I recently reviewed the Epocrates 2013 Mobile Trends report. The study has a somewhat unusual participant profile, consisting only of primary care, 3 medical specialties and no surgical specialties; nonetheless the observations are probably close to the mark and are consistent with my experience with my first tablet a couple of years ago.
I purchased an iPad within a couple of months of the introduction of the first model thinking it was perfect for EMR use in my office. I abandoned it after a couple of months when I discovered several shortcomings. First, the first iPad was too heavy to hold by the edge and had to be held by a fully supinated hand (totally flat palm facing up). Try that for 5 minutes and see how your forearm feels. The first iPad was also too big to put in a physician’s white coat pocket. And the screen resolution of the first iPad models was not good enough to display a busy EMR screen. But the biggest drawback was that the early remote desktop apps did not work very well.
The iPad mini addresses all four of these issues. The Mini is small enough to fit in a white coat pocket with the standard magnetic cover in place. It is easily and comfortably held by its edge. It needs a Retina screen badly but the display is better than the original iPad and is (barely) adequate for my 50-year-old eyes to see. And remote desktop apps have come a long way. It appears that similar advances have been made in tablets from other manufacturers as well.
I was therefore surprised to learn from the Epocrates study that although a majority of providers (53%) use tablets for patient care related activities, only a small portion (2%) use tablets for actual patient care record keeping in an EMR. So I thought it would be interesting to outline my current methods of using a tablet that put me in the 2% category as well as the 53%:
- Entering data into my EMR via a Remote Desktop app. There are important lessons here. Don’t expect to stick a tablet in the physician’s hand and have it work like magic. Our office workflow is designed to optimize the physician / tablet combination. I use the tablet for only 2 data fields in EMR: assessment and coding (CPT and ICD). The office staff enters all the other parts of the note and initiates treatment workflow through the EMR at the physician’s direction. After the patient is seen I review all parts of the note (on a laptop or desktop), make additions / corrections, and sign it.
- Cloud based voice-to-text. This takes the tablet from merely useful to spectacular. There are 3 characteristics of Apple’s built-in cloud-based speech recognition that make it comparable to the Dragon software I have used in various forms for over 10 years: 1. It is embedded seamlessly into the soft keyboard, 2. An inexpensive external microphone plugged into the headphone /microphone jack raises transcription accuracy tremendously, and 3. It works well with Remote Desktop, eliminating the need for a “dictation box” or other similar workaround. These attributes make up for its most serious drawback, the lack of a medical (or at least customizable) vocabulary. At the moment I have the right people talking to each other to address that problem.
- Hospital EMR. Our hospital is still in the implementation phase of a new Cerner system. I am still learning the system myself but my initial experience using the system on my tablet using Citrix Receiver has been very positive.
- Patient education. LUMA, a product of Eyemaginations, is a very nice product for showing surgical patients the complex head and neck anatomy of their diagnosis and/or proposed surgical procedure. There are both online and iPad versions available. I can switch back and forth between EMR and LUMA without losing the Remote Desktop connection.
- Medical imaging. I can’t load an image disk directly onto my tablet but I can load it onto my desktop and take a photo with my tablet to review relevant images with patients. I have tinkered with some apps that allow me to draw on the image to help educate patients. Still looking for a way to conveniently reduce the file size to facilitate copy-pasting into EMR notes.
- Literature searches in the exam room. Not glamorous but helpful, most commonly to review medication side effects.
I think that is a pretty complete use of the tablet for the physician. No doubt new uses will appear before long.