Apple’s iPad is increasingly finding use in health and medicine, with applications ranging from giving individuals instant access to a wealth of reference, educational and personal health information, to helping hospitals streamline their operations, reduce labor costs, improve efficiency, and helping health professionals with analysis and diagnosis.
However, recent reports suggest the touch tablet devices could be doing more than was originally intended, driven by a pressure for change that is is coming from users, as health care providers seize the new tool with renewed passion, and demand more from the technologists.
Some hospitals have installed kiosks where patients, visitors and medical staff use the securely mounted touchscreen tablet to look up information. For example, at Singapore’s Changi General Hospital, people use iPad kiosks to find their way around the facility.
Staff at New York Methodist Hospital uses their kiosk-mounted iPads as diagnostic aids in electrocardiogram and other systems.
At Massachusetts General Hospital in Boston, clinicians use iPads to access up-to-date clinical information before and during patient consultations.
In fact, it appears that once they have tasted their value, the main thing holding back budget holders from purchasing more of these versatile, handy gadgets, is how to keep them securely inside the hospital.
In the meantime, the number of applications (apps) that can be downloaded and used on the device is growing rapidly. And, some hospitals are so eager to implement iPad technology, they are developing their own apps.
One example is Ottawa Hospital in Ontario, Canada; a facility comprising four campuses and 1,300 beds. Back in 2008 they appointed a new chief information officer, Dale Potter, a man with little professional experience in health care but a strong background in IT.
In an interview reported by TabTimes in November 2011, Potter said the first thing he did was shadow clinicians to observe how they used computer information. He said he was dismayed to see how their “work flow” was disrupted. Doctors were printing stacks of patient charts and notes to take on their daily rounds. And sometimes they would leave the patient’s bedside to go and look something up or enter it into the system, and then come back.
The hospital had tried mobile computing before, both in the form of computers wheeled around on trolleys and more recently, tablet PCs. But the trolleys cluttered up corridors and the tablet PCs took too long to boot up and ran out of battery power too quickly.
What they needed was what Potter called a more “practical and elegant” solution to support the mobile work flow of the hospital staff.
Potter came back from a Las Vegas engagement in early 2010 with four new iPads. He kept two in his department for assessment, but then gave two to clinical staff: one to a surgeon and the other to an internal medicine expert.
Potter recalls their response was, “How quickly can we get these?” So he took a big career risk, battling arguments that the devices were just glorified toys, and bought over 1,000 iPads. He also got his own team to develop an iPad version of the hospital’s electronic health record (EHR) software. He had tried to get an outside software house to do it, but they were already booked up with special project orders from other customers.
So now Potter has his own development team of around 70 people, a mix of employees and contractors, just developing apps for the hospital’s iPads.
They launched their iPad-based EHR software in January 2011. At first it only allowed medical staff to view the EHR data. They are now working on adding functions that allow clinicians to order lab work, digital imaging and medications.
Potter says there is a huge appetite for “apps”: he has challenged his team to develop one a month. The IT team develop the apps in response to medical staff suggestions.
They have just developed a new app for pain management that helps patients communicate the location and intensity of their pain. The nurse hands the patient the iPad showing a map of the human body and asks them to touch the screen at the place where they feel the most pain. Then they show how intense the pain is by selecting a color from a grid (eg crimson being the highest intensity pain).
This information goes into the hospital database, where the hospital system checks it, and alerts the appropriate physician or anesthesiologist if the patient’s input information falls outside set parameters.
Potter said he is very pleased with the results, and in fact, the iPads have exceeded his expectations, but there are also limitations they are trying to find ways around. Because the iPad is primarily a consumer tool, its system’s administrative rights aren’t strong to allow them to do things like control images remotely. But apparently Apple are working on this: they didn’t envisage when they launched the iPad that it would become so useful in health care.
Another limitation is how to get information into the device easily and quickly: medical staff are not willing to carry mobile keyboards around with them, as well as the tablets. So, Potter and his team are looking to test a speech-based entry system based on Dragon Mobile Medical Recorder from Nuance Healthcare.
Another environment that seems to have taken the iPad to its bosom is medical education. At first it was just a tool that students brought with them of their own initiative: but more and more medical schools are now switching to iPad as the main platform for delivering the curriculum.
But, what starts out as an initiative to make campuses greener, is beginning to deliver other unexpected benefits, such as cost savings and improvements to the learning process itself.
Take Yale School of Medicine, for instance. Last fall, they gave each of their 520 medical students an iPad and an external wireless keyboard. They will no longer receive printed course materials. iPads will be the primary source of medical teaching.
Assistant Dean for Curriculum, Dr Mike Schwartz, said in an interview for the Winter 2012 issue of the School’s Alumni Bulletin Yale Medicine that it costs about $1,000 per student to provide paper copies of course materials. This is about the same cost as providing an iPad and supporting apps.
“We pretty much break even,” said Schwartz, “but the iPad is better for the environment – and as an information delivery system, it’s much more versatile.”
