Tablet PCs Have Finally Arrived in Health Care

In 2008, I wrote an article for MDNG about the use of tablet PCs in health care titled “Where’s the Love for Tablet PCs? (http://hcp.lv/ l0chXo). The short answer at the time was, “there isn’t much.” Despite compelling arguments in favor of adopting tablet PCs for use in the clinical setting, these devices remained largely ignored by health care providers. The promise existed but the passion just wasn’t there. My, how things have changed. In the three years since the publication of my original article, many physicians have decided to use iPads and other tablets in daily practice, and surveys show that one in four physicians plan to purchase a tablet PC during the coming year (http:// hcp.lv/kZ6390). What happened to change so many minds? To me, the answer is obvious.

Practically speaking, the tablet revolution really began on April 3, 2010, with Apple’s introduction of the iPad. Although tablet computers had existed in various forms for 25 years, none sparked the response of the iPad. The iPad was the natural result of an evolutionary process that began with its immediate precursor, the iPhone. The iPhone offered all of the expected smartphone features, but added an easy-to-use, intuitive graphical interface (iOS) along with access to thousands of useful and entertaining apps. Thus, the iPad was introduced to a market that was already well primed by its smaller sibling for a larger platform that required no additional learning curve (http://hcp.lv/lnDQyb; http://hcp. lv/k06s0D).

The iPad offered a revolutionary hardware design, continuous access to the Internet via 3G cellular or wi-fi, and a price point that put the device within the reach of many millions of potential owners. The larger screen made it possible to view more data more easily while also allowing control and data input with a finger.

Not surprisingly, the iPad was also an instant success with physicians. In fact, physician ownership of tablets exceeds the level in the general population by about a factor of five, with surveys showing that more than one-quarter (27%) of physicians already own a tablet (http://hcp.lv/ lDctFL). Projections suggest that fully 38% of US health care providers will purchase an iPad for personal use within the next year (http://hcp. lv/kv40Ad). Furthermore, studies show that physicians are not (only) using them to play Angry Birds; 59% of surveyed health care providers reported that they use their tablets for medically related tasks (http:// hcp.lv/lentV2).

Clearly the iPad is making an impact on health care (http://hcp.lv/ m7Vn7Z). Physicians are routinely using tablets to aggregate digital versions of journals, newsletters, textbooks, and PubMed searches onto one readable, portable device. They have also discovered a burgeoning repository of medical apps. A good starting point is iMedicalApps.com (http://hcp.lv/ieKh0x), a site that reviews and catalogs lists of the best apps for a variety of tablet and smartphone platforms. Many apps are content-oriented, whereas others, such as medical calculators, provide task-specific functionality.

The right tool for the enterprising physician

Perhaps the biggest as yet under-recognized opportunity for tablet adoption is in the enterprise. The iPad has already transformed the business workplace. Ted Schadler, vice president and principal analyst with Forrester Research, expects tens of millions of tablets to be in use in America’s workplaces by 2015. He predicts “the fastest uptake of any device in the enterprise ever. Faster than PCs, faster than laptops, and faster than smartphones.” (http://hcp.lv/jSxYCK) Indeed, the phenomenon is already being referred to as BYO, for “bring your own [computer]”. (http://hcp.lv/lwhSoh).

What is true for the business sector will likely also prove true for the health care enterprise. John Halamka, MD, MS, Chief Information Officer of Beth Israel Deaconess Medical Center and Chief Information Officer and Dean for Technology at Harvard Medical School, has described a “perfect storm” for tablet adoption in medicine. In an interview with CNBC, he explained, “You have alignment of funding; a cultural change where doctors want to use devices to improve quality; you also have new devices and new software that are much easier to use” (http://hcp.lv/mjr7Ns). At the eye of this perfect storm lies the EMR.

Meaningful use of EMRs holds the promise of safer, more effective patient care (http://hcp.lv/kAk1zT). To accelerate meaningful use, physicians are being offered government incentives of up to $44,000 per doctor over five years of certified EMR use for Medicare or $63,750 for Medicaid (http://hcp.lv/kz7u4b). Given their portability, ease-of-use, and clipboard-like form-factor, tablets may prove the ideal vehicles to help physicians reach the goal of meaningful use.

