How Tablets are Influencing Healthcare

This article first appeared in the January/February 2013 issue of HealthLeaders magazine.

Like a surging tide, the next wave of technology has landed in hospitals, changing the nature of healthcare delivery. Tablet computers are overturning concepts of how clinicians will use technology, raising work-life balance issues, and having a beneficial impact on hospital IT budgets.

Tablet computers have gone from relative obscurity to something approximating the appearance of stethoscopes: Nearly every doctor has one. What's different with this generation of technology is that demand is coming from clinicians rather than being rolled out by IT departments.

"Certainly the iOS devices from Apple are very popular among physicians," says Ferdinand Velasco, MD, chief health information officer at Texas Health Resources, an Arlington-based system that includes 25 hospitals, more than 21,100 employees, 5,500 physicians with staff privileges, and 3,800 licensed hospital beds.

A recent internal survey of more than 2,000 Texas Health–affiliated physicians found that 80% of them have smartphones and 50% have tablets, Velasco says.

The spread of these devices parallels a recent surge in bring-your-own-device—or BYOD—behavior at hospitals. But the so-called consumerization of IT is hardly unique to healthcare, Velasco notes.

Apple's iPad has been the catalyst for tablets in healthcare, says Frederick Holston, chief technology officer at Intermountain Healthcare, a Salt Lake City–based network that includes 22 hospitals, a medical group with more than 185 physician clinics, an affiliated health insurance company, and more than 33,000 employees.

"We have PCs at every bedside, so tablets haven't been a big thing for us," Holston says. "But for us, the word tablet changed with the iPad, and it changed because we had a long-battery-life device that was very light and had a very intuitive user interface that was very responsive and provided what was really missing in tablets."

Unlike many previous iterations of the personal computer, clinicians want to use them, says Jonathan Perlin, MD, CMO and president of the clinical and physician services group at HCA, the Nashville-based for-profit company that includes about 163 hospitals and 110 freestanding surgery centers in 20 states and England and employs approximately 199,000 people.

"We love tablets because our providers, physicians, nurses, and pharmacists have an emotional attachment," Perlin says. "They want to use these devices. That makes uptake really easy, and it improves the security because they tend to store their own personal information, have their own apps, so they guard devices judiciously."

More than 5,000 HCA physicians use tablet technology daily, and Perlin describes the technology as providing a new level of work-life balance for these physicians. He describes a typical day in the life of one of those physicians, starting with the ability to log in to a virtual desktop from home, checking Meditech electronic health records and vital signs from her tablet computer.

"In an electronic age, we couldn't possibly have enough workstations in the hospital, and even if we did, the workstations are in one place. Tablets allow the information to be securely available anywhere a decision-maker needs it."

"In an electronic age, we couldn't possibly have enough workstations in the hospital, and even if we did, the workstations are in one place," Perlin says. "Tablets allow the information to be securely available anywhere a decision-maker needs it."

The rise of tablets is being matched by the decline of interest in laptops in hospitals. "A lot more clinical services now are mobile and also outside of the hospital walls," says Mark Moroses, senior vice president for information technology and CIO at Continuum Health Partners, a New York City–based system with seven major facilities, 2,180 certified beds, and an annual operating budget of $2.8 billion. "Laptops are kind of clunky when you do that; iPads have a nicer fit in terms of form factor," he says.

"The mobile technologies we now finally have are actually very compatible with the workflow of clinicians," Velasco says. "Clinicians are fundamentally a mobile workforce. They don't work in a desktop or a work office type of environment like in other businesses. They're constantly moving about. They move between their physician office setting and the hospital, and when they're in the hospital, they go from room to room and floor to floor. Even in their own office they're not sitting behind a desk. They're going from one patient room to another, one exam room to another, and to some extent that also applies to the other healthcare workers as well.

"Rather than the old paradigm where we were encouraging clinicians to use these fixed devices, or at least somewhat semi-fixed devices with the laptops on carts or WOWs [workstations on wheels] or COWs [computers on wheels], now they actually carry these devices around, and so the adoption actually is much easier."

"It is becoming a smaller and smaller footprint with greater and greater capacity to be able to help us organize, aggregate, and utilize the kinds of data that are the outputs to make good clinical and business decisions."

