11 March 2011

The iPad and Medicine

The folks over at iMedical Apps had a point-counterpoint the last couple of days, on whether the iPad or Droid tablet devices would come to dominate the medical industry. Here's the argument for the Droid, and here's the iPad's case. I'm not sure there will be a clear "winner" in the sense that Windows has come to have a near-exclusive lock on the desktops within health care enterprises. Rather, there will be co-existence, with some developers/vendors choosing one platform and others, well, you get the idea.

It is clear, however, that currently Apple has the inside track, and in some cases that can be decisive. The iPad is already in existence, mature both from hardware and software perspective, widely distributed, and insanely popular. The Droid counterparts do not yet exist, per se. Honeycomb, the Android 3.0 software, is just now being released, and the Xoom, which may in the end be a worthy competitor, was just released with a still-incomplete feature set. The early adopters in healthcare, including many major insitutional players, are already deploying iPads through their organizations, and developing the software that can run on them. The race is not won based on the start, but an early advantage in the market (and in the mind-share of developers) can have long-term consequences.

OS integrity is another factor that may be a significant advantage for the iPad. From reports (I've never used Droid at length), the OS is buggy and highly crash-prone, whereas the iOS is a mature platform which is ultra-stable. And the walled-garden approach that Apple favors, which admittedly closes the platform to some developers, also provides better integration and interoperation of third-party apps. The relative lockdown of the platform and the resultant stability might also be a factor in the decision for hospital IT departments to go with the iPad.

Enterprise support is one area where Apple has notoriously failed over many years, and may be its achilles heel in this competition. While the iPad OS does contain a number of enterprise-friendly features, it's not clear that the purchasing departments for hospitals will overcome their long-help antipathy for Apple, and not clear whether Apple will develop the support systems necessary to really compete in the corporate environment.

Lord knows which way things will go. It's not clear to me that any tablet device will become as indispensible as some evangelists believe it will. Neither the iPad nor any competitor excels as a data input device to the standards that would be necessary for bedside charting. It may be a handy reference device to carry on rounds, to access and review clinical data, but even then, the ubiquity of desktop terminals in the hospital environment renders that less critical. If you gave me a tablet device which was fully integrated with my EMR, I'm not sure I would have much use for it in the ER. For practitioners who rove all over the hospital I can see it being more useful, but pending the development of EMR portals which are wildly superior to any that exist now, I am dubious that a table will ever be the primary input device for clinicians' charting.


  1. I am a hospital rover (and occasional barker) and I have no use for a device too big for my pocket, too delicate to flip off the end of the bed without breaking, and unable to be sterilized with a swipe of disinfectant. I would much prefer breaking-er, using-the nice stable PC or COW that belongs to the hospital. You can't walk two feet without tripping over a device in my hospital, and that is terrific.

  2. what people tend to miss in the whole apple/android argument that often leads to the venerable flash/no flash debate is that everything is moving to HTML 5. That means apple or android, future "apps" should move towards living on the web and therefore be accessible by all. (not to mention accessing them from relatively slow old PCs too.)

    it begs several other questions, like security and network access, though that will impact any networked system.

  3. In today's IT world, the windows/mac and Android/iOS arguments are becoming largely irrelevant. EMR's can be delivered to either device through a virtualization client and appear to be native to the device.

    Android probably has the edge over iOS due to the fact that a hardware company can build a device that will meet whatever specs the market will buy, (1", 7", 937", etc), whereas the market often must accept whatever Apple offers. Want it ruggedized or water resistant, too bad.

    The real issue to me is creating interfaces that account for both the device (touch vs keyboard) and the use case (bedside or desktop).

    Android vs. iOS is about as important as whether the cafeteria serves coke or pepsi

  4. I'm going to be contrary here and throw in a vote for HP/Palm's WebOS. True, there's nothing of note in the market *now*, but once there is... Seriously, think about it, the real-company quality control of Apple plus the familiarity with procurement and support of a PC vendor. And they plan to ship WebOS on their PCs as well so there will be even more incentive to develop for it.

  5. Which will prevail will be the one that's most secure [I predict]. And right now SIDEJACKING is a significant threat.

    “Sidejacking” occurs when you login to a secure website or browse the web on an open Wi-Fi network, such as those provided at coffee shops, airports, or hotels, where your activities can be monitored by others that are also connected to that Wi-Fi network. It has always been possible to sidejack others on a wireless network, but doing so required specific hacking abilities.

    An add-on called Firesheep was released by a freelance web developer. This add-on makes it easy to sidejac.

    Secure Log-ins/ons (HttpS://...) are NOT possible with iPhone and iPad apps, so there is no way to protect yourself when using those devices connected to open Wi-Fi.

  6. Speaking of unintended consequences ("Lord knows which way things will go.")

    Have you read the lastest unanticipated cost increases resulting from Obamacare right now:

    Over-the-counter drugs, like aspirin, now require a prescription in order to use one's flexible spending accounts!!! Thus enriching doctors, and clogging up supply to truly needful patients, for things that were once-upon-a-time free.

    The WSJ tells the story at:




  7. Imagine you are face to face with a patient. You jot some notes with a stylus. You speak your orders into the device, then dictate your HPI right into the device on your way to the next patient. Other charting elements are imported from nursing documentation and data repository. Your results come back, you dictate your medical decision making, tap to pull discharge instructions (dictating additional instructions in real time if needed), then e-prescribe. All on a device that costs 1/18 a PC workstation. That's what's coming.

  8. If I were a physician in a hospital I would probably have less need to use a tablet for EMR due to the ubiquitousness of installed PCs in hospital rooms. But I would still want one. My experience with physicians that use EMRs is that they spend even less time looking at me, and even some time almost completely faced away from me, because the computer is bolted into a wall away from the exam table. As an acupuncturist in a small practice where I do EMRs on my laptop, I still feel that I am not getting enough (pardon the apple jargon) facetime. As a practitioner in a small practice without computers in every room, a tablet EMR solution is exactly what I need. I can have any chart, any diagram, illustration, reference book, etc. all on one device that I can take anywhere.

    Now security may be an issue here, provided that the server is not password protected, the wifi connection is not encrypted, and the app providing the EMR is not password protected and encrypted. But the chances of a physician using a setup without all this is nearly nill, and if you don't have all of these then you are technically not HIPPA compliant anyway. If you have all this setup and someone hacks your network, then that hacker would get into the network whether you are on a tablet or not.

    I would love to see a healthy competition between Android and Apple for the EMR tablet landscape, but right now as you point out, apple has the apps and the developers for the future apps. Android apps on par with the Apple ones are 6 months to a year behind. Give me an Android Tablet with the apps and I will be happy to use it.


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