But if tablets are the vehicles to meaningful use, application virtualization is the fuel. Referred to as the “killer app” for health care (http://hcp.lv/jTOeEk), application virtualization software allows a user to securely and seamlessly interact with an EMR (or other application) running on a remote server. Client apps, such as the widely-used Citrix Receiver (http://hcp.lv/mnNf8b), allow a user to experience the application much as if it was running locally on his or her own device. Because the application and any associated databases reside entirely on a remote secured server, no data is ever stored on the user’s computer, thus minimizing the security consequences of a lost or compromised portable device. Furthermore, since the application always runs on the server platform for which it is designed, EMR vendors do not need to develop for multiple platforms.

iPad competitors are on the horizon

It seems inevitable that most physicians will soon be using tablets in their work. Anecdotal reports of enhanced productivity are compelling (http://hcp.lv/mkVqi6). The ideal device for health care applications is not yet clear, however. Currently the iPad maintains a commanding lead in consumer tablet market share, accounting for roughly three-quarters of all tablets sold (http://hcp.lv/kz7u4b). It is also the clear consumer tablet choice of physicians, with 79% of US health care providers preferring the iPad to other tablets for professional use. (http://hcp.lv/lentV2). But there are competitors. In fact, some 80 new devices have been announced or hinted at by a wide variety of manufacturers (http://hcp.lv/kz7u4b). What will they add to the market?

The iPad 2 sets the standard against which any new device will be judged. Success in the marketplace therefore demands that new devices match or exceed the iPad 2’s ease-of-use, long-battery life, form-factor, price point, and available application base. Because of this, new tablets may appear superficially more similar than not.

Instead, the operating system, or OS, has emerged as the major point of distinction among tablets. iOS (Apple) is, as expected, the clear frontrunner, with Android (Google) showing large gains. Windows 7 (Microsoft) is currently the OS for only a small proportion of tablets. Upcoming devices running on a new OS will include the Blackberry Playbook and HP TouchPad.

Android currently powers 1 out of 5 tablets, and continues to show strong growth (http://hcp.lv/kz7u4b). Android’s success is attributable not only to its functionality and ease-of-use, but also to the fact that it is freely available as open-source software. As such, manufacturers are free to incorporate the OS with little or no investment. Manufacturers are also able to customize Android as they see fit in order to optimize specific features of their hardware. Some application developers complain that such “tweaks” create heterogeneity within the Android environment, a phenomenon called fragmentation (http://hcp.lv/jmf9pb). In practice, however, fragmentation has little effect in deterring Android development or adoption; more than 100,000 apps are already available and the number is growing rapidly.

The latest version of Android represents a significant advance for tablet users. Whereas previous versions were primarily designed for use on smartphones, Android 3.0 (nicknamed Honeycomb) was designed from the start for implementation on tablets. More recently, Google has added further enhancements aimed at enterprise deployment, such as encryption, security, and device administration features (http://hcp.lv/ iGJMoU).

The rest of the field

Although iPads and Android devices account for the overwhelming proportion of current tablets, devices based on other OSs should not be dismissed. All versions of Windows 7, for example, include support for pen input and handwriting recognition, a feature that is not natively offered by iOS or Android. This might be a compelling feature for physicians familiar with the difficulty of prolonged tap-typing on a touch screen. Furthermore, Windows 7 tablets run familiar desktop productivity software, such as Microsoft Office. Users who want these capabilities might look to the HP Slate 500 (http://hcp.lv/l0oRSB), a Windows 7 tablet that is small enough to fit in a lab coat pocket (the iPad doesn’t). There are currently several Windows 7 devices available, with more expected to hit the market soon (http://hcp.lv/jaHBVA). There is also speculation that Microsoft may soon introduce an OS fully dedicated to a tablet environment (http://hcp.lv/mkvJXe).

It is projected that 52 million tablets will ship this year (http://hcp. lv/iqfEAP). It is therefore not surprising that other manufacturers hope to gain a piece of the market. Research in Motion recently introduced The Blackberry Playbook (http://hcp.lv/jL7Rw5), a fast and agile device that weighs less than a pound and also fits in a lab coat pocket. Hewlett Packard is also launching the TouchPad tablet (http://hcp.lv/jxCg51), which uses developer-friendly webOS, an operating system that allows for application development using familiar HTML and Javascript (http:// hcp.lv/kjIxhT). How these newest devices will play out in the tablet market remains to be seen. Given the influence that Microsoft, HP, and RIM currently exert in health care enterprise IT, it is a market worth watching.

Although this article has focused on consumer tablets, it is essential to remind readers that these devices are not specifically designed for the demands of the health care environment, where infection control and data security are critical (http://hcp.lv/iHwsW2). For these reasons, health care users should strongly consider devices that are explicitly designed for use in the clinical setting. One example is Motion Computing’s C5v, a ruggedized Windows tablet that can be disinfected, and includes RFID and barcode scanners (http://hcp.lv/kAKnSE). Alternatively, perhaps specialized protective cases that can be disinfected might eventually be developed for consumer-oriented tablets.

A prediction

The combination of ease-of-use, size, connectivity, long battery life, and an app for every need ensures that tablets are here to stay. These features, combined with the unique needs of the health care market, guarantee tablets an expanding role in the medical practice of the future. In fact, tablets may well help define health care of the future. Physicians who don’t currently use one in their practice almost certainly will soon, either by choice or by necessity.

Dr. Nace is program director for Internal Medicine Residency and an associate professor of Clinical Medicine, Department of Medicine, University of Illinois College of Medicine, Peoria, IL.