With the new iPads, teachers will be able to change the course materials as often as necessary, and the graphics should be much clearer too.
The School trialled the iPads with a handful of students in a pilot program in the Spring 2011 semester. They used their touchscreen tablets to download course curricula, take notes in class, and update course material.
“It’s hard to think of anything else that has had such a profound and rapid impact,” said Schwartz.
Med student Vicki Bing, described herself as “paper-person” when she was invited to take part in the pilot scheme. Before the iPad came along, she would have to have everything printed out. After one semester with an iPad, she became a convert. She appreciates having all the material at her fingertips when she is attending a lecture, and she welcomes the iPad’s portability:
“I travel a lot, and I used to bring paper copies of everything with me to study on the road. With the iPad it’s so much easier. It’s all right there with the touch of a finger.”
And the Yale administrators are also starting to see other unexpected benefits: in the ways courses are taught.
Dr Robert L. Camp teaches pathology. He said the iPad is an ideal tool for teaching small groups.
“Computer screens, which we used to use, create a barrier between you and the person you are talking to. It’s not interactive. But the iPad is more like a piece of paper. You hold it more like a book and you can pass it around. It tends to engender more group thinking and group discussion,” said Camp.
The signs of how much more the iPad could deliver were visible even at the pilot stage.
Nicholas Bergfeld was in his first year at Yale School of Medicine when he took part in the pilot scheme.
“Using it to take notes in class was their baseline goal, but we quickly exceeded that,” said Bergfeld, explaining how for instance in the pathology lab the iPads allowed for greater collaboration between the instructor and students, who were able to answer survey questions and draw on slides in real time, “It made the class a lot more interactive, a lot more fun.”
Yale is not the only medical school introducing iPads. The trend is taking off in Medical Schools all over the US, including at Brown; the University of California, Irvine; Stanford; and the University of Minnesota.
But Yale’s program is different in that it is giving iPads to all its med students, not just first and second years. And to allow third and fourth years to use them in clinical settings, the School has encryped their iPads so they are security and privacy-compliant.
Harvard is undergoing a similar revolution, in a different way. They aren’t providing a specific tablet device, so they are not insisting on iPads; instead they have chosen to focus on providing apps support. They are testing pilot apps that students can use on other platforms such as the iOS and Android. One example is an app they can use to track patients on their smartphones.
Last August, Apple editors announced the top 5 medical apps for iPads and iPhones in 2011. Here is a brief rundown.
Top of the bill is an app called Airstrip Cardiology, by AirStrip Technologies, that allows clinicians to review the extent of a patient’s ECG history. A free demo version is available for anyone to access via the App Store, with the functioning application available for purchase by hospitals for their clinicians.
In a December 2011 article published by iMedicalApps, Dr. Shaival Kapadia, a Cardiologist at St. Francis Medical Center, a Bon Secours facility in Virginia, explained why this app is so popular:
“The nurse runs the EKG, processes it, and instantly it’s pushed to your phone. That’s huge because that determines whether I rush to the hospital to take care of this patient, or whether it’s something that the ER can handle.”
“… you can quickly pick up your phone, view the EKG, and take care of patients remotely. AirStrips makes it seamless,” he added.
Second on the list is Skeletal System Pro III ($5.99, by 3D4Medical.com). Primarily a learning tool, physicians, educators and professionals are increasingly using this app as a reference and identification tool. It allows them to show detailed areas of bone system to their patients and students, making it much easier to explain conditions, ailments and injuries.
The third most popular 2011 Apple app is EyeDecide MD (free, from Orca Health). Primarily an educational tool, it sports three features: Anatomy, Condition, and Find a Specialist. The app uses annotations and medical images specific to each eye condition to describe it and show what it looks like, including cataracts, conjunctivitis (pink eye), dry eyes, floaters, glaucoma and age-related macular degeneration (AMD).
Fourth on the 2011 top iPad apps list is Mobile MIM, a free app by MIM Software Inc, used for viewing, registration, fusion, and/or display for diagnosis of a range of medical images, including SPECT, PET, CT, MRI, X-ray and Ultrasound, (excluding use for mammography). The AppStore describes it as useful for reviewing images, contours, DVH, and isodose curves from radiation treatment plans. Mobile MIM can be used to approve these plans.”
And finally, fifth in Apple’s 2011 top five apps is another free app by by MIM Software called VueMe intended for non-diagnostic viewing of medical images by patients. One example could be to take your medical images with you when you go and see the doctor.
The MIM apps use a facility called MIMcloud, an Internet medical imaging service that allows users to store, share and view medical images in a secure and easily accessible way, so they don’t have to carry a stack of CDs around. They just call up the image from the Internet store on their iPad or iPhone.
Another impressive app is Medscape Mobile, a huge free resource from WebMD and available on several platforms, including iPad, iPhone, iPod Touch, Android and Blackberry. It is the leading medical resource most used by healthcare professionals.
