Where's the Love for Tablet PCs?

"Nobody knows the form of the information tool that may transform medicine, but we can begin to discern some of its characteristics. The tool must be able to answer highly complex questions and so will have to be connected to a large valid database. Inevitably, it will be electronic, but it must be portable, fast, and easy to use."

Richard Smith, then editor of the British Medical Journal, writing in 1996

Healthcare computing is unique. First, healthcare is mobile. It is practiced wherever the patient resides at the moment. Second, time is scarce for clinicians. Our interactions with our tools must be effi cient and seamless. Finally, healthcare information is sensitive, demanding high-level security to ensure our patients’ privacy. As evidenced from the opening quote, physicians have long anticipated a device that will satisfy our distinctive information management needs. Could it be the tablet PC?

What is a tablet PC? According to Microsoft, tablet PCs are computers powered by Windows operating systems that support functionality for input using digitizing screens designed to interact with a complementary pen. Tablet PCs have the full functionality of laptop PCs, but are primarily distinguished by pen input capability. One can use the pen directly on the screen just as you would a mouse to do things such as select, drag, and open fi les, or in place of a keyboard to handwrite notes and communication. By interacting directly with the screen, the PC becomes both more comfortable and easier to use (especially for poor typists).

Handwriting recognition, which translates handwritten screen input into editable text, distinguished the original tablet PC versions of Windows XP. Windows Vista now incorporates integrated support for tablet PCs, which, according to Debbie Martin, Microsoft’s OEM account manager for mobility, refl ects Microsoft’s solid commitment to the tablet PC platform. “We’ve always felt that the tablet is an important technology,” Martin said. “Some people at Microsoft believe that tablets are already mainstream,” which is why support for tablet PCs was embedded within Vista, and why further improvements in pen input and inking were included in Windows XP’s successor.

Physicians should know that contemporary tablets also have the hardware horsepower to run voice recognition applications. Thus, one device can off er a variety of input options (keyboard, handwriting recognition, digital ink, point and click, speech), depending on the need and the user.

In addition to pen input, the tablet PC’s form factor off ers additional advantages to clinicians. Most tablet PCs are designed as “slates” without an attached keyboard (although keyboards are available as optional accessories), or as “hybrids” with attached keyboards that can be optionally folded out of the way beneath the screen. Therefore, there is no need to find a fl at space on which to use the device, nor does a vertical screen impose a barrier between clinician and patient. The form factor lends itself well to use during rounds and other patient settings, much like the ubiquitous clipboard. Screen size for most tablet PCs is about 12” (measured diagonally), resulting in a device that is similar in size, or in some cases, smaller than a clipboard.

Some tablet PCs, such as Motion’s new C5 model, are engineered specifi cally for healthcare environments and include features such as shock-resistance, integrated RFID readers, optional bar code scanners, and cameras for documentation of clinical findings. The C5’s case is even designed to allow for disinfection.

Tablet PCs are generally priced between $1,000 and $2,500, and are off ered by a variety of manufacturers. Tablet PCs should not be confused with ultra-mobile PCs (UMPC). Although UMPCs might be considered smaller siblings of tablet PCs, the two devices are not functionally interchangeable. A UMPC is about the size of a paperback book and weighs less than two pounds. UMPCs feature displays of 4-7 inches and touch capabilities (using pressure-sensitive touch screens as opposed to the digitized screen input used in tablet PCs). Th ese devices also use the Windows Vista or Windows XP operating systems. However, their small screen size and hardware limitations currently make them inadequate replacements for tablet PCs for clinical computing tasks.

Why has adoption been slow?

In 2001, Bill Gates proclaimed that the tablet PC “is a PC that is virtually without limits, and within fi ve years I predict it will be the most popular form of PC sold in America.” Based on the device’s usability, such a prediction might indeed have seemed justifi ed (even considering the source). Yet even in healthcare, an industry that would seem ideally suited to adoption of the device, tablet PCs are not yet commonplace. Why not?

Many experts, such as Joel French, vice president of Motion Computing and general manager of its Healthcare Business Group, appropriately emphasize that the hardware interface is only one component of the total computing experience. “It’s a mistake to think of [a tablet PC] as a discrete device,” he says. Successful design “has to encompass infrastructure, software, user needs, and hardware.”

As an example, consider wireless networking. Mobile clinicians must be able to depend upon seamless and reliable network access. Without it, even the best hardware interface is unlikely to be used. Yet a survey by Spyglass Consulting found that 64% of nurses believe that currently available wireless infrastructure is not reliable enough to support point-of-care computing solutions.

Similarly, software vendors must specifically tailor their interfaces to best exploit pen input. Motion Computing, in designing their C5 model specifi cally for use in healthcare, began working with software suppliers two years before the device was marketed. Recognizing the importance of the platform, clinical software vendors are increasingly developing applications that are optimized for use on tablets.

In the age of HIPAA, security is a critical component of healthcare computing— especially for a device designed for mobility. According to Microsoft’s Martin, “Vista was a huge leap forward in making the tablet more secure.” Some tablets, such as Motion’s C5, also off er biometric user authentication.

As for the device itself, battery life remains one of the most frequently cited limitations. Battery life for most current tablet PCs is at best about 3.5 hours. French rhetorically asks, “Should a clinician ever have to change a battery during a shift? No. Clinicians shouldn’t have to do things that detract from patient care.”

In studying clinician workfl ow patterns, Motion found that clinicians often place their tablets on a desktop surface while doing other tasks, suggesting that the devices might instead be dropped into a docking station for a quick charge. When docks are provided in patient care areas in ratios of 2-3 docks per device, battery life becomes “a non-issue,” according to French. Another approach, of course, is to build a better battery. TabletKiosk, another manufacturer of tablet PCs used in healthcare, is now off ering an optional extended battery capable of 10 hours of continuous use in a wireless setting.

Given the tablet PC’s evolution, it seems surprising that the devices are not yet more ubiquitous. The reason undoubtedly has more to do with the healthcare environment than it does with the device. As French puts it, “There’s a digital threshold below which it’s not worth migrating to a mobile device. As the threshold of digital information increases, [we] expect to see a multiplier effect.”

Once healthcare exceeds that threshold (and it won’t take long), I suspect the tablet PC may yet prove to be “the information tool that may transform medicine.”

My experience As part of my research for this article, I decided to make hospital rounds with a tablet PC. The only device available to me was an aging fi rstgeneration device with an anemic battery. Given those limitations, here are my thoughts.

I found the device to be unobtrusive. (I’m not even sure that all of the patients recognized it as a computer instead of a clipboard.) The pen interface worked pretty well for selecting patients and retrieving clinical results. (We have not yet implemented computerized provider order entry, so I can’t address data input.) It was fairly easy to transport, and it was convenient to have immediate wireless access to our enterprise electronic medical record. I did have to restrain my tendency to multitask between reviewing data and interacting with the patient so as not to distract my attention from the latter.

My frustrations paralleled those of other clinicians. I intermittently lost my connection with the wireless network as I moved around the hospital. Each dropped connection resulted in having to go through several login screens to re-establish access. (Th is was obviously not a fault of the device.) Also, the tablet I used was powered by an old battery that didn’t last through rounds.

My conclusion? Given a more contemporary machine with faster performance and better battery life, coupled with a more reliable wireless network, I suspect that I might make the tablet part of my routine. (Perhaps readers using tablets in other settings would share their experiences?)

Dr. Nace is a MDNG editorial board member and an assistant professor of clinical medicine and associate program director, department of medicine, University of Illinois College of Medicine at Peoria.