14 June 2010

iPad use in the ER

GruntDoc and a few others asked me about the medical apps available for the iPad.  As I said in my previous post, I am not at this time using my iPad in the ER.  However, that clearly is not the case for many other ER docs, and I would encourage any who are using it to email me their experience and I can post it for others to learn from.  Having said that, there are certainly a number of excellent medical apps for the iPhone and iPad and if the circumstances are right for you, it could be a great addition to your daily work.

Bear in mind this is written from the point of view of a practicing physician.  There are a gajillion educational applications which are excellent for medical students or EM residents. But my needs are not in the educational line anymore (at least so I hope!), rather the tools I use every day in clinical practice.
Here's where I envision the bang for the buck being with an iPad in the ER:

EPIC is one of the most popular electronic medical records in the large clinic/hospital environment.  It's not my favorite: we are on Picis and have had a great experience with it.  But Picis is not supported on the iPad (it's a browser-based system and only fully supported on IE6 & 7, I think).  If you work in an EPIC shop, however, you are in luck.  There is an EPIC client for the iPad, called Haiku.  If your IT department licenses Haiku, that could be a spectacular situation.  I'd be very interested to hear from anybody who has experience with this set-up.  There's a meaningful likelihood that we may convert to EPIC, so it's not entirely an academic question for me.

As an e-book reader the iPad is unparalleled.  Some of the most useful and prestigious EM texts are available online in PDF format.  You will need a reader like GoodReader, but the files are only 60-90MB and you can have Rosen's, Roberts & Hedges, and Auerbach in your hand all the time. 

I have been a user of UpToDate for several years. I find it to be expensive but a great value. It almost always has an answer to my question when I am at the point of care, and you get CME as well.  It's probably my most or second-most used reference on a day-to-day basis.  There's no app per se, but I saved a bookmark icon to the home page and it "feels" like an app, though it is technically browser-based.  The mobile web site is pretty well optimized for mobile Safari, so it is pretty functional.  And did I mention that you get CME for everything you look up?

Epocrates: I remember carrying around the Tarascon Pharmacopeia for years and years. It was my annual ritual: when the new year's edition was released I would get it and carefully transfer all the useful notes from the back cover of my old one to the new: phone numbers, passwords, etc. Those days are long past.  Now Epocrates has replaced it as my primary drug reference.  It is not perfect: it's a bit slow, not yet iPad optimized, and has an annoying habit of popping up messages or demanding updates when I am trying to get a piece of quick information.  But it is 100% reliable in getting me the information I want when I want it, and it is free.  In fairness, Tarascon does have a few apps, but they are kind of spendy and it is hard to compete with "free," so I have never seriously checked them out.    

Medscape: A free reference which is pretty useful.  Not quite as robust as UpToDate, but as I said, free is hard to compete with.  UpToDate gets me my answers more rapidly and with less hassle (Medscape interface is a little click-happy).  If you don't feel like shelling out the cash, this could be a good alternative, and is effectively a companion app to Epocrates.  It has free CME, which is nice, but a little test is required; UpToDate allows passive accumulation of CME based on subjects you research.

Medical Calculator: This is one of a few generic apps which provide useful formulae. Nothing you can't get in 5 seconds with Google, but nice to have right there in the palm of your hand.  

The Wheel RE: A cute, old-fashioned OB wheel-of-misfortune pregnancy slide rule. Oddly, the slide rule interface is still better than any digital calculator I have come across, at least for me, since I routinely have to calculate forward or backwards depending on what date(s) the patient or I may know or not know.  

eRoentgen: This app helps you determine what diagnostic imaging studies are most useful in picking up certain conditions.  It's not too useful in that you have to search by suspected diagnosis, and you have to use their exact phrasing (i.e. Abscess, Epidural will yield a result but epidural abscess will not).   

Stat ICD-9: A free coding app.  Fortunately I don't self-code my charts, so this is primarily for curiosity use.    

I would be remiss if I did not once more plug 1Password, which is an absolutely essential app for anyone in a hospital with multiple IT platforms, each requiring its own unique signature.  This will save a lot of neurons and prevent a lot of gray hairs (from the aggravation over repeatedly forgetting your passwords). 

 There is also the fine blog iMedical Apps which has a excellent set of reviews and other useful tidbits on uses of the iPad and iPhone in clinical practice.  Also not to be missed is the review by ER physician and CMIO of Beth Israel John Halamka describing the use of the iPad on clinical teaching rounds.


  1. I have the free Epocrates, Medscape, and have purchased Davis Drug Guide on my iTouch. Love Davis Drug guide as it goes into great detail for those who actually administer drugs, which, is what nursing must have at hand. However Skyscape really F'd up with their latest update. I had to delete it and reinstall the earlier version off my laptop. One more quicky is Eponyms just for "what the heck is that syndrome?!"

    I think the pad would be too cumbersome for me, really. I would worry about it getting ripped-off since I cannot hide it away in a pocket. And seriously, just where would you want to set that thing down? As soon as you did it'd get barfed on or bled on ;o(

    I've used EPIC, think it's OK, can be cumbersome depending on how much management screws with it.


  2. Brian Phelps8/27/2010 9:27 AM

    My company (Montrue Technologies) is developing an EDIS for the iPad that can interface with the legacy EMR. It includes tracking, CPOE, RN documentation, MD documentation (with ability to write notes at the bedside and dictate key portions of the H&P while incorporating other elements from nursing notes and prior visits). We plan to beta test in early 2011. It's a very simple and uncluttered interface, designed by EM docs, nurses, and coders.

    As far as theft, that is a concern; but since the iPad completely replaces the 3-ring binder, we think doctors and nurses will never be far away from the device for long. Encryption and data wiping solve the problem of health information security. As for barf and blood, we are testing a variety of cases in health care settings, and the iPads are holding up very well.

    My iPad fits in my coat pocket, but it's a little awkward to walk quickly. Again, no one puts 3-ring binders in their coat pockets and we seem to manage those okay.

  3. You mention having access to PDF versions of EM texts of Rosen's, etc. Where is a good place to get ahold of these files? All vie found are shady bootleg download sites. Thanks.


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