iPad Update Apps Abound

	Jon Walsh, MD, a trauma surgeon at Bronson Methodist Hospital in Kalamazoo, Mich., uses an iPad to discuss images with a patient.

A year after its introduction and on the heels of the launch of the iPad 2, the world's most celebrated gadget continues its hot streak. Physicians certainly aren't immune to its appeal. Nearly one-quarter of American physicians bought an iPad in 2010, according to Chilmark Research. Others are jumping on the bandwagon. Four out of five physicians surveyed recently by Aptilon plan to buy an iPad this year.

The reasons behind the buying spree are multi-faceted and compelling. The iPad is a breeze to implement from an IT perspective—if the organization has the right infrastructure in place. Physicians report a bevy of handy apps, ranging from image viewing and patient education at the bedside or point of care to anytime/anywhere ECG access and medication ordering. It's lightweight, yet solid and just plain handy.

This month, Health Imaging & IT visits with an assortment of stakeholders to delve into the iPad's appeal.

The hospitalist: Images at the bedside

"I use the iPad for everything," asserts Henry Feldman, MD, a hospitalist at Beth Israel Deaconess Medical Center (BIDMC of Boston). Feldman and several of his hospitalist colleagues purchased iPads last year with a hazy, yet hopeful, idea of how they would use them.

With a frenetic schedule, Feldman is rarely in one spot for any amount of time. "Even though we have tens of thousands of computers and they are very well-spaced, there are many times during the day when I'm not there. The iPad lets me practice as if I'm at a desk no matter where I am."

Feldman uses the iPad to complete orders, write notes, educate patients, review images and reconcile medication lists. But, he asserts, imaging is the "killer app." That's because the iPad provides a platform that lets him bring the patient's images right to the bedside.

Feldman loaded Netter's "Atlas of Human Anatomy" onto his iPad to help patients make connections between advanced imaging exams, anatomic locations and their diagnosis. For example, nuclear studies are infamously fuzzy to the untrained eye. But when Feldman flips back and forth between the anatomy plates and the images, the light bulb switches on.  

The model is enabled by a web-based PACS running on Citrix. Feldman admits the lack of a keyboard and mouse can make it a bit awkward to retrieve images using the Citrix client. For more sustained image use, he does "sneaker net" images from his workstation onto the native iPad PACS Osirix via CD, rather than directly accessing images via Citrix. He uses this back door model for some patients whose cases entail multiple image sets and consults because it provides full PACS capability at native speeds and ability to manipulate images in real time.

Because the iPad is equipped with OsiriX imaging software, Feldman can access desktop PACS tools. If the hospitalist and a surgical colleague review a case in the hall and circle a region of interest, it syncs back to the desktop PACS for later review. Surgeons can employ the same model, even in the OR, shares Feldman.

During the last year, the hospitalist has put the iPad through the rigors. It's been dropped, cleaned with infection control wipes and wrapped in sterile bags. Feldman has figured out a few tricks to optimize the system. For example, he bypassed the keyboard and learned to touch type on the onscreen keyboard instead.

Feldman's advice echoes that of other early adopters. "Before [physicians or CIOs] dismiss the iPad, they should try it without preconceived notions and see what they can do with it."

The CIO: Streamlined deployment

What started as a trickle has morphed into a torrent at Kaweah Delta Health Care District in Visalia, Calif. Last spring, Vice President and CIO Dave Gravender approved an exploratory purchase of Apple's device, eager to see how it might fit into the hospital's open connectivity model. "We had it up and running in 20 minutes. We had no idea it would be that easy," recalls Gravender.

Today, Gravender estimates that 40 of the district's 300 physicians use iPads.  

"The iPad fits our strategy perfectly," explains Gravender. That is, the IT team pledges to support whatever device physicians want to use. All portable devices use the guest wireless network rather than the hospital network, which minimizes security concerns and reduces internal network bandwidth requirements.

Plus, the iPad helps the IT department support the six rights of information management: delivering the right information to the right person in the right place at the right time in the right format for the right value.

The CIO credits Citrix infrastructure with enabling the model. The healthcare district provides access to its EHR via Citrix, enabling physicians to access all data including documentation, images and telemetry data. It also circumvents security concerns as no patient data are stored on the iPad. "We're confident that we have the right security in place to meet HIPAA," confirms Gravender.

In addition, Citrix has a relatively flat learning curve; physicians use the device to access familiar local applications, so they don't need to learn new ones. Instead, physicians learn new gestures associated with navigating the iPad, such as pinching an image to minimize it.

With physicians at Kaweah Delta Health Care District using the iPad for an array of applications and the IT department embracing an open model with respect to portable devices, Gravender offers simple advice to his IT colleagues. "Try it. Provide people the flexibility to explore and see what works."

The trauma surgeon: Testing the waters, looking ahead

Bronson Methodist Hospital, in Kalamazoo, Mich., like countless other hospitals in the U.S., is in the midst of a massive health IT transition. Its "i-Optimization" project will replace multiple interfaced best-of-breed systems with a single vendor (Epic). "We hope that the iPad figures prominently in our strategy moving ahead," offers Jon Walsh, MD, trauma surgeon, physician informaticist and member of the i-Optimization Physician Advisory Team.

Walsh and a number of his colleagues are working with the hospital IT department to determine the best practices for tablet use. The slow and steady model is a good fit for the hospital, explains Walsh, as early adopters can establish a framework for use and work out glitches prior to widespread adoption among diverse users including employed and community physicians and allied healthcare providers.

Test pilot physicians at Bronson Methodist Hospital use the iPad for five types of applications: productivity, patient education, healthcare reference, communication and teaching, says Walsh. The ability to access internal applications on the iPad has boosted Walsh's mobility. "It lets me practice medicine the way I want to—at the patient's bedside."

Walsh accesses lab results and images on the iPad, sharing data with patients to help them better understand their diagnoses. Although the imaging interface doesn't provide the comprehensive toolset of the PACS workstation, Walsh predicts features will be developed in time as healthcare increases its understanding of the value of the iPad. For example, the integrated Epic system will incorporate clinical decision support and offer single sign on.  

Next on the horizon? Walsh plans to pilot using the iPad for videoconferencing prior to trauma transfers, remotely examining the patient via integrated iPad cameras and advising local physicians on how to best prep the patient for transfer. Walsh could recommend blood or fluid resuscitation or guide local physicians through a procedure that shouldn't wait until transfer. "It will be like I'm there in the room."

Walsh has worked closely with IT to understand the infrastructure and support needs associated with the iPad. He expects that the hospital will have to upgrade its wireless infrastructure as the iPad becomes the device of choice for additional staff. "We must evaluate the integration of this device into our system carefully so that we can prepare optimally for the use of these devices without causing new technical issues with the wireless needs," he explains.