iPad: Right Time, But Not Quite Primetime – Part I
Do 11 concurrent evolutions equal one revolution?
Implications of a recently released mobile tablet
Does the arrival of Apple's iPad really cause any revolutionary changes in the HCIT scene? Announced in January and available for about a month, the iPad has been associated with a lot of hype and speculation, including Healthcare Informatics and other HCIT blogs.
In just 28 days, Apple sold one million iPads, whose owners had downloaded 12 million applications and 1.5 million e-books by the end of April. It took the original iPhone 74 days to hit 1 million. iPad has achieved celebrity status, having appeared on every major news program, The Daily Show, SNL, and of course the requisite visit to Oprah. And now, the iPad is appearing at a Starbucks and in a hospital near you!
It's an interesting product, but does it have any special significance in the era of striving to demonstrate Meaningful Use at hospitals? After a few weeks of both personal use and observation of its use by others, I think it brings 11 unique implications worth paying attention to as critical opportunities.
In this, the first of a three-part look at the iPad, we’ll explore the first four of my 11 implications.
1. Pure mobile device play. The iPad can serve as a carry-able PC desktop, in the same sense that Citrix allows any Web browser to launch an interactive connection to a desktop. Within a few minutes of unpacking it, I had the iPad connected wirelessly to a PC running Windows XP, using VNC. I launched an existing, remotely-accessible EMR that requires no locally installed software. It worked immediately.
After a little experimentation, I found that a considerably easier, faster and more functional option existed using the Remote Desktop capability in Windows XP (and Windows 7), which also goes by the names RDC (Remote Desktop Connection) and uses RDP (Remote Desktop Protocol). In the parlance of iPhones, "there's an App for that" thin-client terminal server computing. In fact, several, some of which are free. Remotely controlling a PC desktop all works - left mouse, right mouse, mouse-over hover, automatic reconnection to dropped sessions without data loss. And, of course, the legendary zoom, pinch stuff and a clear, bright display completely preserving the 1024x768 VGA on a more than adequate 9.7 inch display. Is any of that that even evolutionary, much less revolutionary? Absolutely not.
2. Docs have iPhones. Here's where the iPad starts to get very interesting. Lots of docs have iPhones. Their perception is that they're already trained and familiar with the operation and utility of the iPad. There's a halo effect, whereby they assume that there's a very small learning curve to becoming fluent on an EMR that's accessible "iPhone style." It may be more of a false psychological comfort, but it sure beats the opposition, the irrational heightened anxiety when they first see EMRs that appear intensely foreign. This makes the iPad clearly a win for physician adoption.
3. "There's an App for that." The iPhone (and iPod Touch) really did benefit from a user interaction model that was designed for the smaller screen, multi-touch interface, and unique "patterns" that the iPhone supported.
A pattern (also known as Design Pattern) is a reference to the programming model on the iPhone that encourages apps to start and exit immediately, with no branding splash screens, seamless Web access, and an awareness of the CrazyBusy, mobile lifestyle of its users.
This is a distinction from an older desktop model typical of PC software applications, such as Microsoft Office applications like Word, with massive menu options and related navigation, ribbons, application "chrome" (unused screen space), and often sluggish responsiveness. Do we want to move that forward to mobile, Web-enabled computing?
This raises the issue of whether iPhone Apps are appropriate and ideal for the iPad. My experience so far suggests that there's plenty of room for existing mature desktop apps, as well as clever enhancements to iPhone apps, and something much more usable than either - fully threaded workflow.
Fully threaded workflow, as exemplified by the Partners HealthCare SmartForm platform, demonstrates a UI with guided ( CDS-based) information review, documentation and ordering/prescribing. Imagine the user being able to see all at the same time, focus in on a page or section, and have them all stay in context, whether on a tablet or 30 inch monitor. The ARRA process arrested this development, both in the industry and the homegrown world (although most vendors and Partners systems can demonstrate a healthy usable start, whether it's called a Form or a Clinical Desktop or one of many branded HCIT terms) . The re-emergence of the realization that processes like discharging a patient should not be managed as isolated tasks ( see link and description of Jim Walker's From Tasks to Processes article from Geisinger) will benefit from the kinds of threading we're starting to see supported by these hyper-mobile devices. Even this isn't primetime on the iPad; apps can only sometimes return to the app that launched them.
4. The age of ARRA/HITECH/Certification/Meaningful Use: Demonstrating meaningful use calls for acceleration and adoption of interactive access to EMRs. The most challenging involve entry of documentation and orders.
Take, for example, the requirement to maintain "Problem lists." Problem lists, in both the paper world and the electronic world, are incomplete and uncodified in actual practice today ( this is discussed by Hopkins' Steve Mandel as described here ). The HITECH mandate creates a new financial incentive; the additional work and usability issues are an independent formidable challenge. Adding mobility and a more natural interface will probably help.
Today's technology, largely keyboard and mouse use, and/or the use of a stylus in existing tablet or "pen-based" computers has worked. But they are also objectively clumsier than manipulating the screen directly with ones fingers. Here, the iPad does push the usability ball forward, with a combination of a large screen with crisply accurate finger tip control. However, don't expect it to work wearing surgical/medical gloves!
For those of you who have experience with an iPad, or those who have related questions or comment, they are most welcome. Will any of my points from five to 11 reveal the iPad is revolutionary for the HCIT world? You’ll learn more in Part II. Stay tuned.