Mobile EHRs: A Guide for Practicing Physicians

It's 2 a.m. and 10-year-old Johnny's mom calls because he has an ear infection. She knows he's allergic to something, but she's not sure what.

In the past, Johnny might have suffered hours of pain and a perforated eardrum because his primary-care physician couldn't get to his charts and prescribe appropriate medication in a timely fashion, says pediatrician Barbara Morris, chief medical officer of Community Care Physicians, a 200-physician practice with locations throughout the Albany, N.Y., area.

Today, now that a growing number of physicians at the practice are equipped with Apple iPhones and iPads that connect to the Community Care's EHR, patients like Johnny get care and relief more quickly. And that's just the first of many benefits.

"It's an immediacy of clinical information," says Morris. "Sometimes it's a life and death [situation], sometimes it's convenience, sometimes it's being able to initiate a treatment."

Community Care is one of a growing number of practices, large and small, whose physicians are connecting to EHRs via mobile means - especially via media tablets. Physicians are warming up to iPads in particular, according to several studies, and because many are eager to use the devices to connect to their EHR systems, some observers are wondering whether the iPad will do more to encourage EHR adoption than any government stimulus or vendor promotion ever could.

But as with any new technology, there also are some limitations to mobile EHRs that will take time to work through. For physicians on the fence, here's some guidance on the benefits and limitations of the emerging mobile EHR.

The state of mobile EHRs

Mobile devices have come a long way. Today's smartphones, for example, allow a physician to do everything from download medical-reference apps to view high-resolution X-ray images quickly and easily.

But the introduction of Apple's iPad in April 2010 has done more to advance the concept of a truly mobile healthcare delivery system than any other device, software release, or technological development - including, perhaps, the Internet itself. The iPad's laptop-like screen size (10 inches), its phone-like portability (it's about 1.33 inches thick and weighs 1.3 pounds, depending on the version), and its powerful battery (up to 10 hours on one charge), seem to combine to make it a busy physician's dream gizmo.

Further explaining the iPad's success in mobile health has been sheer serendipity: Its release coincided almost exactly with the implementation of the final Stage 1 rules for the government's EHR incentives, which, in turn, spurred the adoption of EHRs.

According to our Physicians Practice 2012 Technology Survey, Sponsored by AT&T, taken by 1,369 physicians, practice managers, and other healthcare workers in the first quarter of this year, use of mobile technology, has risen substantially. More than half of all practices have a fully implemented EHR, and 63 percent of respondents said they use mobile devices for work purposes. Of those, nearly half (45 percent) use an iPad or other media tablet, and 82 percent use a smartphone.

All this has given rise to a new category of EHR - one that runs on a smartphone and/or media tablet - that most vendors are working on developing, if they don't have something already.

Most "mobile EHRs" are extensions of desktop-computer EHRs: They reside on mobile devices as "thin-client" applications (either as Web-based apps or apps that are native to the tablet's platform, such as Apple's iOS) that connect to the practice's EHR through the device's Web browser. While some EHR apps conform to a device's particular operating-system constraints so the EHR looks natural on a smaller screen, not all of them do.

A few vendors have made attempts at developing EHR systems to run natively on the iPad. For example, the former ClearPractice launched an iPad-only EHR program called Nimble as far back as 2010, but has since changed its name and corporate focus. More recently, Epocrates introduced an iPad-native version of its Web-based EHR. Most vendors, though, are working on (or have released) tablet applications of their existing products, rather than tablet-native tools.

"Most of what we see with [mobile EHRs] is really Apple iOS apps, and a handful of Android apps," says Jonathon Dreyer, senior manager for mobile solutions marketing at Nuance Healthcare, which makes voice-recognition technologies for use in both desktop and mobile environments. "Mobile EHRs are being developed by a number of the legacy EHR manufacturers and new manufacturers. Most vendors have created a front-end 'shell' that will let you connect to an EHR anytime, anywhere."

Jonathan Bertman, a practicing physician and president of EHR vendor Amazing Charts, says because most EHR companies haven't redesigned their electronic charting to support a fully mobile or iPad experience, most things physicians need to do inside their EHRs - especially typing in the absence of a physical keyboard - will be either difficult or impractical to perform natively on mobile devices.

Why docs are raving

In addition to helping little Johnnys with eardrums on the brink of rupturing, having a mobile EHR allows Community Care physicians to do more when they're not in the office. And, says Morris, it gives the practice a "competitive advantage" when it comes to attracting younger, more technology-savvy doctors.

That's why physicians who work for the practice only need ask to receive iPhones and iPads that connect to the practice's EHR system - even though these doctors are already given Lenovo ThinkPad laptops for working at home.

"There's multiple layers of benefits," says Morris. "It makes the physician more efficient away from the office, [and] it allows for more efficiency in the office. It allows the physicians to see their schedules before their days [start], and it allows for better patient care because of the easy voice dictation built into it, so the patient information is in the chart the next day. If I'm gone Friday, any business I conduct is in the system before Monday."

