My mother works in the healthcare field, and when they announced the iPad I immediately knew that doctors would be clamoring to use them, and it's good to know that, at least with the webapp-based systems, that the iPad 'just works'.
However, I'd also be interested in hearing from doctors that might not happen to be "chief information officer and dean for technology" and see how easily and effectively they can use the device.
I'm a surgery intern. I think tablets will have to become as ubiquitous and uninteresting as cell phones before residents would start carrying them. If there's a code and you have to respond, you can't just drop a tablet in your pocket and run. If you leave it at the nurse's station at the county hospital, there's every reason to assume some gangbanger visiting his gangbanger buddy will take it. If you're going to the OR, there is precious little horizontal space where you can safely lay something down, or even lean it. Everything in an OR is on wheels, and is likely to get sprayed with some fluid, before, during, or after the case.
I also think authentication will need to get lighter and more responsive. I think thumbprint detectors in the margin would be ideal. Pick it up and login. Logout if it sits without input for 2 minutes. If someone else picks it up, immediately log me out and log them in.
Along with authentication, most hospitals use Citrix clients, but not all Citrix servers seem to be configured for various clients. I have never been able to access our Citrix server via iPhone, but the BlackBerry folks can.
As for electronic notes, the "eCare" system at Sentara hospitals here in Virginia is overall faster than the paper notes at the naval hospital, but not as coherent. Designers need to come in, look at hand-written notes, and figure out how to lay that out in electronic notes. Tables upon tables of (value, high/low marker, units, normal range) for all 30 or so elements of a CBC is unnecessary when all I want is
\ 13 /
7.2 ---- 335 84 N
/ 35 \
and that should fit on two lines, and the BMP should fit next to it, and the calcium-mag-phos should fit next to that, and the LFTs, and the coags . . . it should take all of 2-3 lines on the note, because that way it all stays in your field of view and you can think about it without having to scroll back and forth past gobs of data you're not interested in. Same with radiology: echo the impression, not the whole report. Vitals: always, always, always Tmax, Tcurrent, HR, BP, RR, SpO2, unless you're in a critical care setting, where you want the same order, but with ranges.
It's all really fairly straight forward, but someone who knows CSS needs to sit down and figure it out.
I'm a physician also, and I want to offer a counter-point. Handwritten notes are done the way they are for speed, not because it's the best way to present data. For example, in the notes I read the CBC "fishbones" often have little arrows or annotations next to them indicating trend or prior values. They do a very respectable job, but I disagree that emulating them is the best approach moving forward.
Also, our hospital also uses Citrix. It sucks. I cannot think of any reason why this approach would be preferable, from a user's point of view. But then, nobody who buys this stuff actually has to use it, which is the crux of the problem.
Citrix is not a panacea, to be sure. There are lots of things that could be done better. If people could just wrap their heads around web apps, I would be much happier.
The fishbones won in the wild against all competitors over a long period of time (decades), and in times when the data-ink ratio was at a premium (because it came from a pen, pushed by a doctor's fist). Now ink (computer printing) is cheap, but that is no reason at all to start reducing the data-ink ratio. It is a reason to look even harder at the practices of the past that used ink most efficiently. Mainly because that efficient use of ink almost universally leads to more data in the eye-span, which inherently leads to better thinking.
Maintaining a high data-ink ratio is probably Tufte's greatest explicit contribution to design. One of his great implicit lessons is to look to the past for examples of great use of ink: the more valuable ink was, the smarter it was used it.
And caliber of thought is the primary concern. Always.
It's true that handwritten notes are optimized for speed of writing, but they're also optimized--perhaps secondarily--for the speed of reading, which happens at least as often as writing (we can certainly hope).
There's a third optimization at work, for small size, both for its own sake and as a byproduct of optimizing for writing speed. Less ink tends to be faster.
Tufte frequently mentions the importance of saving ink when drawing charts, going as far as the rule of thumb that if any line can be erased without changing the meaning of the chart, the chart is better after doing so. But of course, it's not really about saving ink itself, it's just that total ink is a good proxy for the presence of distractions that impair clarity (chartjunk).
Similarly, fast-to-write notes like the fishbone also tend to be fast for trained practitioners to read at a glance. Though they may not be exactly what we'd come up with if starting from scratch with reading speed as the sole criterion, they get much closer than the typical lab results report.
Current electronic alternatives tend to be optimized for something else entirely: ease of printing on a fixed-pitch line printer. We can improve readability greatly by broadening the formatting options beyond that, to include options previously only possible with freeform pen and paper.
An ideal layout optimized for readers and free from obsolete constraints (such as writing speed and legacy print engines) would probably abbreviate fewer words compared to handwritten notes, because unusual abbreviations slow down the reader. At the same time, it would get rid of common words that ended up being frequently repeated on computer reports (medjunk). It could include better graphical and formatting cues (selective boldfacing, symbols, sparklines, spatial layouts like fishbones, etc.)
We can also take advantage of handheld devices like the iPad to allow trends and ranges to be brought up by tapping on a result, instead of trying to display everything all at once.
To your point about laying out electronic notes like compact paper notes, the Lifespan system of hospitals in Rhode Island is able to do exactly this. Their residency programs all use a web application that displays fishbones graphically using CSS, and other information in a compact format. I went to some lengths when developing it to abbreviate relevant medications and lab results the way the residents used to on their handwritten notes. They had developed the original format over many years to efficiently convey information, and it made sense to model the electronic version on it.
Different services use their own shorthand and prefer different levels of detail on reference printouts. An entire Surgery patient census with demographics, labs, meds, and notes is designed to fit on a single page. (Even at 2-3 lines per patient, the print had to be quite small, but surgeons seem to like that.)
