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IPad in Business: St. Louis Urgent Cares

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tldr: Drchrono does the exact same thing as any other EHR...but on an iPad.

"Physicians can each create their own exam templates and enter data quickly by tapping checkboxes or selecting from menus, rather than having to write or type. For physicians who don’t type well, the touchscreen makes information-gathering a lot simpler than trying to use a keypad, says staff physician Dr. Carol Ann Smith, who also takes advantage of the speech-to-text feature in drchrono EHR to dictate notes."

As someone who spent the last hour charting(takes me about 2 minutes a patient with templates) I think this part of the article glosses over the real difficulty of using a tablet for EHR--namely that when patients are sick you have to manually enter a lot of data that wouldn't be in your template.

For example:

Subjective Findings: Patient presented to clinic for a 4 day history of cough and 2 day history of vomiting. He has vomited 3 times and there is phlegm in the vomitus. He also complains of a rash on his forehead that has spread down to his trunk that is maculopapular and itchy. The patient denies any fever, chills, dizziness, or headache.

A template can't do that for me...and it's a pain to enter that on a tablet. It effectively nullifies the use of tablets as effective EHR.

In my opinion the ideal solution is a macbook air(or similar ultralight) based EHR.

I think a keyboard dock could make those cases bearable, though, no?

Yes, indeed. That's what I suggested to my attending...that he have keyboard docks in every exam room for the tablet. That would solve the data entry problem but we would then essentially have a laptop that has a touchscreen instead of a mouse.

I'd like to try it but my attending already made up her mind against getting a tablet.

Cool. I think the touchscreen itself could probably get you there 80% of the time without being docked, so a bit different from a laptop with a touchscreen :-)

Might require thinking about the flow of an encounter, though, so that it's docked at the appropriate times. That could be a problem?

I thought it allows for dictation as input?

I also think you're underestimating the usefulness of a tablet form factor when physicians are sharing information with their patients. Harder to do that with a laptop.

This would seem to be an advantage of the voice input API in Android. Something the iPad lacks.

Android certainly has an advantage here, but a smattering of iOS apps, including the EHR in question, seem to licence speech-to-text and integrate it fairly seamlessly. Siri (before Apple acquired them) and Orchestra (a new to-do app) are good examples.

It's also worth mentioning that screenshots of internal builds of iOS 5 have a microphone on the keyboard, seeming to imply speech-to-text could be a surprise feature of iOS 5.

“A template can't do that for me...and it's a pain to enter that on a tablet. It effectively nullifies the use of tablets as effective EHR.”

Entering so little text on a tablet is definitely not a pain for me and, though quite a bit slower than typing on a hardware keyboard, it’s also quite a bit faster than handwriting for me.

I don’t get why so many people seem to think that tablet keyboards are unusable, I never had any problems typing a few paragraphs of text on them. This seems like some kind of weird meme demonizing all software keyboards as inferior to everything.

It's not a "weird meme". It's my personal experience. You may be able to enter data quickly on a tablet but many of the physicians I work with still type(painfully slowly) with 2 fingers. Maybe drchrono will be appealing to younger physicians who are comfortable with tablets...but the average physician is old.

If I demo'd drchrono and it was slower than my current system you're not going to sell me by telling me that "I'll get used to it." They're definitely not going to sell any major hospital on drchrono unless they also offer a computer based interface. The "old dog" physicians will never figure out how to type on it.

The weird meme are the grandiose claims of failure. I can’t square those with reality.

"but the average physician is old."

this is a curious statement to me for three reasons:

1) the ipad has been hailed as a device for first time computer users—the very old and the very young or even the physically/mentally challenged.

2) if they type painfully slowly with two fingers on a tablet, how do they type on a laptop?

3) the layers of abstraction are much greater on a laptop than a tablet.

true, data input may be a little more tedious, but it will still be infinitely less tedious than dealing with paper files, with the added bonus of being instantaneously transferable should the patient be traveling. and if they are already using a laptop, then what is the dilemma?

anyway, the "old dog" argument strikes me as a lazy cop-out—but if true, doesn't bode well for the mental acuity of said old dogs. i've always assumed that doctors are innately curious, always trying new things tempered by the old things that work†. if these old dogs can't step out of their comfort zone to try something new, it doesn't give me much hope for their patients.

† i understand the toxicity of the new, when science claims to have found no difference between breast milk and formula, for instance, but gathering information does not necessarily equal an endorsement. and for the record, touch screens are very old technology, we just haven't been able to implement them in a mostly non-frustrating way until now.

many of the physicians I work with still type(painfully slowly) with 2 fingers

Aren't those the people for whom typing on a tablet software keyboard won't be any slower? Surely, if anyone does, it's fast touch typists who have problems with slowdown.

"Entering so little text on a tablet is definitely not a pain for me"

There's a flaw in your argument right there. The fact that you specifically suggest that entering a little bit of text isn't a problem implies that entering large amounts of text is.

