Cost: The base level iPad costs $500. This configuration includes wireless, Bluetooth (for connecting a dedicated keyboard), and enough horsepower to run any application including Citrix. Compare that to the base cost of a Motion C5 tablet at over $2000.

Security: The iPad uses a closed OS with no known viruses (or ways of getting viruses), which saves on software costs as well as CPU processing time. In addition, the iPad can be locked down to prevent users from installing their own software on it via Apple’s Enterprise Management toolkit.

Typing: Typing on the iPad is possible because the screen can accept multiple simultaneous touches. While there’s not tactile feedback, there is visual and audio confirmation, which is easy to adjust to. For those who must type, you can pair a Bluetooth keyboard with the iPad or use the keyboard dock.

The Bad

Fragile: The iPad has a glass front, and a fall from five feet could potentially shatter the glass. This can be prevented by getting a shock case for the iPad. But even if an iPad falls, you can replace it for $500 and still be saving more than $1000 over the cost of a ruggedized tablet PC.

Screen Size: While the screen supports 1024x768 (XGA), it is packed into a 9.7” form factor, which could make reading difficult, especially for Citrix-delivered applications.

Expandability: There is only one “dock” connector on the iPad and expansion via USB is kludgy at best with an expensive adaptor and limited peripheral compatibility. For example, you won’t be using your iPad to assist with barcode medication administration — at least not until one with a camera (which can be used as a barcode reader) comes available.

The Working-on-it: Software

As I previously noted, a critical failing of tablet computing to date has been software tailored to the tablet experience. Most healthcare-specific software applications are either a direct port from the windows version or a Citrix-delivered window running the PC application.

Back in 2005, a reporter asked me about the Microsoft Origami platform— a mini touch-PC with a small screen (800x480). I said that while the devices looked interesting, there was no way that a Cerner Millennium screen would be usable at that resolution. Physicians would never agree to scroll that much to see the patient record. I stressed that in order to succeed, the vendors would need to change their software to work on the new form factor.

In the intervening years, the trend in desktop software has run toward requiring higher resolution for more on-screen display. XGA is a minimum configuration, with most vendors asking for nothing less than 1440x1280 resolution on a 20” screen.
While the iPad screen is workable for Citrix delivered applications, the best experience for iPad users will be applications developed directly for the platform. Allscripts’ Remote and Epic’s Canto are the first, but more will come.

Conclusion

There are indicators throughout the industry that there’s a tablet computing renaissance underway. The other day, I was visiting a client IT department and walked past a cube filled with iPad boxes. They were being loaded with Citrix to be rolled out to the emergency department. A few days later, I was visiting another facility that was in the process of evaluating the feasibility of iPads to replace existing tablet PCs for their rehabilitation therapists. The following week, I was at a small community hospital, where the CIO and a small set of pilot physicians were testing iPads using Citrix to connect to their EMR. It seems that I’m seeing iPads everywhere.

Even in facilities where there is no formal project underway to assess iPads for clinician use, I’ve seen physicians proudly brandishing their own, self-purchased iPads, taking notes, and using medical reference tools. These same pioneers were the ones demanding patient data to be sent first to their Palm Pilots, then to their iPhones, and are now knocking on their IT department’s doors for support of the iPad.

If you’re considering the tablet PC form factor for your organization, the iPad is a viable choice today with a competitive price and support for existing Windows applications via Citrix. Investing in the iPad today ensures you’ll be “ahead of the curve” as software vendors develop iPad native versions of their applications. The iPad is poised to finally deliver on the promise of the tablet form factor in healthcare.

Next Steps: Implementing the iPad in Your Organization

Here are some practical considerations for evaluating the use of the iPad in your organization.

Application Support:

Can the application run in an XGA window (1024x768) window easily?
- Consider the amount of readable data. A screen that looks “busy” on a 21” monitor will be indecipherable on a 10” screen.
Is the application capable of running in a standalone mode via Citrix, or is there software required on the client PC to make it work?
- Some tools require local files for security and connectivity, which will not work on an iPad.
For thin-client and browser-based applications, is a specific browser or plug-in (like Adobe Flash or custom ActiveX controls) required?
- Some PACS toolsets will not launch without detecting Internet Explorer.
- Adobe Flash is not supported on the iPad as of Q4 2010.
- Some vendors have re-compiled their PC-based applications as ActiveX controls, which have the same underlying hardware requirements as their PC brethren and will not run on iPad (or Mac, for that matter).

Infrastructure and Governance Support:

Ensure you are running a version of Citrix that is compatible with the iPad Citrix Receiver tool
- You may need to update your enterprise Citrix Server license and do additional configuration to support the iPad client.
Make a Support Policy distinction between support for physician-owned iPads and facility-delivered iPads (in the ED and elsewhere):
- A variant on your laptop policy will be appropriate. What do you allow physicians to access using their own laptops and what needs to be accessed using a facility-managed device? Since this is not a PC device, look to your current Macintosh support guidelines as a starting point.
- But bear in mind that some of the distinctions regarding Protected Health Information (PHI) and virus protection aren’t relevant in the iPad world since data is not stored locally, and the iPad is not a virus delivery vector.
If you are using an enterprise software delivery and provisioning toolset, work with the vendor to see if the iPad is a supported “target device”.
- If not, there are documented ways to securely deliver this software to your fleet of iPads, including iTunes or a secure intranet site.
For details on security and management of iPads in the enterprise, you will want to review Apple’s library of guidelines at http://www.apple.com/ipad/business/resources/
- This includes information on how to integrate iPad with VPN, ActiveSync/Exchange, security options, and over-the-air deployment of applications and settings.

iPad, iPhone, iTunes, and Macintosh are Registered Trademarks of Apple, Inc.
Android is a Registered Trademark of Google, Inc.
Canto is a Registered Trademark of Epic Systems Corporation.
Remote is a Registered Trademark of Allscripts.
Citrix is a Registered Trademark of Citrix Systems.
Bluetooth is a Registered Trademark of Bluetooth SIG, Inc.
Motion C5 is a Registered Trademark of Motion Computing, Inc.
Microsoft Windows, Internet Explorer, ActiveX, and Origami are Registered Trademarks of Microsoft Corporation.
Cerner Millennium is a Registered Trademark of Cerner Corporation.
Palm Pilot is a Registered Trademark of Palm, Inc.
Adobe Flash is a Registered Trademark of Adobe Systems, Inc.