The iPad is dead. Long live the iPad.

By the UI Guy

Is the Apple iPad dead in the water – where healthcare’s concerned – before it’s even available? From all the mudslinging directed at Steve Jobs’s latest portable offering, you would think so. Much criticism has been leveled at Apple for failing to enable multitasking on the iPad. That’s fair comment with regard to the increasingly short attention span of the typical home user, who’s used to having instant and concurrent access to multiple applications at once, and flitting between them without spending more than a few minutes in each.

However, when it comes to the medical community, this supposed limitation could actually be a blessing. If a facility is giving its resident and attending physicians on-the-go-access to real-time patient chart data on the iPad, surely administrators want them to concentrate on this information. It would be less than desirable for a doctor to be checking e-mail, sending a tweet or updating a social media profile while he or she was supposed to be working on delivering the best possible care outcomes. The lack of a multitasking capability actually creates a more focused user experience for physicians, nurses and other clinicians, which in turn can positively impact patient care and service.

Then we come to another bugaboo with the iPad – no stylus. The visionaries in Cupertino have copped more flak for this omission than any other, with the possible exception of the Flash support (or rather, the lack thereof) debacle. For hospitals, this does put Apple at a disadvantage when going head to head against tablets that support digital ink and pen-like input. There is also a usability issue, in that e-ink enabled tablets have a very small learning curve with clinicians due to the replication and enhancement of the familiar pen and writing surface experience.

The way the blogosphere has been lighting up over the stylus issue, you’d think that Steve Jobs got to the day of the unveiling and said, “Hey guys, looks great but you forgot the pen.” No. Apple doesn’t do things by accident, nor (with the exception of that escalating Flash debacle/war with Adobe and caving-in on the two-button mouse) do they leave out required functionality. Most people initially thought the click wheel on the iPod was crazy because there were no buttons, and many (Apple employees included) believed the app store was a mere sideshow. Those theories didn’t work out too well for the skeptics, did they?

It’ll be the same with the stylus. Either app developers will innovate because of its absence, or, if Apple recognizes a need, it will release such a thing. This is a Bluetooth-enabled device, so what’s to stop Griffin and other third party accessory developers from coming up with a Bluetooth stylus? In fact, TenOne is already halfway there with its Pogo. The Apple accessory market can also come up with screen covers to withstand medical sanitation, splashes and the other day-to-day hazards of the hospital environment. For instance, impact-resistant cases are already available. Check two more complaints off the list.

Going back to the software issue, developers of iPad applications will undoubtedly find ways to change their UIs to accommodate Apple’s unique interaction model. This will likely manifest itself as a lot of movement-focused tasks that allow physicians to take advantage of the patented multi-touch gestures exclusive to the iPad. Use cases are unlimited for patient education. A physician could, for example, pull up a diagram of the heart and manipulate it with touch gestures and by rotating the device to the preferred viewing angle, taking advantage of the iPad’s accelerometer. This would help the doctor explain a patient’s condition in a clearer and more engaging fashion than with a piece of paper.

Steve Jobs and his cohorts would’ve made it a lot easier on themselves if they’d included every feature the public demanded: camera, multitasking, stylus input, Flash support and so on. But the genius of Jobs has always been about the degree of difficulty. While everyone else is doing predictable tricks, Apple is making Shaun White like moves (check out McTwist 1260). And, just as we saw with White at the Winter Olympics – he who dares the extraordinary, risks falling, but also risks winning extraordinarily. Just gotta stick the landing.

Apple’s vision eclipses the desires of the mainstream and moves consumer technology in innovative directions. Yes, there is some reason for skepticism about the iPad’s impact on healthcare, but Apple did not release the product on a whim, nor will it be adverse to making significant changes to future versions (and maybe even reluctantly giving us that elusive stylus, and a more rugged housing designed for hospital use). The combination of Apple’s couldn’t-be-simpler (and sharply focused) user interface, commitment from an ever-growing app developer base, and the potential for future advances (think how far the iPod has come) mean that the iPad is here to stay in healthcare.

Thank you to UI Guy for kicking off HIStalk Mobile’s Readers Write. I welcome all comers. Please feel free to submit your own articles up to 500 words in length. The only requirements are that the article be original (as in not previously published elsewhere), and thought/opinion pieces and not thinly veiled advertisements.

Nearly ten years ago, the industry was abuzz with mobile activity. Palm’s introduction of the Palm Pilot a few years earlier, in 1996, launched the personal digital assistant (PDA) revolution. Spurred on by the dot com mania and the rapid market penetration of PDAs, dozens of companies set their sights on healthcare where the opportunities for mobility were mind-numbing.

