

A doctor’s review of rounds with an iPad - mikecane
http://www.medcitynews.com/2010/06/a-doctors-review-of-rounds-with-an-ipad/

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kylec
My mother works in the healthcare field, and when they announced the iPad I
immediately knew that doctors would be clamoring to use them, and it's good to
know that, at least with the webapp-based systems, that the iPad 'just works'.

However, I'd also be interested in hearing from doctors that might not happen
to be "chief information officer and dean for technology" and see how easily
and effectively they can use the device.

~~~
niels_olson
I'm a surgery intern. I think tablets will have to become as ubiquitous and
uninteresting as cell phones before residents would start carrying them. If
there's a code and you have to respond, you can't just drop a tablet in your
pocket and run. If you leave it at the nurse's station at the county hospital,
there's every reason to assume some gangbanger visiting his gangbanger buddy
will take it. If you're going to the OR, there is precious little horizontal
space where you can safely lay something down, or even lean it. Everything in
an OR is on wheels, and is likely to get sprayed with some fluid, before,
during, or after the case.

I also think authentication will need to get lighter and more responsive. I
think thumbprint detectors in the margin would be ideal. Pick it up and login.
Logout if it sits without input for 2 minutes. If someone else picks it up,
immediately log me out and log them in.

Along with authentication, most hospitals use Citrix clients, but not all
Citrix servers seem to be configured for various clients. I have never been
able to access our Citrix server via iPhone, but the BlackBerry folks can.

As for electronic notes, the "eCare" system at Sentara hospitals here in
Virginia is overall faster than the paper notes at the naval hospital, but not
as coherent. Designers need to come in, look at hand-written notes, and figure
out how to lay that out in electronic notes. Tables upon tables of (value,
high/low marker, units, normal range) for all 30 or so elements of a CBC is
unnecessary when all I want is

    
    
      \ 13 /
    

7.2 ---- 335 84 N

    
    
      / 35 \
    

and that should fit on two lines, and the BMP should fit next to it, and the
calcium-mag-phos should fit next to that, and the LFTs, and the coags . . . it
should take all of 2-3 lines on the note, because that way it all stays in
your field of view and you can think about it without having to scroll back
and forth past gobs of data you're not interested in. Same with radiology:
echo the impression, not the whole report. Vitals: always, always, always
Tmax, Tcurrent, HR, BP, RR, SpO2, unless you're in a critical care setting,
where you want the same order, but with ranges.

It's all really fairly straight forward, but someone who knows CSS needs to
sit down and figure it out.

~~~
phren0logy
I'm a physician also, and I want to offer a counter-point. Handwritten notes
are done the way they are for speed, not because it's the best way to present
data. For example, in the notes I read the CBC "fishbones" often have little
arrows or annotations next to them indicating trend or prior values. They do a
very respectable job, but I disagree that emulating them is the best approach
moving forward.

Also, our hospital also uses Citrix. It sucks. I cannot think of any reason
why this approach would be preferable, from a user's point of view. But then,
nobody who buys this stuff actually has to use it, which is the crux of the
problem.

~~~
ashearer
It's true that handwritten notes are optimized for speed of writing, but
they're also optimized--perhaps secondarily--for the speed of reading, which
happens at least as often as writing (we can certainly hope).

There's a third optimization at work, for small size, both for its own sake
and as a byproduct of optimizing for writing speed. Less ink tends to be
faster.

Tufte frequently mentions the importance of saving ink when drawing charts,
going as far as the rule of thumb that if any line can be erased without
changing the meaning of the chart, the chart is better after doing so. But of
course, it's not really about saving ink itself, it's just that total ink is a
good proxy for the presence of distractions that impair clarity (chartjunk).

Similarly, fast-to-write notes like the fishbone also tend to be fast for
trained practitioners to read at a glance. Though they may not be exactly what
we'd come up with if starting from scratch with reading speed as the sole
criterion, they get much closer than the typical lab results report.

Current electronic alternatives tend to be optimized for something else
entirely: ease of printing on a fixed-pitch line printer. We can improve
readability greatly by broadening the formatting options beyond that, to
include options previously only possible with freeform pen and paper.

An ideal layout optimized for readers and free from obsolete constraints (such
as writing speed and legacy print engines) would probably abbreviate fewer
words compared to handwritten notes, because unusual abbreviations slow down
the reader. At the same time, it would get rid of common words that ended up
being frequently repeated on computer reports (medjunk). It could include
better graphical and formatting cues (selective boldfacing, symbols,
sparklines, spatial layouts like fishbones, etc.)

We can also take advantage of handheld devices like the iPad to allow trends
and ranges to be brought up by tapping on a result, instead of trying to
display everything all at once.

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bradleyland
This is a really detailed account of the kind of advancement that multi-touch
tablets can make in domain specific applications. Why are people rolling
around computers on carts to perform simple interactions with web apps? I
can't think of a better use case.

