Physician Practices Embrace Tablets

Several times a day, Frank Adams, a solo pulmonologist in New York City, uses his Apple iPad to access his practice's EHR, to review charts and prescribe medication, and to pick up e-mail messages from his staff. Only nine months since he purchased the device, he can't imagine his life without it: Having an iPad has improved Adams' work flow and made him more available to patients.

"If I get an emergency phone call at home or on the road I can call up a patients' record in a matter of seconds," he says. "Just last weekend someone called my answering service with a history of severe cough. I happened to be in the middle of Manhattan but spoke to the patient on my cell phone and decided that an antibiotic was indicated. I asked the patient if she had any drug allergies and she said she wasn't sure. I had taken the iPad with me since I was on call and quickly accessed my EHR and found that she did have a history of an allergic reaction to an antibiotic that I might have prescribed. I then e-prescribed an alternative drug."

These days, Adams is in good company.

In the year since the April 2010 release of the iPad, the most popular media tablet to date, Steve Jobs and Co. have changed the way people think about personal computing. Nearly 18 percent of 1,400 physicians surveyed for Physicians Practice's 2010 Great American Physician Survey said they used tablet computers. That poll ran from March through May of last year. And adoption continued at a rapid clip after that. According to a separate survey of 2,206 physicians and other clinical workers in January and February 2011 by Physicians Practice's parent company, UBM Medica, 38.5 percent said they plan to buy an iPad or other media tablet this year.

The iPad and its emerging rival tablets belong to a category of mobile computing devices defined by their shape, size, and power. They're lighter and thinner than laptops, feature touch-screen interfaces, take up less dimensional space than a piece of notebook paper, and can be held like clipboards. iPads look like blown-up iPhones.

At a growing number of practices, physicians, and supporting staff are using media tablets in lieu of laptops to do everything from collecting data to showing patients how a disease can manifest itself in their body to retrieving medication-allergy information in the dead of the night for a panicked patient.

But before joining the tablet party, you should consider how the devices compare with those mobile computing devices your practice may already know and love - specifically, smart phones and laptops.

Tablets vs. laptops

Whether they're using them to input patient data into an electronic chart or check on medication allergies, doctors say tablets' user-friendly design often make them preferable to laptops.

Because tablets are lighter and skinnier than laptops, they're also easier to carry. The iPad, for example, weighs 1.33 pounds and measures 9.5 x 7.31 inches, so it can be slipped into a briefcase or a purse. Other tablets, like the newly released BlackBerry Playbook, sport even smaller dimensions (5.1 x 7.6 inches; 0.9 pounds) and can fit into lab coat pockets.

And because they're lighter and skinnier than laptops, they're inherently less cumbersome.

Holding a tablet is similar to and easier than holding a clipboard; a physician can hold a tablet in one hand, and use his other hand to operate the touch screen. Laptops, of course, have the advantage of a physical QWERTY-style keyboard, but they're also bigger and bulkier. Carrying them around all day is a burden, and they rarely have more than a few hours of battery power.

However, the touch-screen interface of an iPad can be a problem - at least at first. Because most doctors are trained to type using a tactile keyboard, typing on a digital screen where there are no keys to push into can feel unnatural, slow down the input of information, and make you more prone to typos.

Barbara Morris, a pediatrician with 200-provider practice Community Care Physicians in Albany, N.Y., says the process of getting used to a touch-screen interface was one she had to "persevere through."

But so many other things about the iPad made it worth the effort. For example, Morris likes being able to expand images by moving just a couple of fingers outward.

Additionally, "the landscape view makes it easy to see stuff," she says. "Laptops have lightness, but not small physical size for carrying around."

Physicians who cannot bear the thought of doing without a tactile keypad do have a few options, however. They can buy a separate keyboard attachment to use in the office or at home (some models use Bluetooth radio frequencies to wirelessly connect to tablets). There is also the option of purchasing a hybrid "tablet" computer that looks and feels like a tablet when held, but comes with a slide-out or detachable keyboard.

Family practitioner J. Scott Litton, Jr., of Pennington Gap, Va., uses a tablet of this style. His HP EliteBook 2740p Tablet PC looks and works like a tablet. But with a few twists of its 180-degree screen and a couple of tugs, the device transforms into a laptop with a full-size physical keyboard.

"While using a tablet PC, you put the tablet on your lap," says Litton. "So the patient doesn't get the sense that you're using a computer. You have a stylus in your hand and you look like you're taking notes. The patient doesn't get the feeling you're ignoring them."

And for many physicians, voice recognition software, in the form of a downloadable application, may largely replace the keyboard in most situations.

Tablets vs. smart phones

Like laptops, tablets come with high-resolution graphic interfaces, WiFi capability, high-speed download rates, hours of battery power, and other comparable features that allow tablet-toting doctors to do everything from videoconferencing to viewing multiple images simultaneously.

These features give tablets a huge advantage over smart phones, which physicians currently use to access EHRs and to send messages. Because tablets' screen size is about four times larger than that of a typical smart phone, everything doctors can do on smart phones looks bigger and better on the tablet, and is easier to work with.

The number of medical apps available to help doctors is growing every day on both smart phones and tablets. Today, there are iPad apps to help you identify pills, check on drug interactions, look up ICD-10 codes, look up medical terms, check out high-resolution photos of wounds, and view realistic diagrams of the human body. The possibilities for the future of apps and add-ons are endless; physicians are already using them to connect to everything from voice dictation software to video chat applications.

Thanks to built-in WiFi capability, plus the option of dual-mode connectivity, media tablets can be used to access critical information through cellular airwaves when you're not near a WiFi hotspot.