Most of the early hopefuls targeted either e-prescribing or charge capture – the two functional areas with the easiest to articulate value propositions. Several of these venture-backed companies raised millions of dollars. Yet, despite their undeniable value, nearly every one of these companies either went out of business, or were rolled from one company into the next until they eventually disappeared. Epocrates emerged during this period and had phenomenal success gaining clinical adoption, but suffered from a yet-to-be defined business model.

I started working with MercuryMD when its two founders were still in residency. The Company literally operated out of a loft apartment in the old tobacco district in Durham, North Carolina. MercuryMD began as many other high-flying VC-backed start-ups were crashing and burning. Our premise, unlike that of the solid-gold, “3 month ROI” VC darlings was simple and yet confounding – we would integrate into a hospital’s disparate HIS environment, capture only the pertinent information, reassemble the information in a patient-centric database, and then serve it to physician handheld devices according to their specific census. The premise was confounding because few understood why anyone would pay for just data.

Ultimately, the crux of MercuryMD’s data delivery solution was that everything starts with the information. Clinicians will not use a mobile device simply for the sake of using it. The device must first earn its way into their workflow, which requires having mission critical information. Once that information is in-hand, getting clinicians to adopt adjunct functionality, anything from charge capture to context-based clinical decision support, becomes relatively simple.

To deliver this solution, MercuryMD had to solve several key problems, including rapid low cost HIS integration, a reliable enterprise data conduit, and delivery to the end device.

Fast forward to today, and things look surprisingly similar – with one glaring exception. In 2000, devices were extremely limited in their capability. They were really only beginning to support WiFi, which didn’t matter that much because most hospitals didn’t have it (other than in isolated locations, like ED). You certainly couldn’t make a phone call with your PDA. Color screens were cool back then, but cool generally meant shorter battery life. Back then we used to care about how big an application was, and how many you had on your device. And, to be clear, the devices were purely consumer-oriented, meaning virtually no native enterprise capabilities.

Today, devices all but ship enterprise-ready. They are powerful, capable, and multi-functional. They support Bluetooth, WiFi, and cellular (GSM/CDMA), and they are pretty good at jumping between them. Memory is no longer an issue, nor is processing. Blackberry especially and iPhone increasingly are shipping in an enterprise mode for simple fleet deployment and management. Security, while still suspect, is getting better with each new OS upgrade. I would say that the vast majority of the challenge facing enterprise mobile solutions in 2000 no longer exists.

And yet, despite the capability of smartphones and their ubiquitous presence, most of the smartphone apps leave something to be desired. Yes, iPhone passed a billion downloads, but how many are like the iFart app that my daughter downloaded onto my phone this past weekend? Momentarily humorous and then forever discarded.

Looking back at the MercuryMD solution, it is clear that everything from the database to the data deployment to the end-devices has radically improved. The laggard? Data integration. And, actually, to be more specific it’s data availability – “integration” is an issue only because vendors make it one. Enterprise data is the missing element needed to create enterprise solutions.

While I have plenty of reservations about when and how healthcare information exchange (HIE) is going to happen, I believe it holds the key to breaking enterprise mobility wide-open. Imagine all of the developers and development shops who are sitting around trying to think of self-contained healthcare applications. There doesn’t seem to be a lot to work with. Don’t hold me to anything here. I’m not suggesting we’ve exhausted the limits of useful, standalone healthcare apps. I simply believe that if you want physicians, and clinicians more broadly, to use mobile devices in their daily workflow – and I’m sure they want to – you need to start with enterprise data.

MercuryMD, now part of Thomson Reuters, is more than capable of pulling out read-only data from enterprises… and there are dozens of others who can do the same. But it should not be a required competency to develop and create useful enterprise apps, and hospitals should not be paying for integration every time a new vendor shows up at the door.

HIE, provided it does not become yet another vendor-controlled platform, has the potential to turn-on the data spigot for hundreds of mobile development shops, all vying to create high-value solutions. Let’s hope that this is done correctly, and in our life time.

Email David

How I Use My Mobile Device

by Joseph Crozier, MD/PhD

As a psychiatry resident at an academic medical center I am in contact with many patients each day with a wide range of psychiatric and other medical diagnoses. I use my mobile device – a Palm Centro – as a way to carry medical references with me wherever I go in the hospital or clinic with the ultimate goal of having key information available to aid medical decision-making.

The main applications that I use are the Epocrates Essentials suite and several digital books that I read using Mobipocket. These books include the DSM-IV Handbook of Differential Diagnoses, the Quick Reference to the APA Practice Guidelines, and the Quick Reference to the DSM-IV Text Revision. The main utility for me of these mobile applications is in having clinically useful information available immediately when needed. For instance, when I am admitting a new patient to the hospital I can use Epocrates to check the patient’s medication list for harmful interactions and for a guide in dosing medications that I may add to the patient’s regimen.