~~~
patio11
_Why are people..._

Carry a clipboard with patient names and diagnoses on it, OK, you're pretty
much kosher. Carry a tablet which accesses patient names and diagnoses over a
wireless connection and you probably just bought six or seven figures in
infrastructure and auditing requirements.

HIPAA: Comply Diligently, Or Get Intimate Domain Knowledge About Emergency
Room Operation.

~~~
niels_olson
> probably just bought six or seven figures in infrastructure and auditing
> requirements.

This has already been paid. Citrix is already deployed at most hospitals, and
doctors routinely access it over wifi and 3g from laptops, the "COWs" the
author refers to, and even their home computers. And Citrix has an iPhone
client, a Linux client, and a BlackBerry client, all free.

~~~
tl
I can't speak to the quality of the iPhone version, but the Linux version is
absolutely terrible. It's slow and crash-prone (think early flash releases).

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jrockway
Sounds like the iPad makes for a really good dumb terminal. I guess the
advantage over a real computer, in this case, is that it's cheaper and the
battery lasts forever. (And it has a good screen, something that Lenovo and
others can't figure out how to buy.)

And we never thought thin clients would catch on...

~~~
niels_olson
the form factor is huge. The clipboard metaphor is very valuable. However, the
maximum dimension that most white coat pockets can accomodate is a 8.5x11
folded in half the fat way, narrow edge down.

~~~
jrockway
I heard about some touch-sensitive e-ink-based devices that were supposed to
come out in this form factor. I don't know about doctors, but I would buy one
on launch day ;)

~~~
stcredzero
I predict that a 8x6 or approximate tablet with multitouch and 10 hour or more
battery life will be produced soon.

Both the iPhone 4G and the HTC Evo are plays for doctor's money. The larger or
more detailed screens of these devices can still fit in coat pockets.

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philwelch
It's encouraging (to Apple, I guess) that most of the weaknesses are just
small points in their system's particular software that don't work well with
iPad. Those will just get ironed out.

~~~
metachor
Other than printing, yes. And I recall some email from Jobs where he said
printing on iPad would be solved eventually.

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pmccool
The article describes a situation where an ultra-portable device with long
battery life is a winner. It's not clear whether the iPad is any better than a
netbook would have been. I would imagine it would win on standing-up use and
lose out on typing. At any rate, it seemed more about the virtues of an
ultraportable than the particular virtues of the iPad.

edit: which is not a criticism of the article, merely an observation that it
applies to more than one device.

~~~
YooLi
Netbooks have been around long enough now that if they worked in this
situation, they would have been adopted already. Think clip board, not laptop.
The standing-up use is essential. He said the typing worked just fine. Add the
12+ hour battery life and the iPad fit the situation quite nicely.

~~~
pmccool
I was making the point that a lot of the advantages mentioned apply to
netbooks. Some of the ones that don't (e.g. standing-up use) would be a case
of swings and roundabouts. I agree that standing-up use, particularly data
entry, is one of the iPad's advantages. I didn't get how much of the standing-
up use was data entry (where it's game, set and match to a touchscreen) and
how much of it was passively displaying data (where the advantage is smaller).

One place mentioned in the article where the iPad wins over netbooks is ease
of cleaning, having way fewer crevices than a device with a keyboard. Not an
impossible problem, but I imagine it's nice not to have to worry about it.

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ams6110
_When there was a bug in a MySQL database being used by folks for chart
review, standing there on the wards, I was able to securely get into the MySQL
server back in informatics_

THAT doesn't sound HIPAA compliant....

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ZeroGravitas
How much competitive advantage do Apples traditional strengths bring them in
this Market vs generic web tablets?

I'd say none.

~~~
jemfinch
The fact that the iPad is the _only_ significant player in this market _right
now_ is a pretty doggone big competitive advantage.

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zaidf
The patient management app at my dad's office is all Flash. There goes any
chance of iPad adoption.

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petercooper
My name is Dr Cheeks and I'm a little behind on my rounds.