I hear that this type of system isn't common, apparently because not many vendors go to the effort. Displaying the fields as they appear in the database also complies with the specification and serves the purpose, just not quite as well.
Onscreen, the web application has fewer space constraints and also supports progressive disclosure. For example, abnormal lab results are highlighted on the printout, but their trends and normal ranges are only available by clicking or hovering over the result. Fitting everything onto a single page also becomes less of an issue because you can always jump from patient to patient via a table of contents, without shuffling paper.
An iPad or high-resolution device like an iPhone 4 could marry some of the best features of paper and screen: portability, navigation, progressive disclosure, and the ability to edit.
i feel like i see a lot of clipboards with paper in medical dramas, etc. - in terms of form-factor and what you were saying about horizontal surfaces, how do they work out?
The most common form factor in the wild is the 8.5 x 11, usually folded once to make it 8.5 x 5.5. The most common clipboard is actually one that folds exactly like that: http://www.whitecoatclipboard.com/
I worked for a medical imaging company last year developing the communication channel for a web portal to allow referring physicians to access study images remotely. The tablet isn't the hurdle, it's the lame network infrastructure and ridiculously slow internet connections. Most the imaging companies have viewers that are nothing more than glorified jpeg viewers. The pain points are accessing the data and how it's stored. Doctors often have extra image studies performed simply because getting the images from previous studies performed at another imaging center is such a hassle.
This is a really detailed account of the kind of advancement that multi-touch tablets can make in domain specific applications. Why are people rolling around computers on carts to perform simple interactions with web apps? I can't think of a better use case.
Carry a clipboard with patient names and diagnoses on it, OK, you're pretty much kosher. Carry a tablet which accesses patient names and diagnoses over a wireless connection and you probably just bought six or seven figures in infrastructure and auditing requirements.
HIPAA: Comply Diligently, Or Get Intimate Domain Knowledge About Emergency Room Operation.
> probably just bought six or seven figures in infrastructure and auditing requirements.
This has already been paid. Citrix is already deployed at most hospitals, and doctors routinely access it over wifi and 3g from laptops, the "COWs" the author refers to, and even their home computers. And Citrix has an iPhone client, a Linux client, and a BlackBerry client, all free.
I can't speak to the quality of the iPhone version, but the Linux version is absolutely terrible. It's slow and crash-prone (think early flash releases).
I think a good number of hospitals have that infrastructure in place already. The doctors at ours all carry around laptops, then have to balance them awkwardly or find a table to set them on. Aside from being physically awkward to use at times, there does seem to be a lot of benefits. I can go to one doctor at one clinic and he can pull up my medical records and see what medications another doctor has prescribed me. Basically, any doctor I go to at any medical facility here has instant access to my entire patient history if they need it. This seems to me like it would be particularly valuable in an emergency situation. I'm not exactly in a big city, either. It's a rural area of eastern Kentucky. I tend to think the medical profession is one of the markets with the biggest potential with regards to tablets, the other being schools.
> Why are people rolling around computers on carts to perform simple interactions with web apps?
Please, don't even ask that question. It's the wrong question. They are a temporary placeholder until tablets come along. The clipboard metaphor is what you want.
Sounds like the iPad makes for a really good dumb terminal. I guess the advantage over a real computer, in this case, is that it's cheaper and the battery lasts forever. (And it has a good screen, something that Lenovo and others can't figure out how to buy.)
And we never thought thin clients would catch on...
the form factor is huge. The clipboard metaphor is very valuable. However, the maximum dimension that most white coat pockets can accomodate is a 8.5x11 folded in half the fat way, narrow edge down.
I heard about some touch-sensitive e-ink-based devices that were supposed to come out in this form factor. I don't know about doctors, but I would buy one on launch day ;)
It's encouraging (to Apple, I guess) that most of the weaknesses are just small points in their system's particular software that don't work well with iPad. Those will just get ironed out.
The article describes a situation where an ultra-portable device with long battery life is a winner. It's not clear whether the iPad is any better than a netbook would have been. I would imagine it would win on standing-up use and lose out on typing. At any rate, it seemed more about the virtues of an ultraportable than the particular virtues of the iPad.
edit: which is not a criticism of the article, merely an observation that it applies to more than one device.
Netbooks have been around long enough now that if they worked in this situation, they would have been adopted already. Think clip board, not laptop. The standing-up use is essential. He said the typing worked just fine. Add the 12+ hour battery life and the iPad fit the situation quite nicely.
I was making the point that a lot of the advantages mentioned apply to netbooks. Some of the ones that don't (e.g. standing-up use) would be a case of swings and roundabouts. I agree that standing-up use, particularly data entry, is one of the iPad's advantages. I didn't get how much of the standing-up use was data entry (where it's game, set and match to a touchscreen) and how much of it was passively displaying data (where the advantage is smaller).
One place mentioned in the article where the iPad wins over netbooks is ease of cleaning, having way fewer crevices than a device with a keyboard. Not an impossible problem, but I imagine it's nice not to have to worry about it.
Netbooks have half the screen and a fraction of the navigation and presentation usability for this particular scenario.
As owner of both types of devices, I'd venture that the on screen keyboard on the iPad is at least as touch-type-able as the miniature netbook keyboards.
Also, Penultimate with its wrist rest detection suggests what domain specific charting software could be like.
When there was a bug in a MySQL database being used by folks for chart review, standing there on the wards, I was able to securely get into the MySQL server back in informatics
However, I'd also be interested in hearing from doctors that might not happen to be "chief information officer and dean for technology" and see how easily and effectively they can use the device.