In the past I have also used the full Epocrates Professional suite including Epocrates Lab for advice in interpreting labs and Epocrates Dx as a quick refresher on medical conditions that I don’t encounter frequently. In addition to Epocrates, I use more psychiatric specific applications through digital textbooks that I purchased from PsychiatryOnline. These textbooks are useful for constructing differential diagnoses, planning initial work-up of patients, and provide advice in constructing evidence-based treatment plans.

I have found that having information on medication, labs, and diagnosis readily available saves me time in that when I have factual questions I do not have to find an open workstation and log on to look up information. I just pull out my mobile device and most of the times can find what I need. I have also found some of the attending physicians that I work with have grown to appreciate that fact that I have this information readily available and will also rely on what I can quickly find on my various references to help with decision-making.

Favorite Non-Clinical Apps/Uses:

What I use my device most for is texting my girlfriend who lives a thousand miles away. I also use the Palm calendar for my work and non-work appointments and as an alarm clock.

(Joe was kind enough to kick-off what I hope is a long and successful series of first-hand accounts from clinical-users in the trenches.  Please tell us your story.)

Paul Adkison is the Founder and CEO of IQMax.

First off, Paul, thanks for being an interview subject. You are the first one for HIStalk Mobile, so I appreciate that.

Happy to do it, and happy to be here.

Great. So, first question I have for you, can you tell us a little bit about the different partnerships that you have going on right now and what they mean for IQMax.

First of all, to give everyone an idea of how IQMax does business, and our business model – we are a middleware provider of mobile technology. We have several other offshoot technologies. We have decided that instead of building up a huge sales force, which causes products to increase in price, we have chosen to partner with other providers of technology and services that integrate well with our solutions.

We are focused on distributors and VARs to carry our products – that have a complimentary service or product to integrate with. Integration to our distributors and VARs needs to deliver a better value proposition to the customer than just our respective stand alone products. In doing that, we have actually gone out into the industry and looked at different partners that have a complimentary service or product offering that with the addition of our technology will create a better value proposition.

For example, we are happy to announce that we just recently executed a distribution agreement with Fast Chart, which is a division of Applied Medical Services. Fast Chart offers multiple services of which transcription is one of their core offerings. Our mobile dictation application on a Blackberry or iPhone integrates well with their transcription service and adds a much stronger value to both the companies and most importantly the customer.

In some cases, we will partner with a company such as Fast Chart to sell the IQMax product directly to end-customers. In other cases, we will actually OEM our product. We are very happy to announce today that we have executed an agreement with 3M. They will be OEM’ing our mobile suite of products to offer to their customer base, which is a huge opportunity for a company like IQMax and a huge win for mobility.

When working with one of these partners who are focused on specific functionality, how much opportunity, how much access do you have to the end-customer to promote or up-sell your full-suite of mobility offerings?

One of the advantages that we have is multiple applications within our suite, and if you look at our distribution partners, they tend to be very focused on some segment of healthcare. For example, in our recent deal with Fast Chart –their core product offering is transcription. As such, we are very focused on delivering our mobile dictation application to their customer base. And, so, the question is, how can we leverage that relationship that is very focused on one application and one segment in the healthcare spectrum, to now up-sell and fill out the full suite of applications. That is a unique and good challenge for IQMax.

The answer first comes with understanding our technology. When we install any single application, we have installed the majority of our platform technology. We are only missing additional applications. Simply, we walk in hand-in-hand with our distribution partner and actually assist them in making the presentation. In this case, let’s say we are going to add on charge capture. Having worked with our partner to understand the customer’s needs, we will present the value of the offering. If the customer is interested – because they have already installed the core technology – adding additional functionality is literally as easy as flipping a switch on our server. The next time the physician logs in, she will have the charge capture application on her device. We anticipate the customer will want additional applications and thus make it very simple for them to scale to any application. We also see a natural progression with most of our applications. So, as you can see, it’s relatively easy to scale. It just takes time.

It ends up being a very simple model. It gives us great access to customers. If a customer has dictation needs, we can simply drop our dictation application without having to go through all of the necessary steps of satisfying the system’s larger mobile strategy. By the way, a lot of facilities have not yet developed a clear mobile vision. When we walk in, we have already developed a relationship. We are a known entity. The providers are already using our applications. It’s relatively easy now to lead clients into our full suite of applications and to aide them in defining their mobile strategy.

In order to provide the type of solutions that you provide, you have clearly developed a core competency in systems integration. As such, you now have a very good opportunity to participate in health information exchange (HIE) discussions. You recently announced as much. Who is buying HIE and how do you differentiate yourself?

