By Gilly Munavalli, MD, MHS, December 03, 2012
History is fraught with epic battles between contenders and challengers; the Spartans vs. the Persians, Kennedy vs. Nixon, Frazier vs. Ali — and, today, Apple vs. Samsung? As we continue our quest to integrate electronic health records (EHR) into our practices, we must make our own tough decisions on hardware platforms. Do we choose the classic (sessile, yet upgradable) desktop PC to compose electronic notes and e-prescribe or would we benefit from a more mobile tablet computer platform to use in patient rooms?
When deciding to outfit your office with computing power, cost, functionality, and compatibility with existing office infrastructure are the most important initial factors to consider. One of my favorite tech writers, Tim Bajarin of PCMag.com, noted recently that although the computer industry is still selling at least 300 million laptops and desktops a year, its growth has stalled. He quotes International Data Corporation (IDC) reports that desktop PC sales for 2012 will grow by only 1 percent. Most potential computer buyers are torn between tablets and laptops when it comes to buying a device to fit into their business or personal lifestyles. [pagebreak]
The original tablet PCs ran a full, keyboard-centric operating system on a bulky touch-screen enabled laptop. This concept has largely vanished, as the touch-centric interface of newer tablets has replaced the need for constant keyboard or mouse interaction. Early adopters of new tablets, such as the iPad, quickly discovered that while they were marketed as media-consumption devices, they could also cross over to serve as a keyboard-optional productivity tool. Tablets were redefined as lightweight, portable computing devices.
As laptops are getting cheaper, thinner, lighter, and faster, physicians often defer upgrades as they try to identify what best fits their office needs and the ideal balance of tablet and laptop use in their professional lives. At the same time, tablet technology continues to improve, which raises the question of which is preferable. Most laptops on the market today are quite powerful with better hardware components to allow for better multi-tasking, keyboard entry, more powerful wireless radios for faster/more stable Wi-Fi connection, and better connectivity with peripheral devices.
But despite all these new advances in laptops, tablet computers, and smartphones, the desktop remains the go-to computing tool for many doctors. Survey data published in the July 2012 issue of the AMA newsletter, based on the responses of 1,190 physicians, found that 75 percent of doctors use their desktops for practice management tasks. By comparison, 25 percent used a laptop for such work, 10 percent an iPad or another tablet, and 6 percent a smartphone. Desktops were also the most common tool used for clinical tasks (59 percent of respondents), electronic prescribing (52 percent), and accessing an EHR (44 percent). Responding physicians cited the need for multitasking ability and larger screen real estate as factors why they would stay with a desktop. Lack of confidence in the security of mobile devices has also been cited as a concern. [pagebreak]
However, as Bob Dylan warned us long ago, the times, they are a-changin’. In 2011, 30 percent of doctors in the United States owned a tablet computer, compared to only 5 percent of the general public. According to American Medical News, “One year after Apple launched its first iPad tablet computer, 27 percent of primary care and specialty physicians owned an iPad or similar device — a rate five times higher than the general population.” As costs on some tablets fall into the sub-$200 range, their use is slowly but surely spilling over into the medical office.
In the context of the doctor/patient interaction, the traditional PC is still a Himalayan-size barrier, which screams of impersonability. It is very challenging to pay attention to a patient while rapidly typing or clicking and staring at a large screen to take notes, whether the PC is sitting on a desk or a rolling cart. Laptops are less cumbersome and present less of a physical barrier between patients and physicians, but still require typing and use of a mouse or trackpad that can make the physician seem detached.
These feelings of detachment can be amplified in dermatology because of the sheer number of daily patient encounters. Demand for dermatology services often dictates short appointments. But as my residency program mentors often reminded us, studies have shown that the short six-to-eight minute average patient encounter can be perceived by the patient as five to 10 minutes longer in duration if the physician spends that time sitting and interacting face to face. Laptops are better than desktops for this, but tablets allow us to maintain eye contact without a physical barrier, keeping the all-important doctor-patient bond intact, while letting our fingers do the charting. [pagebreak]
Dermatology-specific EHR applications are catching on to the market desire for the less-intrusive nature and touch-input capability of tablets. Even though most EHR/practice management (PM) systems were created to run on desktops, at least eight of the 10 EHR applications that I reviewed for this article are able to utilize a tablet (specifically the iPad) for patient data entry using a touchscreen interface. Most of these utilize a professional remote desktop/terminal server client to connect the tablet to the desktop. Software such as Splashtop, Citrix, Logmein, or free apps such as Remote Desktop Lite or VNC are designed to connect to a local or remote cloud for interacting with the EHR application itself. (Make sure your connections are secure or you may run afoul of HIPAA.) Another solution is to use a tablet browser such as Safari on the iPad, or Google Chrome, Firefox, or Dolphin Browser on Android-powered tablets to securely interact with online forms that comprise Web-based EHR platforms.
Practical experience from our own office illustrates what hardware decisions many offices face in the near future. It also illustrates how companies can improve their products to meet the demands of their client base. We were caught right in the middle in the laptop/tablet paradigm shift and this was a true dilemma for us. We initially made a large investment in touchscreen laptops and licenses, to run a fully integrated EHR/PM software. The software relies on the enhanced computing power and touchscreen interface of the laptops for full navigation and use. The trade-off for our willingness to tote around six-pound laptops in the patient rooms was the ability to fully document, schedule, and bill our patient visits. Ironically, I noticed, much to my dismay, that almost all the medical assistants tended to use the laptops as keyboard-centric classic laptops rather than utilizing the built-in clamshell/stylus functionality. Since they input most of the history before I see the patients, I wanted them to do this rapidly by getting comfortable with the stylus/touch interface of the EHR application on the laptop. However, melding a touch interface into the current Windows-based application environment isn’t ideal and wasn’t easy for them to learn and master in the typical dermatology workflow of many patients with multiple complaints. [pagebreak]
We are now moving to replace/repurpose these laptops to use iPads, running a new native iPad client. We can easily transfer the iPad app license from the laptop without penalty, and the new client incorporates all the functionality of existing laptops. With a new native touch-based interface and enhanced iPad functionality, we believe our workflow will improve. For example, HPI documentation should be faster because less typing will be required. The ability to capture photos from the iPad camera right into the patient record will help to eliminate snafus in surgical and biopsy site documentation. The ability to use the Siri voice recognition engine to uniquely voice-modify each note will also dramatically help workflow.
So, in this battle-royal between desktop PCs, laptops, and tablets, the fight rages on. First-adopter types such as myself will invariably spend more in money, time, and frustration to achieve the right balance of workflow and technology. Our patients will ultimately benefit by getting more of our time and attention and we can get back to the practice of medicine and use electronic documentation as the facilitating tool it was designed to be.