Cost to health systems
Fewer clinicians are clamoring for the latest and greatest laptops, so these new consumer devices will result in less expensive hardware at the bedside and in the patient care area, Velasco says.

"This small footprint of the device replaces the biomedical equipment interfaces that we see in laboratories, our clinical research benches, and in the critical care units where we have so many monitoring devices," says Mary Alice Annecharico, senior vice president and CIO of Henry Ford Health System, a Detroit-based seven-hospital system with more than 1,900 beds, 2011 revenue of $4.22 billion, net income of $21.5 million, and more than 24,000 employees. "It is becoming a smaller and smaller footprint with greater and greater capacity to be able to help us organize, aggregate, and utilize the kinds of data that are the outputs to make good clinical and business decisions."

"There's tremendous convergence between what our clinicians want and what we'd like to have happen," Perlin says. "From the clinician's perspective, their life is incredibly complex. Healthcare is more complex, the administration of medicine is more complex, and people are working very, very hard. When they say, ‘If I could use my device, it would improve my efficiency and my effectiveness,' that's a pretty compelling statement."

Leadership's goal is safe, effective, efficient, compassionate, informed patient care. "So this is a wonderful meeting of the interests: their desire for efficiency and effectiveness, our desire for efficiency and effectiveness," Perlin says. The tablet trend may be about to kick in to a higher gear, as clinicians clamor for the latest iPad, the lab coat pocket-friendly iPad Mini, which shipped in November.

"It's almost a perfect size for a physician who's doing rounding or somebody who wants to travel with less in their hands, if you will, and just put things in their pockets," says Michael Saad, vice president and chief technology officer at Henry Ford.

Enhanced clinical care
Aside from convenience, smartphones and tablets are also playing an increasingly important clinical role—involving both physicians and patients. At Texas Health Resources, as part of a secure messaging initiative, the system is purchasing iPhones for its employed hospitalists, Velasco says. But messaging is just the start. For physicians with heart patients, Texas Health supports AirStrip, a suite of applications delivering critical patient information, including virtual real-time waveform data, directly from the patient's location to a doctor's mobile device.

"There's tremendous convergence between what our clinicians want and what we'd like to have happen...When they say, ‘If I could use my device, it would improve my efficiency and my effectiveness,' that's a pretty compelling statement."

"These are actual digital representations of the EKGs, the waveforms, so they can zoom in and do fine evaluations of the waveform on the EKG that would not otherwise be possible on a static, just purely analog representation of EKGs," Velasco says.

Because AirStrip's applications are FDA-approved, Texas Health is assured of the integrity of the data being transmitted wirelessly to phones and iPads, Velasco says. Texas Health obstetricians are using the AirStrip OB application to remotely monitor fetal heart rates with these same devices, he says.

R. Malcolm Stewart, MD, of Neurology Specialists of Dallas, is a leading researcher of motor disorders and interim director at the neuroscience center at Texas Health Presbyterian Hospital Dallas. Stewart developed a number of tests to assess patients for early signs of Parkinson's disease and similar motor disorders. In the future, Texas Health will be porting these applications to the iPad so patients will be able to take these tests on their own tablets without having to travel to Texas Health's laboratories, Velasco says. Clinicians can track these patients' progress and, if necessary, make adjustments to their treatment regimens.

Due to their newness, tablets aren't yet running full implementations of the most popular EHRs. "As the EHR vendors improve their support for tablets with better user interface, additional functionality, and less typing, we will see more use in the hospital and the office," says Mark Laret, CEO of the UCSF Medical Center that has a total of 660 beds, 180 of which are for the UCSF Benioff Children's Hospital. "Once they can support ordering [CPOE] and note writing, they will start to replace some of the workstations.

"We will deploy tablets in creative ways going forward: patient self-registration, MyChart sign-ups, providing educational content in waiting rooms and patient rooms, patient questionnaires, etc.," Laret says. "Still, they are a piece of technology and tactical infrastructure. Our strategy is to use whatever device is most appropriate to provide the most complete, accessible information to our patients and caregivers at the ideal time. I expect that providers will have their own devices, and that we will provide the infrastructure to support them. We may consider a device for trainees when they start here."

