30 December 2011

Factors slowing the adoption of tablet computers in hospital

Filed under: Connected Health, mHealth, security, tablets, usability — David Wood @ 12:35 pm

Tablet computers seem particularly well suited to usage by staff inside hospitals.  They’re convenient and ergonomic.  They put huge amounts of relevant information right in the hands of clinicians, as they move around wards.  Their screens allow display of complex medical graphics, which can be manipulated in real time.  Their connectivity means that anything entered into the device can (in contrast to notes made on old-world paper pads) easily be backed up, stored, and subsequently searched.

Here’s one example, taken from an account by Robert McMillan in his fascinating Wired Enterprise article “Apple’s Secret Plan to Steal Your Doctor’s Heart“:

Elliot Fishman, a professor of radiology at Johns Hopkins… is one of a growing number of doctors who look at the iPad as an indispensable assistant to his medical practice. He studies 50 to 100 CT scans per day on his tablet. Recently, he checked up on 20 patients in his Baltimore hospital while he was traveling in Las Vegas. “What this iPad does is really extend my ability to be able to consult remotely anytime, anywhere,” he says. “Anytime I’m not at the hospital, I’m looking at the iPad.”

For some doctors at Johns Hopkins, the iPad can save an hour to an hour and a half per day — time that would otherwise be spent on collecting paper printouts of medical images, or heading to computer workstations to look them up online. Many doctors say that bringing an iPad to the bedside lets them administer a far more intimate and interactive level of care than they’d previously thought possible. Even doctors who are using an iPad for the first time often become attached, Fishman says. “Their biggest fear is what if we took it away.”

However, a thoughtful review by Jenny Gold, writing in Kaiser Health News, points out that there are many factors slowing down the adoption of tablets in hospital:

iPads have been available since April 2010, but less than one percent of hospitals have fully functional tablet systems, according to Jonathan Mack, director of clinical research and development at the West Wireless Health Institute, a San Diego-based nonprofit focused on lowering the cost of health care through new technology…

UC San Diego Health System’s experience with iPads illustrates both the promise and the challenge of using tablet technology at hospitals. Doctors there have been using the iPad since it first came out, but a year and a half later, only 50 to 70 –less than 10 percent of physicians– are using them…

Here’s a list of the factors Gold notes:

  1. The most popular systems for electronic medical records (EMRs) don’t yet make apps that allow doctors to use EMRs on a tablet the way they would on a desktop or laptop. To use a mobile device effectively requires a complete redesign of the way information is presented.  For example, the EMR system used at UC San Diego is restricted to a read-only app for the iPad, meaning it can’t be used for entering all new information.  (To get around the problem, doctors can log on through another program called Citrix. But because the product is built on a Windows platform and meant for a desktop, it can be clunky on an iPad and difficult to navigate.)
  2. Spotty wireless coverage at the hospital means doctors are logged off frequently as they move about the hospital, cutting off their connection to the EMR
  3. The iPad doesn’t fit in the pocket of a standard white lab coat. Clinicians can carry it around in a messenger bag, but it’s not convenient
  4. There are also worries about the relative newness of the technology, and whether adequate vetting has taken place over patient privacy or data security.  For example, as my former Symbian colleague Tony Naggs asks, what happens if tablets are lost or stolen?
  5. Some clinicians complain that tablet computers are difficult to type on, especially if they have “fat fingers”.

Let’s take another look at each of these factors.

1. Mobile access to EMRs

Yes, there are significant issues involved:

  • The vast number of different EMRs in use.  Black Book Rankings regularly provide a comparative evaluation of different EMRs, including a survey released on 3 November 2011 that covered 422 different systems
  • Slower computing performance on tablets, whose power inevitably lags behind desktops and laptops
  • Smaller display and lack of mouse means the UI needs to be rethought.

However, as part of an important convergence of skillsets, expert mobile software developers are learning more and more about the requirements of medical systems.  So it’s only a matter of time before mobile access to EMRs improves – including write access as well as read access.

Note this will typically require changes on both the handset and the EMR backend, to support the full needs of mobile access.

2. Intermittent wireless coverage

In parallel with improvements on software, network improvements are advancing.  Next generation WiFi networks are able to sustain connections more reliably, even in the complex topography of hospitals.

Note that the costs of a possible WiFi network upgrade need to be born in mind when hospitals are considering rolling out tablet computer solutions.

3. Sizes of devices

Tablets with different screen sizes are bound to become more widely deployed.  Sticking with a small number of screen sizes (for example, just two, as in the case with iOS) has definite advantages from a programmers point of view, since fewer different screen configurations need to be tested.  But the increasing imperative to supply devices that are intermediate in size between smartphone and iPad means that at least some developers will become smarter in supporting a wider range of screen sizes.

4. Device security

Enterprise software already has a range of solutions available to manage a suite of mobile devices.  This includes mechanisms such as remote lockdown and remote wipe, in case any device becomes lost or stolen.

With sufficient forethought, these systems can even be applied in cases when visiting physicians want to bring their own, personal handheld computer with them to work in a particular hospital.  Access to the EMR of that hospital would be gated by the device first agreeing to install some device management software which monitors the device for subsequent inappropriate usage.

5. New user interaction modes

Out of all the disincentives to wider usage of tablet computers in hospitals, the usability issue may be the most significant.

Usability paradigms that make sense for devices with dedicated keyboards probably aren’t the most optimal when part of the screen has to double as a makeshift keyboard.  This can cause the kind of frustration voiced by Dr. Joshua Lee, chief medical information officer at UC San Diego (as reported by Karen Gold):

Dr Lee occasionally carries his iPad in the hospital but says it usually isn’t worth it.  The iPad is difficult to type on, he complains, and his “fat fingers” struggle to navigate the screen. He finds the desktop or laptop computers in the hospital far more convenient. “Are you ever more than four feet away from a computer in the hospital? Nope,” he says. “So how is the tablet useful?”

But that four feet gap (and it’s probably frequently larger than that) can make all the difference to the spontaneity of an interaction.  In any case, there are many drawbacks to using a standard PC interface in a busy clinical setting.  Robert McMillan explains:

Canada’s Ottawa Hospital uses close to 3,000 iPads, and they’re popping up everywhere — in the lab coats of attending physicians, residents, and pharmacists. For hospital CIO Dale Potter, the iPad gave him a way out of a doomed “computer physician order entry” project that was being rolled out hospital-wide when he started working there in 2009.

It sounds complicated, but computerized physician order entry really means something simple: replacing the clipboards at the foot of patient’s beds with a computer, so that doctors can order tests, prescribe drugs, and check medical records using a computer rather than pen and paper. In theory, it’s a great idea, but in practice, many of these projects have failed, in part because of the clunky and impersonal PC interfaces: Who really wants to sit down and start clicking and clacking on a PC, moving a mouse while visiting a patient?

Wise use of usability experience design skills is likely to result in some very different interaction styles, in such settings, in the not-too-distant future.

Aside: if even orang utans find ways to enjoy interacting with iPads, there are surely ways to design UIs that suit busy, clumsy-fingered medical staff.

6. Process transformation

That leads to one further thought.  The biggest gains from tablet computers in hospitals probably won’t come from merely enabling clinicians to follow the same processes as before, only faster and more reliably (important though these improvements are).  More likely, the handy availability of tablets will enable clinicians to devise brand new processes – processes that were previously unthinkable.

As with all process change, there will be cultural mindset issues to address, in addition to ensuring the technology is fit for purpose.  No doubt there will be some initial resistance to new ways of doing things.  But in time, with the benefit of positive change management, good new habits will catch on.

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