Physicians live in these systems. If your a developer, consider it analogous to an IDE. Are you ready to switch to full-time coding on a tablet?

I think tablets are awesome, the iPad especially... I also think Dr Chrono appears to be doing some really cool things in their re-thinking of the EMR for tablet computing.. but I think there's a big difference between you and I being happy with the iPad for our email, and physicians using it to document their EMRs (at least by typing). Lots of work to do.

Full disclosure: I build EMR/EHR systems, and have for quite a while.

There is a difference between writing pages of text in one sitting and writing bits and pieces spread out. I was specifically responding to the use case of entering that paragraph of text the parent mentioned.

If there are situations where physicians have to type pages of text not spread out over the day but all at once they probably shouldn’t use a software keyboard.

I think this is something of a fallacy that we might tell ourselves (as developers). There's a friction quotient to mobile-text-entry. Let's just assume there's linear friction (for your argument to be benefited by non-linear friction typing on a mobile device would have to become more painful the longer we do it in a sitting, which I don't believe happens). So if the friction cost is say 30% for me to type on a mobile device compared to a traditional keyboard.. it's often worth the cost to me to achieve a given outcome. Especially if there's actually a net benefit to the mobile-ness.

Inviting a friend to a party. Keyboard cost: 30 seconds. Mobile cost: 40 seconds. But say I'm out and about or in the car? Suddenly the benefit swings big time.

In the same situation, say I need to write a long email. Keyboard cost: 30 minutes, Mobile cost: 40 minutes.. and suddenly the distance from my house may not be a factor. Now imagine I have about 20 of those emails to write today...

I'm worried that the way we use our mobile devices (facebook, etc) can warp our perceptions of just how significant the friction for data entry is, and promote this idea that little-text is easy, long-text is still hard. I think that's wrong, by a lot.

I think there's loads of innovation left to do in human-computer-interaction with touch screen and mobile devices and projects like Dr Chrono get me really excited because I think it plunges a team of smart devs headlong into a problem-space that in the long run, won't tolerate less than stellar friction quotients.

The system that I work on could definitely handle that with a template. Of course we have spent over a decade working on our tempting system and we employ numerous clinicians. Unfortunately our system is designed for a specific area of the hospital and our website is very vague (enterprise system), so giving you further information is unlikely to be helpful.

Having real people using the app in a video demo is 10x more effective than a cute animation explaining your features.

I love that they're doing this. It does, however, bring up one disadvantage that the paper record does not.

Suppose you're sitting in the room with your loved one and you want to see what the doctor wrote about their condition and treatment suggestions. You can pick up the records and look through them, and ask questions about what you don't understand. With the iPad, you're kind of left out in the cold and at the mercy of whoever is there. That's a weakness of the system I'd like to see them address.

BTW, I'm not saying that you'd be able to understand all the medical shorthand on the charts, which is definitely a language unto itself, but you'd at least be able to have a starting point for a conversation. "Hey, what's this..?"

I've never had a patient ask for their medical records...and frankly they wouldn't understand them if they saw it. It's filled with doctor's handwriting, abbreviations like OM(otitis media), PRN(take med as needed), etc. It's mostly a reflection of what the patient has told the doctor and doesn't contain much information that is useful to the patient. It would be better to ask the doctor your questions directly.

If you read the chart and asked me "hey what's this?" for every question I would be tired of you within 2 minutes and tell you not to worry. If it was important I would tell you.

Hospitals generally print out a copy of electronic records if patients want to see them.

It looks like the same app is available for android, though it doesn't have all the features yet:

https://market.android.com/details?id=com.drchrono&rdid=...

If the versions are the same in the future (so the same app is available for android tablets), why would doctors/hospitals choose the iPad over an Android device? Would there be any compelling reason for doctors/hospitals to want one over the other?

It's harder to provision an Android device to HIPAA requirements. iPads are also cheaper.

My Asus Eee Pad Transformer with maxed specifications (32Gb storage, 3G & wifi and keyboard dock with SD-card reader, USB-slots and about 8 hours extra battery-time) costs me the same as an 16GB 3G iPad 2. That's a 16GB storage and keyboard dock in delta, and not in Apple's favour.

It may be a more favourable comparison if you go for the plain iPad, but Apple doesn't sell them any more, at least not where I live.

Anyway: Putting out "iPads are cheaper" as blanket statement like that is either uninformed, dishonest or plain trolling.

Fewer ports are better with HIPAA. You don't want somebody sneaking out data on a card. You don't want doctors with all their personal crap on the tablet, so what does it matter if there's 2x the storage on a Transformer? Do you put 2-3x times the ram in a dedicated app server just because?

In this case, everything a consumer wants is antithetical to what the hospital wants. I think you're the one trolling, talking about consumer needs in a locked down situation.

Also, seriously?