Andrew Barbash, a former practice-based neurologist who now works at a Silver Spring, Md., hospital, owns an iPhone, Motorola Droid smartphone, and an iPad. Armed with his gadgets, Barbash is constantly on the go, e-mailing clinicians, e-mailing patients, conducting mobile videoconferences, and showing images to patients. He uses medical apps to look up information. And that doesn't even include all of the things he does related to using his mobile EHR, which he accesses via a thin-client Citrix Gateway receiver.

"There [are] a lot of things that have been tried in healthcare that never achieved a rate of adoption until they were mobilized," says Barbash. "Physicians don't have downtime between their [patients]. And so, everything they can do to do as much of their viewing, results management, communication, documentation, orders checking, and follow-up requests from nurses on their mobile device gives them that much more efficiency. There are key elements of functionality within the EHR that unless a physician could actually do them while they are moving around during the day or while they are on break, they literally wouldn't be able to use the EHR as effectively."

[For more from Barbash on the benefits and drawbacks of a mobile EHR, watch our video.]

Washington, D.C.-based orthopedic surgeon Denis Harris, proudly "paperless since 1983," has been using the latest version of his EHR for two years. These days, he appreciates how easy it is to do things while on the go with his iPhone and iPad, with which he can access his LifeDox EHR through a thin-client-based connection.

"A [mobile] EHR shows you in real time what you're doing with another doctor," says Harris. "EHRs are getting better and better, and newer ones allow patients to be involved … I'm an orthopedic surgeon, so 40 percent of my practice comes from another doctor, and [information] can get lost in translation between different doctors. In the past, the patients would have to carry charts or bring pictures or whatever."

Mobile disadvantages

Today's smartphones and media tablets are sleek, fast, and fun - so it's easy to get lost in their sex appeal and forget that in reality, mobile technology isn't quite as fast as your desktop computer. What's more, it's also not as fast as the wireless industry says it is.

For starters, cellular network speed - the speed at which a user can transmit and receive data over a cellular, as opposed to a Wi-Fi, network - is overhyped. Though fourth-generation (4G) wireless smartphones and tablets promise speeds of 1 gigabit per second, they rarely achieve that speed in actual usage. A variety of influences, from network traffic to the amount of bandwidth an application requires, slow down data-transmission rates.

"There's a lot of hype behind 4G," says Thomas Handler, a physician turned technology consultant and research director with Gartner Group. "There's a huge potential difference [between 3G and 4G], but in reality it isn't as fast."

This is something to consider if you need access to the Internet anytime, and anyplace. Most of the time, however, you'll probably access your network via a Wi-Fi connection at your practice, hospital, or home. Wi-Fi is usually faster than 4G and is not subject to the same restrictive data-transmission caps that cell carriers impose.

Networks aside, there are other disadvantages to accessing an EHR through a mobile device instead of the computer.

Many physicians will admit that typing is hard sans a traditional, tactile QWERTY keyboard.

Harris gets by this by dictating notes into his EHR via cloud-based, medical speech recognition technology. "I can carry data on 35,000 patients and I can carry them on my iPhone and iPad, and interact with Nuance speech recognition on it, and I can look things up," says Harris. "I can't possibly remember 35,000 patients so it's very handy having it available."

For Barbash, the "ultralight" Bluetooth-enabled Targus keyboard is a constant companion.

Dreyer, however, is skeptical that special keyboard accessories for mobile devices deliver the same functionality.

"Even a detachable keyboard, it would become extremely cumbersome if you had to carry a device along with you," he says. Many iPad users, though, have gotten used to carrying their devices in one of the many available cases that include Bluetooth keyboards. Or a practice could simply have keyboards available to iPad-carrying physicians in each exam room, so they can plug in as needed without having to carry them around. {C}

Another challenge: security.

"It's easier to steal, lose, or break these devices" than a laptop, says Handler. Plus, as physicians are more likely to transmit regular, unencrypted text or e-mail messages when using a mobile device, the risk of being found guilty of a data breach (and having to pony up fines and suffer penalties for violating HIPAA) increases.

"I encourage every person to password-protect their phone," says Barbash.

Ready to go mobile?

Before buying a bunch of iPads for your docs, consider:

1. The EHR factor. Think about the mobile-friendliness of your EHR or any you're contemplating buying. If you have an EHR that doesn't offer a mobile app, find out what the vendor's plan is for mobile access, and when it expects to execute on those plans. For practices still shopping for an EHR that want the option of mobile access, it's important to explore how EHRs you are looking at are leveraged on mobile devices. "My advice is to be sure you can access the charts from your home without extra cost, and from your smartphone without extra cost," says Bertman. "Physicians should also be warned that they can't expect the same experience [from mobile devices]." But make sure that you understand the nature of the experience your doctors can expect; insist, at a minimum, on seeing a demo run on an iPad. Talk to a vendor's current users, and ask those users about the extent to which their physicians are accessing the EHR system via mobile devices, and how they like it.