It’s a great opportunity for us to leverage our skills set. We have been a middleware provider of technology that mobilizes both acute care systems and ambulatory care systems since 1999. We have a tremendous competency interfacing to diverse back-end systems across the full healthcare continuum, including transcription systems, lab systems, large HIS systems, and various ambulatory systems. We really have built up a tremendous amount of interface and technology expertise focused entirely on integration of backend systems.

In delivering our mobile solutions over the last 10 years, we have developed a robust clinical data repository and interfacing technologies which I mentioned earlier. If you think about this, we can take information from disparate clinical information systems – let’s say an HIS interface feed from McKesson and an ambulatory feed from Allscripts, and we have combined that into our own clinical data repository that we mobilize using our platform. This disparate data is now presented in a provider view on their mobile device of choice that is patient centric to their individual workflow. We have taken data from the hospital system McKesson and the clinic system AllScripts and allow any provider access to their patients and their workflow on their iPhone, Blackberry or Windows Mobile device. So very simply put, we are acting as a health information exchange by de facto and have been doing this for over 10 years

Our HIE product offering has a strategic advantage in the fact we are patient-centric. This gives us the ability to get patient data down to the point of care and have that data aide providers in the efficient delivery that will execute real meaningful use. Everybody’s talking about how to get disparate information into a common database to be shared. I think the real problem is not getting information or sharing the information. The real problem is getting information to the appropriate provider or providers at the time he or she is seeing the patient to effectively treat the patient. It’s a simple business principal – the more information you know the more informed a decision you will make. No difference in that of a physician. If the HIE can deliver as much relevant information to the physician at the point of care and, here is the critical piece, within the physicans workflow, so he doesn’t have to go find it, the better the decision will be and the better the outcome will be. That’s what I mean by real meaningful use and that is exactly what the IQMax solution does.

What we have done through our mobile technology and understanding of each providers workflow – we can actually take each providers specific patient information across multiple disparate systems and we can relate that right down to the individual physician who, by the way, has a schedule or census list on his mobile device or any internet enabled device with not only information about this particular patient at that particular institution, but now has all the HIE information about that patient from all of their visits in that environment. It’s easier for the physician and seamlessly delivered into their current workflow. Why should any provider have to enter into another system and look up a patient by typing in multiple lines of patient information? It just wastes time and effort and providers won’t do it and at that point meaningful use becomes just another buzz word that doesn’t work.

It’s a very simple and straight forward solution to what I call “the last mile” of HIE, which is to get the proper information to the proper provider at the proper time so that he can have the best information to provide the best care. At the end of the day, that is what the health information exchange has to be. This is what meaningful use is at its essence.

Now the business model – we believe that physicians want the type of information we can provide, and they want it everywhere including on their mobile device. We also believe that they will want all types of applications, such as charge capture and dictation, on their mobile devices as well. There are multiple applications that will support a fee-based model where physicians will pay a small monthly fee to get features and functions that they would not normally get. We believe this is a far better model than other HIE solutions which require physicians to jump through multiple hoops to get that HIE information.

You cannot require a physician to stop what they are doing, interrupt their current workflow to go log into a separate terminal, type in a patient’s name, a medical record number, or a social security number, date of birth, last known address to get health information exchange. It’s just not going to work like that.

IQMax is providing an easy, straight-forward workflow solution that delivers that HIE information within the physician’s schedule or census. He will use it. Then we provide ancillary applications, so that he can capture a dictation, capture a quick charge and then move about his business. It’s a simple solution that bridges the last mile, and it address some of the key challenges of HIE, including financial sustainability and being able to deliver on meaningful use.

This sounds like a great model, particularly for getting physician participation. Ultimately you’re going to need the buy-in of the various large institutions, such as medical centers, within a regional setting who essentially act as gatekeepers for the HIE. How do you get their support?

First of all, we are relying on our customer base. We currently have 150+ installs in 33 states. In the coming months, I think you’ll see additional VARs and distributors coming on board. Some of them will be more specifically focused on the HIE space, including integration consultants. I think the relationship with 3M could provide additional opportunities to extend our position into HIE. In addition to our partnerships which create both opportunities and credibility within the HIS market, I think more and more institutions and HIE organizations will understand our message – that patient-centric, mobile information will drive physician adoption and ultimately meaningful use.

Finally, given the economy and then the uncertainty created by ARRA/HITECH, things have been pretty slow-going for most over the past 18 months or so. How is deal-flow looking today? Are things picking up?

Yes. We are seeing a definite pick-up in activity, which we expect to result in several closed deals in the coming months.

Any big deals to announce?

Probably within the next two to four weeks. We are looking forward to announcing them. We have recently successfully completed the pilot phase with two prominent healthcare organizations and we expect to add several hundred new physicians at these respective facilities over the next several weeks.