June 19, 2010

The Perfect Computer for Healthcare and Electronic Medical Records

So I've been using computers in the healthcare setting for over a decade now. First at Yale than Duke. I've been thru the Veteran's Affairs Medical Center using Vista (New Haven, CT; Durham, NC; Asheville, NC; and Portland, OR). I've been at 5 different community hospitals on both the West and East Coasts. I've used all the different flavors of electronic medical records (EMR) in all these different locations/settings. I'm now using (not by choice) NextGen, Meditech, Rcopia, and PACS currently in the office, hospital operating suites, and inpatient settings.

Throughout this time period, I've used desktop computers, handhelds, laptops, netbooks, and tablet computers. I've even tried to cobble together a semi-functional iPad able to access all the different EMRs I need on a daily basis (read blog about this here).

What I discovered is that the perfect system (in my mind) is ALMOST there... just not quite yet. Maybe in the next few years, it will exist because all the pieces now exist! The bad news is that it does not exist RIGHT now.

So, here's my dream machine and the reasons. I hope some computer company is paying attention!

To understand how this all fits together, one needs to envision how my office works right now. There's a desktop computer in each exam room. Patients are taken back by a nurse and information inputted into the desktop computer. Than the computer is locked and the nurse leaves. The physician than soon follows, unlocks the computer, and then proceeds with further history, exam, and plans treatment which all gets documented in the computer. If tests are ordered (ie, hearing test, blood draw), the doctor leaves and sees another patient while the tests gets done before coming back. As such, the computer stays in the room with the patient. One can envision that there is a lot of back and forth into and out of an exam room movement of nurse, doctor, and patient. The computer gets locked every single time. Furthermore, I need EMR access when seeing patients in the hospital as well as during surgery.

First the Hardware:
• A tablet touchscreen (with no physical keyboard) 12 inches diagonal. That size hits the sweet spot. Any larger and the size itself becomes unwieldy to constantly move around as well as heavy by the end of a day. Any smaller and the screen real estate becomes so small to become inefficient. 12 inches diagonal also allows the possibility of an actual full-size virtual keyboard on the screen with adequate screen left-over to see what's going on.

My experiences with the iPad virtual keyboard was mixed (given it is somewhat smaller than full-size). I CAN do it and I did do it... I just didn't like it to the point I relied on a wireless bluetooth keyboard.

• Bluetooth technology and WiFi are a MUST because...

• With this tablet computer, one can dock it without wires or connector pins (similar in concept to Motion Computing JR3400 with its FlexDock). The docking station allows for use of regular USB keyboards and mouse along with direct ethernet wired connectivity. My dream machine docking station and tablet would communicate with each other using bluetooth or some other alternative short-range wireless technology which makes direct physical connection unnecessary. This is important, because I would have the docking station in each exam room. When I leave the exam room, I would have the option of taking the tablet (and therefore the screen) with me. The constant connecting and disconnecting of current docks is quite the pain given it requires an actual physical connecting port as well as precise placement. With the constant connecting and disconnecting, it opens the possibility for breaking as well.

What would be even cooler would be if the tablet charges when in its docking station using inductive charging similar to how a Philips Sonicare Toothbrush recharges.

Why do I even want a docking station? Several-fold. Ergonomics... I like the screen at my eye level. Also, I can still see the patient while typing away. If I depended on the virtual keyboard like on the iPad, I'm looking down which is not patient-friendly as well as a pain in the neck (from looking down). Also, though I guess I can learn to type fast on a virtual keyboard, I think I would still prefer the physical full-sized keyboard if given a choice. Furthermore, though wireless WiFi for all internet connectivity is nice in principal, it does introduce potential security problems as well as speed issues (wired ethernet in my experience is still the most reliable and fastest way of communication along with being secure).

However, WiFi connectivity is still important as pretty much every medical setting has WiFi and so one does have continuous high speed wireless access. Also, it would allow me to read a little bit of what's going on with a patient before walking into an exam room (I would load up the patient's chart using the touchscreen before walking into the exam room and docking the tablet). I just do not want to always DEPEND on WiFi.

A WiFi tablet touchscreen like the iPad is also great as one can BRING your office with you where-ever you go like the hospital and operating room without bringing a keyboard, mouse, etc. It's all self-contained. It's intuitive. It's all neatly packed into a simple, elegant tablet touchscreen that's highly portable and usable.

• Proximity security whereby the computer tablet "knows" you are right there. When you are no longer around the computer, it automatically locks. When you come back, it recognizes you and it automatically unlocks, all occurring invisibly to me without requiring me to actually do anything. I HATE the fact that I have 4 different userids with 4 different passwords to access the various EMR programs. Though I try to, I do not always remember to lock the computer 100% of the time. It should be all automatic. Does the technology exist? It sure does... It's called Single Sign-On for one userid and password that unlocks it all. And Xyloc by Ensure Technologies to allow for proximity recognition using RF technology. All I ask is that this technology be built-in to the hardware!

In a clinic where I'm constantly moving around where the tablet may not always be with me, due to HIPAA and HITECH, the computer needs to be secured. Though I try, I can not always remember 100% of the time to lock the computer. And same goes for my medical assistants. The security should be automatic, invisible, and secure.

The problem with biometric verification like fingerprint scanning or even ID card swipes is that I have to REMEMBER to do it. And the mere fact of doing it is aggravating because I would have to do it SO many times in a given day.

• Sturdy construction. The tablet is going to move around... a lot... It needs to stay working after being dropped from at least a height of 3 feet.

Which Brings Me to the Software:
What can I say? I LOVE the intuitive and simple interface of the iPad. Now, there's a few things I would tweak about it to make it MORE relevant in the healthcare setting.

• Multi-Tasking is a must. As I literally use Meditech (hospital EMR), NextGen (clinic EMR), Rcopia (electronic prescribing software), and PACS (radiology viewing software) all day long swapping back and forth even with a single patient encounter, I need to be able to easily jump between all these programs without shutting down the others. From what I understand, this functionality on the iPad will soon be reality with the release of the iOS4 operating system later June 2010.

• I constantly move back and forth among Meditech, NextGen, Rcopia, and PACS all day long. As such, having a few physical programmable buttons on one side of the screen on the edge would be wonderful which I could just press and it would take me immediately to my program of choice. Keyboard shortcut works, but imagine what touch-strokes would be required when I'm using it in pure tablet touchscreen mode...

• Apps already exist to connect via Citrix, Remote Desktop Connection, or screen mirroring... so I would just use those programs. If I was prone to unrealistic wishful thinking, I would ask for a single EMR program that incorporates Meditech, Nextgen, Rcopia, and PACS, but I do not forsee anything like that happening for decades (if ever). So, I'm going to stick with what is possible.

• A "tablet pen" is 100% optional and not necessary for use... Tablet touchscreen would be used predominantly using a finger(s) just like on the iPad. Personally, I do not foresee myself ever using a tablet pen. It's just one more thing that can get lost.

That's pretty much it! Is that so much to ask for???

Related iPad and MediTech Blog Articles:
6/12/10 iPad Use In the Medical Clinic and/or Hospital For the Surgeon Doctor
9/8/10 Dr. Chang Featured in Magazine Article on Using iPad with MediTech EMR
9/20/10 UPDATE: iPad and MediTech Electronic Medical / Health Records
10/12/10 UPDATE #2: iPad and MediTech Electronic Medical / Health Records
10/25/10 New Video Produced on Using MediTech on the iPad!
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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