'My old account evidently got flagged "troll" for speaking against the Apple-worship cult found on HN.'

My point was that compared to the Android-option the iPad is more expensive. The minimum config Transformer is cheaper than the minimum config iPad.

I've even backed my statement up with numbers. What part about that is trolling? You are the one with blanket-statements and no data.

Also, seriously? 'My old account evidently got flagged "troll" for speaking against the Apple-worship cult found on HN.'

PG emailed me telling me I had been a bad boy. Now that account is thrown in the deep end of the QOS pool and the site is slow as fuck unless I log on with another account. Besides that votes are not recorded (which is easy to verify using two accounts) and the account is not allowed to submit stories to HN at all.

So yes. Seriously.

Edit: Sigh. Downvotes?

HIPAA does not enforce anything related to the number of ports or any other such nonsense. Most hospitals use standard laptops and desktops with more ports than a tablet will ever have.

for many, the value proposition of apple products means that they less expensive—that is, they cost less frustration. this is not always so—you consider a card reader and usb-slot and keyboard dock to be a net win, but not everyone feels that way, and considering the dearth of honeycomb apps still, it's no surprise that not everyone feels that way.

anyway: putting out (and i paraphrase) ipads aren't a better value for most is either uninformed, dishonest or plain trolling.

for the record, i like the transformer—great screen, pretty fantastic hardware, but good is hardware without great software?

You are grossly overestimating the difficulty of complying with HIPAA.

I'm working on a project with this and my weekend research found while there's a ton of Android 2.2 tablets that are cheap, none of them can rival the build quality or battery life of the iPad. The iPad in a kiosk sense does have a nasty issue: there's no way to block the home button but to build a case around it, or jailbreak it (which isn't a very sound thing to do operations wise)

Laptops are going to be cheaper, last longer, and going to be harder to break IMHO. IPad's are fun and I definitely use mine, but I'm not sure if they are the best bet for this application. Outside of looking cool and making patients think their doctor is really technologically advanced I'm not sure what they bring to the a table that a much cheaper netbook couldn't.

Aren't you asked to turn electronic devices off when you enter a hospital? I don't understand why there's an exception for the iPad. And at least from what you can see in the video their iPads are not in airplane mode, but are actually connected to WiFi and the AT&T network.

I've been in waiting rooms, recovery rooms, at the bedside of post-surgery family, and never been told to shut off my iphone (despite written warnings saying exactly what you mentioned).

When cell phones were new, there was some hand-waving regarding the risks of planes crashing, respirators stopping, etc. As is often the case, these risks were not very credible.

The signs stay up because while the RF signals won't kill anyone, listening to people jabbering on the phone is very annoying. For example, my wife's pregnant, and we spent some quality time in her OB/Gyn's waiting room the other day. Hearing another patient screaming into phone with a graphic recounting of the bursting of some sort of cyst for 30 minutes made the experience of sitting in a 90 degree waiting room for a half hour that much more noxious.

Inside radiology rooms it may be the case, and is absolutely the case in MRI (no metal includes no iPhone...)

I'm sure there are quiet area no cellphone rules for patient/staff sanity, not RF concerns, elsewhere.

Most hospitals use WiFi networks already. Most clinicians use their cell phones in hospitals already.

Wouldn't the iPad be a good way to spread germs?

It's all about internal purpose. Any experience with iPad in public access that all the customers of the point of sales can use?

Lowe's is deploying 42,000 iPhone apps for use on the retail floor.

http://www.appleinsider.com/articles/11/09/08/lowes_deployin...

We've tried iPads in our practice for EHR, including a trial of Dr Chrono. It is unusable because:

- it takes too long to enter notes on a tablet. A "template" system is way too inflexible.

- the dictation feature didn't work.

- nobody has ever been able to even begin to convince us that our patients' data was secure.

Laptops work MUCH better. We do use tablets for patient education purposes, for which they are much better suited.

Consider the iPad all by itself doesn't do EHR, what software packages did you try out before bailing?

Aren't there any packages that check all the regulatory and usability requirements for usage in a hospital/clinic?

What is the security concern?

>nobody has ever been able to even begin to convince us that our patients' data was secure.

Just use Citrix then instead of some random third party application?

I haven't tried it, but maybe with iOS 5, which is rumored to offer markedly improved speech to text capabilities, it might make a difference. I agree that templates don't work great.

If you're already using laptops in your practice, you might take a look at ElationEMR. I got a chance to try their browser-based app a few months ago and was impressed with how well they handle data entry.

For all that I like my iPad, typing is still something of a sore point.

I worked on PACS and incidentally integrating with EHRs in the past -- I'd be very interested in talking with you about exactly what security concerns you have with this kind of solution and figuring out how a system could satisfy them.

I think the dictation issues are non core; either apple fixes it in iOS 5 or drchrono could integrate with a third party transcription provider.

The template and macro thing is definitely at the core to a good ehr

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