by Felasfa Wodajo, MD

Recently, we had the chance to check in with Dr. Henry Feldman. He had posted a detailed summary of his experiences using the iPad as his main interface while rotating on service for a week as a hospitalist at Beth Israel Deaconess hospital (BIDMC) in Boston. Dr. Feldman is also Chief Information Architect for the Harvard Medical Faculty Physicians.

The summary of the following report includes his experience with the hospital wireless networks, using his hospital’s electronic health record system, interacting with patients using the iPad and how the battery life fared with clinical use.

Most important, was that he had a nearly seamless experience accessing his hospital clinical applications wirelessly. He wrote:

The secure wireless network handoff was amazing. As I roved around it was seamless (there is a slight dead zone on 11 Reisman as there has been for years) and the best example is that I would use the elevator ride to catch up on news/tech websites, and every time the elevator doors would open it would reconnect and download some more prior to the door closing.

He also reported that accessing clinical applications at his hospital was seamless, adding “[p]robably the most useful was rounding (or the nurse snagging you as you walked by) and during a trigger where I could stay at the bedside and do/see everything and not leave my critically ill patient.”

However, apparently most of the vital clinical applications (EHR, order entry, signout) at his hospital were designed to run in a browser so they already run “natively” on the iPad. Nevertheless, this should put EHR vendors on notice to create user interfaces that are easily adaptable for mobile devices.

He also found the iPad useful for communicating with patients:

Showing patient’s their EGD/ERCP pics, results/trends and since I have Netter’s on my iPad the anatomy of the procedure, really helped with understanding by the patients. Med reconciliation was easier too. Diet changes were instant on patients (important given the number of ERCP patients we have)

As for the device, he said that typing brief notes was not a problem with the glass keyboard and that the Apple plastic cover worked well and could be disinfected frequently. Not surprisingly, he raved about the battery life:

Battery life is epic, and I finally had to charge today at 3pm (Monday), after last charging Thursday night. This is with frequent use for clinical care, along with the inevitable demos one has to give carrying around an iPad (OMG an iPad! Show me a movie, apps, etc…). On average a full 13 hour stretch with heavy use burned 28% of the battery over the week, best 20% worst 35%.

We interviewed him about his experiences of using the iPad on the wards and focus on three main topics: security, portability, and infection control.

How did you carry your iPad?

Just in my hand like a book with the Apple case. I thought that on a 14+ hour day it would be tiring, but it never was an issue. I often put it down next to me to write a handwritten note, and I can’t imagine any physician not being near a flat surface once in a while.

Did you ever leave your iPad somewhere by accident? How would a mobile physician avoid theft or loss? Do you feel the systems that are currently in place, e.g. “remote-lock”, sufficient for medical grade security?

I never leave my iPad (just like I don’t leave my wallet or $900 signed cashier’s checks around), and one advantage of course is that with everything web based, nothing is stored on the device. I have a couple of strategies though: I have replaced the lock screen with an image with my photo, “Henry Feldman’s iPad”, my cell and pager. I can remote wipe it, each of the applications of course have a username/password in the hospital, and finally have a lock code, and I use an encrypted network connection. That already exceeds the security that almost any institution places on paper charts.

You described being able to access hospital applications easily since they are web based, can you explain?

As a large academic institution which has been computerized since the late 60’s (our “Acid Base Advisor” program was written in 1969 and still runs today!!) we have hundreds of systems. There are all sorts of interfaces to these systems, some of which are even terminal based (which you could access on an iOS device, but most folks won’t have that capability). That being said there are really 5 applications that physicians in our hospital use continously, which are WebOMR (our EHR), POE (our CPOE), Personalized Team Census (Signout), E-Ticket (Billing), Web Based Paging, and the ED Dashboard. All of these are web based and essentially work perfectly on the iPad (with some small occasional quirks).

Were there clinical applications which you could not access?

The one exception program I should mention is WebPACS, which in our medical center is JAVA based, which won’t run on the iPad. There is a PACS [application] for the iPad (the superb OsiriX package), which would require some complicated policy changes [by radiology IT] and some technical changes, but could work.

What improvements can be made to make access to browser based clinical applications on smaller screens?

On the iPod/iPhone form factor, while the programs work, they are not really workable (zooming becomes tedious fast), and here is where direct iOS web API would be helpful. Other applications may not work on the iPad but I never interacted with them. Some of our other applications also require citrix, and there is citrix for the iPhone/iPad if you need it.

Did you consider carrying an external keyboard and how often did you use a desktop computer to type in longer progress notes or more complex orders?

I brought my keyboard to the hospital (the apple keyboard dock as well as the gorgeous “BookArc” iPad stand). They both sat on the shelf for 1 week unused. I used a desktop for writing complex notes such as my admission note and discharge summary, but this had less to do with the keyboard than being able to see multiple web pages at once and I do LOTS of cutting and pasting from data sources to assemble the note. My typical method of writing these notes consisted of doing a “chart biopsy” before seeing the patient, and getting 80% of the admission note written at a desktop. I then went to the patient room and opened the note on the iPad and filled in the details that weren’t available in the computer and details from the patient and my physical exam. I fully wrote letters to physicians or patients (results of studies) using my iPad.

No orders (or even discharge plans) required an external keyboard. I found after 1 beefy paragraph the screen keyboard does feel a tad clunky, but I rarely type more than that except for admission notes and discharge summaries.