"As the EHR vendors improve their support for tablets with better user interface, additional functionality, and less typing, we will see more use in the hospital and the office."

Clinical and business opportunities
As healthcare organizations strive to innovate their way into new business and clinical opportunities, the tablet platform is rolling out the steadiest supply of innovative applications in computing today. In Perlin's day-in-the-life scenario of an HCA clinician, he describes several applications for the iPad in widespread use at HCA:

• Before heading to the office, the clinician can log in to eClinicalWorks to check her outpatient schedule for the day.
• To find out the latest information about her patients' status, the PatientKeeper application allows her to plan her rounds most effectively and alerts her if a fellow physician is on vacation, which adds to the list of patients who she must see on her rounds.
• Fujifilm Synapse Mobility allows the clinician to review x-rays and echocardiograms of patients on the tablet.
• While counseling a family member of a cardiac patient, the physician demonstrates an animation of a beating heart suffering from blockage in the left anterior descending coronary artery, using a tablet application called HeartPro.
• A tablet application provides the Chads2 stroke risk calculator to let the physician calculate stroke risk for atrial fibrillation while the patient and caregivers look on.
• To calculate the safety of anticoagulant medications, the physician turns to the UpToDate mobile app, which includes a reference library.
• Mobile apps from Lexi-Comp, Epocrates, and others permit the physician to consider dosing and side effect questions about different medications.

Perlin notes that HCA also developed an in-house tablet app that gathers the work of hospitalists and makes the necessary referral to a specialist such as a cardiologist.

Because of new technology that connects monitoring devices to the EHR, caregivers can follow patients' vital signs on their mobile devices in real time rather than relying on data entered by hand at the end of shifts. The program, HCA Vitals Now, reduced the average time it took for vital signs to enter the patient's EHR from up to 41 minutes using pen and paper to 23 seconds per patient. The vendor partner is now making the app available to non-HCA providers.

Mobile devices also follow caregivers where computers haven't traditionally been. Intermountain developed an application for emergency responders, the first version of which is being tested by the Life Flight Network of Aurora, Ore.

Responders of Life Flight Network, which operates EMS helicopters in Intermountain's mountainous service area, typically had to document patient information once the helicopters touched down at hospitals. Using the Life Flight app, they can now document while en route to the facility, Holston says.

As a result, patients begin receiving treatment faster, responders write down information while it's still fresh in their heads, and legibility isn't an issue, Holston says. It also speeds Intermountain's billing process, he adds.

In the future, Intermountain could make its app available for sale for other healthcare providers, since it could apply equally effectively to any emergency responder, Holston says. For now, pilot testing continues as Intermountain fine-tunes the application's user interface. Clearly, it is a strategic initiative for Intermountain, but Holston declined to say how much money the organization has invested in its development.

Considering the tradeoffs
As with any new technology, there are some tradeoffs that accompany the tablet and mobile device upheaval. For the vast majority of clinicians, saying hello to tablets means saying good-bye to keyboards, which opens up a host of issues, not the least of which is the tendency of longtime clinicians to narrate their way through their notes, rather than enter them in a more structured format.

"It's really hard for people to get used to the typing on an iPad, the feel of it, so that there's still stronger preference for a keyboard when you're doing order entry or doing any kind of heavy input that would require a lot of typing," Moroses says. "We're hoping in 2013 to focus a couple of different pilots around EMR use when the EMRs are customized for that device, to have less typing and more point and click."

The keyboard gets its share of vilification as a source of germs in hospitals. "A smooth screen is inherently easier to remove bacteria from than the difficult topography—the nooks and crannies—of a keyboard," Perlin says. "So they're cleaner, with the proviso that one appropriately cleans the device."

Holston notes that when clinicians are touching a keyboard, they're usually "in a pretty clean state. Of course, we try to use a lot of barcoding to put in a lot of information along the way so they're not spending a lot of time typing on it; and then for most physicians in our world, I don't see them doing their notes in the room. They tend to go out to kind of a nursing station or a pod to finish those things up."

Elsewhere, such traditional charting habits haven't stopped clinicians from dumping their keyboards as fast as possible as the tablet revolution gathers steam.