However, cellular dual-mode connectivity isn't free (sometimes you have to purchase a monthly data plan, or pay extra money for data usage), and boosting a laptop with cellular "3G" or "4G" connectivity when it's out of a WiFi zone isn't free either (a wireless data card, such as the MiFi card, costs $39.99 and up). If you're already paying a monthly smart phone bill, those costs can start to add up.

Tablets, EHRs, and meaningful use

Joel Anderson, CEO of ClearPractice, maker of the "Nimble" Web-based EHR program exclusively tailored for use on the iPad, calls timing of iPad's release and CMS's meaningful use EHR mandates "a perfect storm." ClearPractice launched Nimble at a trade show at the end of September.

Though Anderson won't give specific numbers, he says sales of Nimble grew 24 percent in the first six months.

"We're out there with our iPads and doctors are almost grabbing them out of our hands," Anderson says. "The intuitive nature of the device itself, it's amazing."

It's no surprise, then, that ClearPractice has a growing number of competitors in this space. Most major EHR vendors we spoke with are either building tablet-friendly versions of their products, or already have one. And other vendors, like ClearPractice, are emerging with EHRs, patient check-in software, and other products built exclusively for tablets.

There are many ways media tablets can help practices gather, collect, and transmit data - helping them meet CMS' meaningful use guidelines while simultaneously providing great patient care.

Litton offers an example: "The way it works is the patient comes to the office, and that signals my nurse to come into the waiting room, and then the nurse enters vital signs. When she's finished, I can use my tablet to open the patient's chart and you have a seamless integration."

Morris, whose practice uses Allscripts' special remote EHR application for her iPad, says that having the media tablet has made so many things easier - especially e-prescribing (a meaningful use Stage 1 measure) and looking up medical records in the middle of the night. And because the Citrix-based remote desktop application she uses on her iPad is accessed through a password-protected VPN, she doesn't need to worry about security of transmitting data, or what will happen if she misplaces the device (the application also requires a password, and leaves the screen as soon as she logs out).{C}

"Let's say a kid gets a laceration and a parent calls and says 'Should I take him to the emergency room for a tetanus shot?' I can look up immunizations, and it makes being on call a lot less worrisome," Morris says. "It's much better from a medical-legal perspective, too. I have a way to document my medical facts when I'm done, rather than relying on my memory the next morning."

But the experience of inputting or reviewing electronic data is not the same for all tablets. A provider's experience will be based on several factors - for example, whether she is accessing a Web-based EHR through the tablet's Internet browser or linking to the EHR through a specially tailored app.

Let's say, for example, a physician wants to use an iPad to access his Web-based EHR. Because the iPad relies on Apple's iOS operating system - which is different from a Windows-based operating system and Apple's own Mac operating system - the EHR won't translate well through the tablet's Web browser. It's better if the maker of the EHR has developed a version for the iPad, accessible via an application.

If you are still EHR-shopping and hope to use a tablet to access your system (or would like that option), make sure you get a tablet demonstration. Don't just assume that tablet access to your EHR would yield the same experience as accessing it via a laptop.

When Adams first purchased his iPad, he says he had to download an app called "Logmein," which allows him to remotely access data from another computer (specifically, his EHR database, stored on software).

"This is one of several apps that allow you to remotely access another computer," Adams says. "I used Logmein on the iPad to access my office computer and the EHR. After a few months the company that makes my EHR, Cerner Corporation, provided direct iPad access via an app called Citrix Receiver. I downloaded it from Apple and now no longer have to go through my office computer to directly access the EHR via the iPad."

Tablet time?

Picking a tablet is like picking a car, and your first consideration should be what will your practice use it for, and how often. Will it be the primary device you use to access your EHR? Will you need to purchase more than one device for use by the entire practice - the front-office staff as well as the doctor's clinical staff? Or will the iPad simply be used like a smart phone when you're out of the office, to look up information and send messages?

Practices should also consider compatibility with existing technology. If you use a software-based EHR, does your EHR offer a remote desktop application that would translate well to a media tablet? If you don't have an EHR yet, are you intrigued by the idea of a 100 percent tablet-based EHR?

Next, you should consider its design: How small or large does your iPad need to be? Are you comfortable with a touch-screen interface? Do you want to use a convertible tablet that comes with a slide-out keyboard?

Finally, there's the issue of cost. Investing in a tablet computer is a minimum upfront cost of $500 per device, and there may be an additional data-plan charge depending on how you'll use the device to get online. There also may be additional, per-provider licensing costs for using EHR software on more than one machine.

A practice that already uses mobile phones (for apps and to access medical data) while away from the office might find that the benefit of having another device doesn't outweigh the investment. On the other hand, your physicians may find the tablet experience so superior to that of smart phones that you opt to convert.

"There are 110 different specialties in medicine, and if you talk to each different specialty, they have a different idea of what they want to do," says Mark Hollis, president of MacPractice, which makes EHR software for Apple products, including the iPad. "But I think some doctors are expecting [media tablets] to do everything for them."{C}

In Summary

Trying to decide whether a tablet, such as the iPad, is right for you? Here's how it compares with laptops and smart phones, and how it's helping some physicians achieve meaningful use.

• Media tablets are lighter than laptops, and are easy to carry around like a clipboard.

• For physicians used to a QWERTY-style keyboard, typing on a tablet's touch screen can feel unnatural, and take longer.

• The number of medical apps is growing every day. Today, there are iPad apps to help doctors identify pills, check on drug interactions, look up ICD-10 codes, and more.

• There are many ways media tablets can help practices gather, collect, and transmit data to meet meaningful use guidelines while simultaneously providing great patient care.

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

This article originally appeared in the May 2011 issue of Physicians Practice.