In 2010, the iMedicalApps Team voted it their number one because:
“The amount of free content provided by Medscape is absolutely mind boggling and seems to continuously grow with each update. 7,000+ drug references, 3,500+ disease clinical references, 2,500+ clinical images and procedure videos, robust drug interaction tool checker, CME activities, and more.”
Although many use it as a simple drug reference tool, Medscape is far more than this: it is “actually a mini-textbook packed with protocols for disease pathologies”, they explain, “It’s not as detailed as the famous Pocket Medicine Red Book – but it does more than an adequate job of providing clinical pearls from the most common to less common pathologies”.
Medical imaging is a field where one can see how the iPad may one day, and perhaps that day is sooner rather than later, go beyond helping teachers, students patients and doctors communicate more clearly, to being a diagnostic tool. However, there are currently some hurdles.
A recent study led by Dr Mark McEntee, from the Discipline of Medical Radiation Sciences at the University of Sydney in Australia, found that the iPad is as good as a standard LCD computer screen when used as a secondary display device, such as those doctors refer to as they do their rounds in patient wards.
McEntee, and colleagues compared how well iPads performed against LCD secondary display monitors for helping to identify lung nodules on chest x-rays, intracranial bleeds and fractures.
They found no signficant differences in performance. The iPad screens had the same resolution as the desktop screens: 130 dots per inch (dpi).
But, while the study gives the rubber stamp to using iPads as communication aids, helping doctors and patients look at images together, the ease of doing so needs to be balanced against the risk of starting to treat the device as a diagnostic tool.
McEntee, and colleagues emphasize that the iPad should remain firmly as a secondary diagnostic tool only: with the primary diagnosis of medical images such as X-rays, CT, MRI and PET scans, being the realm only of specifically designed high-quality primary LCDs, in accordance with radiologists’ professional standards.
McEntee says in a recent press release:
“When no primary display device exists, diagnoses can be carried out on a secondary display device, such as an iPad, but this is only in the most urgent of cases, for example to determine whether a patient is suffering from an intra-cranial bleed.”
There are also strict guidelines to ensure best practice when reading X-rays and other images on an iPad or tablet. These include, for instance, ensuring against poor viewing conditions, viewing images on the move, and dirty or greasy screens.
However, it will be interesting to see what results such a study might find with the new iPad.
Apple launched its third generation iPad earlier this month. It is set to start retailing next week, around the middle of March.
One of the new features that should raise interest among those interested in medical applications (as well as the huge gaming market it is aimed at) is the higher resolution, high-definition screen, comprising 2,048 x 1,536, or 3.1 million pixels, which is not only better than any other tablet currently on the market, it’s also better than all current HD televisions (1920×1080 resolution; so-called Full HD).
Donald Bell is a tablet reviewer for CNET, the online digitial technology and information portal. He wrote in his post after seeing the new tablet at Apple’s launch in San Francisco earlier this month that not only does the new iPad’s QXGA screen exceed your expectations for tablet screens, “your laptop or desktop computer screen will also look shabby by comparison”.
Other major new features that should be useful in medical applications include a faster A5X chip processor, which apparently allows the new iPad to have twice the performance of the iPad2 (essential for driving a high-resolution display); and a 5-megapixel camera with 1080-resolution for video with image stabilization.
The basic design and size remains the same, with the exception that the new iPad is just under a millimeter thicker. Battery life is still about the same: about 10 hours on WiFi and 9 hours on a 4G LTE network.
As with the previous generation, the new iPad will be available in two versions: a WiFi only version, and a version that also includes a carrier network radio so users can connect to the Internet even when they aren’t in a WiFi hotspot. As well as the 3G network capability of the iPad2, the new iPad has 4G LTE network connectivity, a new standard which offers increased capacity and speed over mobile phone and data networks.
The scope for the iPad and its rivals to enhance the field of health and medicine has never been so wide: there is a lot of unexplored (and untested) territory.
But, as far as medical application is concerned, the new iPad appears to offer some extra welcome sophistication, especially on the imaging and resolution side.
This would suggest its gradual penetration into the diagnostic market may well take on a new, more accelerated pace.
Introducing the new devices is already proving to be than a cost-saving exercise; it is also begining to change the way that learning environments work, and that change looks set to carry over into doctor-patient communication.
Bergfeld, the student who took part in the Yale Med School pilot program, says he can see how the iPad will help him work collaboratively with patients, as it has helped him work collaboratively with his teachers. For example, he can see how he and his patients will be able to use the tablets together to look at and discuss X-rays and test results:
“It enables a greater level of personal connection,” he added.
Potter also remains excited about the future: he took a gamble bringing iPads into Ottowa Hospital, and it paid off. And he will be watching the next 18 to 24 months with avid interest.
“We have introduced a disruptive technology. We proved it could work. But now the innovation is coming from the grass roots level, from the physicians themselves,” said Potter.
“I have attending physicians who say they feel more engaged than they have in the 25 years they have been practicing,” he added.
Written by Catharine Paddock PhD