"The patient-physician interaction is much less disrupted by the tablet," Velasco says. "It's much more like the clipboards that some physicians used to have to take notes or to refer to information when they saw patients, either in an exam room or at the bedside, and so it does really lend itself to a much more appealing interaction, and the iPad Mini may prove to be a more attractive form factor because of its smaller size."

Some patients actually like having a doctor typing away during a consult, thinking that when the clinician types something in, the information has been entered properly, Holston says.

Organizations such as Intermountain still haven't completely bought in to the BYOD trend. Only the iPad and iPhone are approved as BYOD, and they must remain off the internal Intermountain network and use the guest network instead, Holston says. Intermountain also gets each employee's agreement to allow remote wiping of the device, including all personal information, should it be stolen or lost, he adds.

While the keyboard debate continues, the growth of tablet-friendly EMR systems, plus alternate forms of input such as speech, will further whittle away the virtues of keyboards, clinicians say.

"The challenge will be for app developers to optimize the entry of information that minimizes the keyboard paradigm, maximize the use of template-driven documentation, and therefore keep free text to a minimum, and perhaps support the need for free-text narrative using dictation and voice recognition," Velasco says.

"The more we move to coded data," Holston says, "where you're selecting very distinct values of things that have well-understood codes that all come together to tell a story the computer can act on, I think, is a powerful platform for touch." But if the industry continues to have a box for extensive open text "and you type whatever you want, even if you try to format it the same every way or we put some form in there that you fill in the blanks but it still ultimately kind of poops itself out as a big text blob, I think it's tough on touch."

Tracking, throughput, and savings
Tablets and phones are being joined by a variety of other connected electronic devices. Some are being used to improve the efficiency, quality, and accuracy of lab work. In an older setup, nurses would have to print barcodes at workstations and walk them back to patients' bedsides to be applied to blood specimen tubes. This printing often would occur in batches, requiring extra care by nurses to not misapply labels to tubes. With small bedside devices now under consideration, these barcodes can be printed right at the bedside, says Annecharico.

By placing RFID chips in digital devices and wristbands, as well as on patients and other equipment, hospitals are coming alive with ambient up-to-date digital information. Such real-time location systems are "a parallel swim lane" to the adoption of tablets, Moroses says.

For instance, one HCA hospital, 94-bed Summerville (S.C.) Medical Center, installed an RTLS system that ensures that clinicians wash their hands by sensing when they enter and exit patient rooms and whether they use hand sanitizers in the rooms. "We've seen about a 25% improvement since we started measuring and analyzing the data in May 2012," says Louis Caputo, CEO of Summerville Medical Center. Have infection rates dropped? Summerville had few to begin with, but the goal is zero and RTLS helps, Caputo says.

Another HCA hospital uses RTLS to maximize patient flow. Last year, Aventura (Fla.) Hospital and Medical Center, a 407-bed acute care facility, faced lag times of three to four hours from the time admission orders were issued to patients in the emergency room to the time those patients got up to nursing units. Not only were the delays complicating care for those patients, but they also created overcrowding in the emergency department, says Chief Nursing Officer Karen Bibbo.

Using RTLS technology from GE, Aventura was able to identify rooms for cleaning as soon as they were vacated without requiring phone calls from nurses to housekeeping. Before implementation, more than 40% of admits waited in excess of an hour for a bed; after implementation, that number declined to as low as 7%, Bibbo says. "Patient satisfaction is much improved," she adds.

The latest tech surge can also mean big savings in further eliminating paper and printing costs. "We have managed to reduce the footprint of printed material that is used for meetings and just general distributions by introducing the iPad for meetings," Annecharico says. "Those who meet on a regular and consistent basis are replacing their laptops with iPads for purposes of having materials distributed to them, and they bring it right up in the meetings, therefore not requiring two things: one, the use of paper, and two, the use of color ink, both of which are simply wasteful in my perspective." Within a four-month time period, one midsize Henry Ford facility reduced its operating expenses by $90,000 by reducing the paper previously required, she says.

"We're at an amazingly exciting point where we're beginning to expect device-enabled support for better care today, and we're beginning to really imagine scenarios that elevate not only care but health tomorrow," concludes Perlin.