How often did you clean or disinfect your iPad ? Are there “medical grade” cases available or do they need to be developed?

I actually cleaned it every few patients explicitly with the disinfecting wipes, and it was constantly bathed in cal-stat, as we “pump-in-pump-out” which meant it had a constant film of alcohol on it during rounds. Infection is certainly a concern, but since we aren’t even taking this as seriously as the NHS in the UK, we still all walk around with petri-dishes we call white-coats, long sleeve shirts, ties, etc. A sealed non-porous surface such as glass or the aluminum case are pretty easily cleaned. A medical grade case might be necessary for ruggedness, of course when it’s your own $900 device, you treat it well.

On average, how often did you hand your iPad to a patient to show them something?

I only handed it to a couple of patients, but showed results to almost every patient with me holding it (infection control). It really helped to show them lab results, pictures of their GI studies, EKG, etc, as patients rarely can visualize these results in their heads. This was invaluable.

Can you give an example of a type of functionality that would be a game changer for the patient physician relationship?

The killer application is to show patients their studies, which already exists. I have the Netters application, which lets me show patients Frank Netter’s amazing anatomy paintings of the anatomy of the procedure we are about to do, or what we are looking for in the diagnostic study we are about to do; note while the application is an “iPhone” application, when doubled on an iPad the images actually were originally very high-res, so they don’t blow up when you doublsize the application, instead you see more of them more detailed (sweet). Then I bring up with studies (GI studies such as ERCP, EGD, Colonscopy, EUS, EKG…) and compare the image with the drawing. Many patients commented it was the first time they understood their disease.

Showing a patient their labs, particularly around chronic diseases that the patient has to manage such as diabetes, is so useful, and you will find that you can teach patients a fair amount about their disease and its management when doing this. Most patients really appreciated this. Our patient portal PatientSite allows them do this as well, but without a physician standing next to them explaining the significance of the results.

The patients also got more of an understanding of how complex their care is, as you could show them all the studies, consults, etc that were “in flight” at the time as an inpatient, so they could prepare for busy/hectic days, and this really improved their acceptance of the hectic nature of modern hospitalizations.
Can you give an example of a functionality of something that is currently hindering the iPad experience in the medical realm ?

I would love to have PACS available at the bedside as well, but as I mentioned before this is a policy issue more than a technical issue as it would require “true” PACS access for physicians. There is a “sneaker-net” workaround that works for showing patients individual images, but that’s inconvenient.

Please describe your job as a “Chief Information Architect”

I design the software the Division of Clinical Informatics builds, which includes both a cloud based electronic health record and a physician licensing system, along with software to support various research projects. I also run the software development group for the Division of Clinical Informatics. The key difference between just a development manager of a software company and clinical informatics, is that I am also a practicing physician and a programmer. Just like a “real” architect, who has to be able to talk to the prospective home owners who have a vision of what their home should be, and the builder who is a technical expert in construction, this is what a Chief Information Architect has to do with providers and programmers. I am fellowship trained in medical informatics, having done my fellowship at the NYU School of Medicine/Bellevue, before joining the division here at Beth Israel Deaconess Medical Center.

What do you think is the biggest disconnect between the “IT world” and “clinical practice”

As a physician (who came from the IT/Software world) and a fellowship trained informatician, I am trained to bridge this gap. This is the scariest shortage in the US right now, in that many of the hospitals and practices which are about to spend the billions in ARA funds to put in HIT, may have IT services, but without informaticians the systems will not match the practice’s workflows, which puts lives and money at risk. When you see our ED dashboard which was written by Larry Nathanson who trained in our fellowship program, it is an airtight match to the clinical and business processes of the ED operations (and evolves as their practice does), as it was written by him who is a physician who practices with it daily in the ED. The same can be said for our systems up on the wards (WebOMR/POE) which were designed by physicians who practice here, and continue to evolve as our practice does.

Informatics is where the business processes intersect with the clinical process, and this is the gap that exists between IT and the care process in most institutions. This is not to say that IT is not critical to this process and without them nothing would actually work of course, but only a provider (nurses, physicians, etc…) can inform the software design process for clinical applications.

We are very spoiled at this institution as our IT is staffed by numerous informaticians such as John Halamka (CIO) who also trained in our fellowship program and Larry Markson (VP of Development), both physicians and programmers, and our systems were designed by in house informaticians. Our systems were designed primarily to support patient care between a patient and provider, not financial data gathering, and as such are really stellar systems. We also wisely invested in all of our core clinical applications being platform agnostic web applications, which made iPad use seamless.

How do you think physicians can best bridge this gap?

The art of informatics is being able to talk to programmers and non-technical providers and be able to talk to each group natively. Over the last 2 years I have written around 50,000 lines of code personally, and had thousands of patient encounters. This is really the push behind AMIA’s 20-by-20 program, as the world (and US critically) is very short of informaticians. I think in the future informatics will have to join the medical curriculum and be a section of the boards (it is becoming a specialty under each of the boards separately).

I think the NLM funding for informatics fellowships should be raised, as the need is much greater than the current training pipeline can deliver. The masters in bioinformatics that many universities are granting are not as useful as they are not mostly for providers, such as practicing nurses and physicians, and bioinformatics is not clinical informatics. These are best trained at fully credentialed clinical informatics fellowships. We have trained both senior nurses and physicians in our program.

Felasfa Wodajo is a writer at iMedicalApps.com.

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