Where's the Love for Tablet PCs?

When tablet computers were unveiled six years ago, it was predicted that they would be widely adopted in medicine. How have such predictions held up? It is hard to tell. Observing what happened is not the uncertainty; the issue is that technology has changed so much that it’s hard to fi gure out what the original predictions actually meant. For those who imagined doctors talking with patients while writing on notebook-size slate tablets resting on their laps, their predictions have fallen short. Part of the reason is that computerization has advanced more slowly in medicine than in other industries. Another factor is that many of the doctors who use computers do so by sitting at a desk and typing on a keyboard and looking at a screen instead of looking at the patient.

Some of us had a vision that using tablets in medicine was going to be diff erent—that it was going to enable more mobility. In 2002, I went to one of Microsoft’s tablet PC roll-out events and was disappointed. I sent a long e-mail that day to a friend who worked at Microsoft and told him that Microsoft had done a nice job on the software but that the hardware was far from optimal, particularly for doctors, who are among the most mobile of information workers. Doctors were mostly interested in mobility, and any device that didn’t fi t into a pocket was not going to be a crowd pleaser. Th e tablet PC could be as big as a doctor’s white-coat pocket to get as much screen area as possible, but mobility was crucial. Six years later, we recognize our focus on mobility as the winner. However, the vision is fulfi lled by devices such as Apple’s iPhone, and less often, by tablet computers.

It's not working Despite the progress toward mobile computing, doctors are not pleased with current computer technologies. Neither the tablet nor the iPhone is optimal for mobile medical computing. Although the iPhone is great for keeping in touch using a small device and for looking up items such as drug interactions, it is hopelessly undersized for serious medical computing. Not only is the screen too small for most medical applications, but the pointing device—a fi nger—is about 20% of the width of the screen, and text entry using the onscreen keyboard is excruciatingly slow. It is hard to imagine anyone using an iPhone to take notes during a patient interview. Also, its support for Internet plug-ins is so restricted that British regulators have banned Apple from claiming in advertisements that the iPhone allows a user to browse “all the parts of the internet.”

People who don’t have signifi cant mobile computing needs already have good options— they can have both an iPhone-size device and a full computer, relying on the synchronization of information like contacts and schedules. However, people who need and want signifi cant mobile computing, particularly those who need to use a device while standing up, are still out of luck. These people need a computer to bridge the gap between the iPhone and the tablet PC; such needs are likely to be considerable in medicine and other industries.

It isn’t hard to describe a mid-size device, since all of its elements exist already in tablet PCs and the iPhone. Such a device needs the following features:

• Phone: A phone that can receive calls all day, as with the iPhone.

• Big screen and small pen: A screen small enough to fit in a white-coat pocket, yet big enough to be useful for serious medical computing. Finger input and multi-touch are great, but it is hard to have any handwriting recognition without a tip smaller than 1% of the screen width, best achieved with a pen.

• Thin: A light and thin form factor, like the iPhone, which is easy to carry around and easy to hand to a patient or colleague to share an image or the output of a decision-support tool.

• Powerful: A powerful computer like a tablet PC, which can be docked at a desk to drive a large screen and use keyboard and mouse input. Despite what many tablet and iPhone enthusiasts will tell you, a keyboard and mouse are by far the best method for text entry while sitting at your desk, especially when no one else is there who would be off ended when you are typing and staring at a big screen. Also, it is important to run more than one application at a time, transcending the severe limitation in the iPhone that closes one application when you open the next.

• Inexpensive: A low cost, and not deceptively low like the iPhone because of a mandatory $1,000 yearly wireless contract.

Such a device would be ideal for physicians who need to use an EHR or use SimulConsult’s medical diagnostic software to help with unusual cases. Rumors abound of such a device being developed either by Apple (scaling up its iPhone) or tablet PC manufacturers making their hardware thinner and adding always-on phone capability.

A much needed change

Who will dominate mobile computing? A good framework for looking at this is the work on “disruptive innovation” by Clayton Christensen, a SimulConsult advisory board member. A disruptive innovation is one that is dismissed at first as an inadequate low-end substitute. As it adds more features needed by powerusers, it slowly displaces the higher capability competitors from the marketplace. A classic example of this phenomenon is how personal computers, initially dismissed as hobbyist toys, replaced expensive mainframe computing.

A logical move for Apple would be to use the iPhone as a disruptive technology, making it more capable by creating a version that is bigger and more powerful and can fit in a purse or a sport jacket pocket. However, the company could easily fumble this opportunity because it remains traumatized by its ill-fated experience in the 1990s with the Newton computer. Besides, Steve Jobs would not be caught dead wearing a sport jacket or carrying a purse. This would leave an opening for other cell phone platforms, such as those built on Google’s Android platform, to fi ll the role of the disruptive innovator. Alternatively, tablet computer manufacturers could show unusual flexibility by adding phone capability and moving down from high-end products to hit the “sweet spot” with computers that look like bigger iPhones. This is what Microsoft and Intel tried to do with the “Ultra Mobile PCs”, but the hardware was clunky, limited, and expensive. The current growth in low-cost “Netbooks” and movement of some computer manufacturers to more cell phone-like pricing are early signs of such flexibility, but there are signs of mistakes being made by Microsoft, such as designing its new mail software in a way that doesn’t work well on small screens.

What'll it take?

The mixture of mobility and capability that has driven interest in tablet PCs since their introduction six years ago remains a potent need. Doctors will need to access EHRs while mobile, and tap into decision support software and resources on the Web at any time. We’ll get there, whether through smaller devices growing or bigger devices shrinking. However, it looks as though it will take another generation of innovative chips, power-saving features, and bets on the right form factor before we see signifi cant mobile computing in medicine.

Michael Segal, MD, PhD, is the founder of SimulConsult, which makes decision-support software to assist with medical diagnosis. He wrote this article on a Motion Computing LS800 slate tablet PC while fl ying from Frankfurt to Boston because it is easier to use a slate while away from a desk.