2. Financial feasibility. Assuming your EHR has a nifty mobile-app companion, hardware and service costs can be significant. Tablets typically run $300 or more apiece. Those with 4G capability cost more and are useless without accompanying cell coverage. Again, the cell plans come with data caps that your physicians will likely bump up against if they're using cell networks routinely to connect on their iPads. Practices who invest in iPads for their physicians (and want to keep a lid on expenses) might want to purchase Wi-Fi-only devices, giving the doctors the option of cell-enabled devices if they want to pay for the extra cost of the hardware and the cell coverage.

3. Life/work style. While media tablets are great, physicians should be careful not to be seduced by their physical features. Instead, they should look realistically at the device and see if it is something they would use, if it would benefit them, and how it would benefit them. "I'd advise a physician to only get an iPad or smartphone if they want it for reasons other than an EHR," says Bertman. "The one caveat is if an EHR company has specifically designed it for an iPad. The dermatologist I share space with uses this kind of EHR and says good things about it. However, I believe that unless you can actually use it in your practice to prove it works - and can do so without impunity if you decide it doesn't work for your practice, meaning you can get a free trial or full refund - I'd recommend holding off for another nine months to a year. The market and technology is advancing, and many vendors will be gone within that time period, I suspect."

For Barbash, being able to use mobile devices to access his EHR not only complements his fast-paced work style, but it also helps him to satisfy his patients.

"Yesterday, I walked into a patient's room, the family was there, and I pulled out the iPad and logged into the EHR to show them some scans," Barbash recalls. "Their response was, 'Oh my God, I didn't realize you could do that' and 'that's incredible.' They were able to hold it themselves. It actually gave us a much more personal interaction while we were collectively looking at information as opposed to if we were using a computer screen."

The iPad effect

Solo family-medicine physician Jeffrey Gladd of Fort Wayne, Ind., can't wait until his EHR vendor unveils an iPad-ready version.

Though he uses a Wi-Fi-ready MacBook Air laptop, "I'd much rather have a mobile EHR on an iPad so I can quickly, if I'm outside the office, access those charts," Gladd says. "When Hello Health comes out with an iPad EHR application, I'll just be able to turn on my iPad and do all of my EHR functions in one convenient location, instead of taking the steps right now it takes to get onto the electronic health record. When I've got a full EHR on the iPad, I'll cut down on two steps and only carry one device." (The iPad version had not yet been released at this writing, but was due soon.){C}

But while Gladd already had his EHR before his vendor announced it would offer a mobile EHR iPad application to accompany it, the growing number of iPad-loving physicians like Gladd makes one wonder whether the sheer existence of Apple's popular media tablet has, to some extent, prompted physicians to purchase EHRs when they otherwise wouldn't have.

After all, many doctors use their iPads in a way they never used their mobile phones - as a light but robust electronic companion that goes from home to exam room to dinner at a restaurant. Armed with the 1.3-pound iPad, a physician can do everything from touch-typing patient notes to looking up patient charts much more easily than she could with a smaller-screened smartphone.

For this reason, Steven Ferguson, patient management officer for EHR vendor Hello Health, says the iPad could be the magic device that gets some physicians EHR-ready.

"Before the introduction of the iPad, I was rather skeptical about the viability of a mobile EHR," says Ferguson. "But now that the third real version of the iPad is out, the user experience is through the roof."

Others, like physician Jonathan Bertman, president of EHR vendor Amazing Charts, say that even with its high level of sophistication, the iPad doesn't have enough functionality to be used for sole EHR access.

"iPads are meant to point and touch, and getting through an encounter would mean hundreds of touches," says Bertman. "So until EHRs are really designed for tablets, I don't think that will happen."

And while the debate continues on whether the iPad is a true catalyst - a technology trigger that compels physicians to purchase an EHR - there is no question a growing number of physicians will start to see the ability to use an EHR on their iPad as a market differentiator.

In other words, vendors that offer iPad functionality (such as through an app) with the purchase of an EHR will find themselves at a competitive advantage with an increasingly iPad-savvy physician audience.

In Summary

A growing number of physicians are connecting to their practice's EHR through a smartphone or media tablet. Here are some benefits and drawbacks to consider:

• Mobile devices help physicians do more when they're not in the office, and make them more efficient when they are in the office.

• Using mobile EHRs, physicians can see their schedules, access patient notes, e-prescribe, and coordinate care.

• The vast majority of "mobile EHRs" are not standalone, exclusively mobile products. Rather, most are extensions of existing EHRs; they reside on mobile devices as apps.

• There are disadvantages to accessing an EHR through a mobile device: for example, touch-typing is difficult without a traditional, QWERTY keyboard.

Marisa Torrieri is an associate editor with Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the July/August 2012 issue of Physicians Practice.