The electronic health record meets the iPad

Early in 2009 Dale Potter, chief information officer at the Ottawa Hospital, asked physicians how much of the information they needed in their work was available in the hospital’s electronic health record. On average they said about 30 per cent of it was. When he asked again at the beginning of this year, all but two respondents said everything they needed was there.

“I was quite proud of that statistic,” says Potter, who became the hospital’s CIO in fall 2008 after stints as a private-sector IT boss at Alcan Engineered Products and Bombardier Transportation. The improvement resulted largely from Potter’s efforts to address what he sees as a serious lag in the health-care sector’s adoption of information technology.

But when Potter tagged along on clinical training unit rounds, his pride in getting all that medical information online was somewhat dented.

“There’s four or five residents and there’s a staff doc and they’ll go off and visit patients,” he says. “I was there at the very beginning, and what they did is the staff doc sat down at the nursing workstation on the ward, logged on and brought up the patient roster for the day – there were 11 patients that they needed to see – and hit print, and the paper came off. And then he went into each patient record and looked at new lab results, new consult notes, new imaging studies or whatever pieces of information that the doc wanted to be able to take to the bedside, and the residents busily put these in manila folders and they built a stack of folders about six inches high, which the staff doc grabbed and off they went.

“So to me, that just woke me up to the fact that we’ve not failed but we’re not finished yet, because we don’t have … a way for a doc to use this information at the bedside.”

Fortunately, the answer seemed close at hand. Everyone was talking about Apple Inc.’s new iPhone. Then, just as Potter started exploring using the iPhone to display health records, Apple followed up with the iPad. So Potter started talking to physicians, asking them whether they would use these portable devices to view information at patients’ bedsides.

From that came a project that has put the Ottawa Hospital at the forefront of using mobile technology to put medical records at physicians’ fingertips.

By November, Potter expects to deploy several hundred iPads to doctors and nurses. By the end of the year he expects 1,000 or more iPads to be in use for mobile access to health records, and the number will go up from there.

Doctors, nurses and administrators will mainly use iPads for mobile access to health information within the hospital. The tablet has a larger screen than a mobile phone, making it more suitable for viewing medical images such as x-rays and magnetoresonance imaging (MRI) scans. But they won’t carry iPads all the time, especially outside the hospital, so there are plans to support iPhones starting late this year. Potter even has plans to support the iPod Touch for some purposes.

This could allow an on-call physician to look at patient information without even leaving a child’s soccer game, says Dr. Glen Geiger, a staff doctor and chief clinical information officer. True, the iPhone’s small screen can’t display as detailed an image as a larger device, and physicians may not use them frequently for images, Geiger says, but they can certainly read reports on the phones and may sometimes find it helpful to look at images.

The rollout started in early summer as the hospital began distributing iPads to physicians and senior administrators. The first devices were simply equipped for access to the hospital’s electronic medical records through a web browser. Rather than printing information to take with them, doctors can now call it up on their iPads as they need it, right at the patient’s bedside. In some cases, Geiger says, a doctor can order tests during rounds and the results are available online by the time rounds are finished. “By the end of rounds it might be 10:00 – well, some of the blood work is back by then, so you just pull it out while we’re talking.”

 “The fact that I can walk around with all of my patient charts in my hand, see them where I am, makes a huge difference,” says Dr. Alan Forster, a staff physician and the hospital’s scientific director of clinical quality and performance management.

Previously, says Forster, visiting patients involved countless trips up and down the hall to look up information at a nursing station. Having information instantly available allows doctors to focus on the patients, Forster says, and allows more time for communication.

But this is only a first step, because the initial interface isn’t easy enough to use. The first iteration uses Citrix Systems Inc. software to deliver electronic health records to the mobile devices. But it can’t adapt the user interface to a different sort of device. “Because (the existing clinical application) has been designed for mouse navigation,” Geiger explains, “it doesn’t work as well for touch navigation. You end up stretching the screen in order to be able to get to the thing you’re trying to click on.”

Mainly for that reason, only about 50 physicians and senior administrators got the first version. “We figured there’d be trouble” with the limited interface, says Geiger. The early deployment mainly helped to show how useful it could be to have mobile access to records.

The Ottawa Hospital’s electronic health records system is Oacis, from Telus Health Solutions. Potter says he talked to Telus about adapting Oacis to mobile devices, but the vendor couldn’t do what he wanted in the time he had in mind, so the hospital had to go it alone, with support from Telus.

So Potter put a team of developers to work on custom applications for both the iPad and the iPhone to provide easier, more convenient access to medical data from the mobile devices. In October the hospital is rolling out a beta version of this software to teams in its clinical teaching unit, whose feedback will help shape the final product.

Instead of just reproducing Oacis screens, the development team has created an iPad application that looks like other iPad apps. Like the iPad’s native mail client, it uses a navigation bar that occupies the left side of the screen when in landscape mode and becomes a pop-up when the device is turned so the long dimension of the screen is vertical. Each record contains buttons – easily selected with the touch of a finger – for critical information about isolation, allergies and blood transfusions.

The software is built in three tiers, explains Carl Maissonneuve, chief systems architect at the hospital. The existing Oacis health records system is the underlying database. Maissonneuve’s team wrote a middle tier that talks to the database and translates data into the REST application program interface, a widely used approach to web applications that the client application for iPads and iPhones (written in the Objective C programming language) understands.

Adapting the interface to the mobile device isn’t the only challenge.

When health records are involved, security is always a concern. Mobile devices are easy to lose, but there’s no potential here for a nightmare along the lines of a laptop full of personal data going missing, because the records remain on the central servers where they always were. To get at them from a mobile device requires two levels of authentication. The devices time out if not used for a preset period of time.

There are also regulatory hurdles. Any device that displays certain kinds of medical images requires Health Canada approval for clinical use. Because of that the Ottawa Hospital can’t yet display some radiology images through its native iPad interface.

But the benefits go well beyond saving paper and time. Forster says nurses often page him with questions about a patient’s medication. If he is in another part of the hospital, or not even in the hospital, he can now check the patient’s record immediately. “It’s going to really help make decisions on the fly,” he says.

To start with doctors will only be able to check patients’ records using mobile devices, Potter says, but in future they could also order medication changes, which would be conveyed automatically to nurses and the hospital pharmacy.

If a patient’s x-ray or electrocardiogram shows a problem, it will now be easy for a doctor to show the patient – and possibly family members – the scan right at the bedside. Previously, this would have meant taking the patient to the nearest nursing station where the scan could be displayed.

“This brings information, not just for the benefit of the clinician but for the benefit of the patient, a little closer to the patient,” Geiger says. “The best conversations I have are sitting on the end of the patient’s bed.”

Homer Yang, the hospital’s chief of anaesthesiology, says the iPad allows him to record information immediately when visiting patients on wards. It also is giving anaesthesiologists access well before operations to information they previously only got – in paper form – outside the operating room as surgery was about to begin.

Patients scheduled for surgery go for a preliminary consultation with an anaesthesiologist to check for potential problems such as drug allergies and medical conditions that could cause trouble. But the anaesthesiologist doing the consultation isn’t necessarily the one present during the surgery, Yang explains. In the past, if the anaesthesiologist in the operating room was concerned about something in the consultation report, it could lead to surgery being delayed. With earlier access to these reports, he says, there’s time to check with the anaesthesiologist who did the initial consultation and clear up any questions.

“Certainly mobile health applications can do two things that are so necessary in the health system,” says Richard Alvarez, president and chief executive of Canada Health Infoway, the government-backed organization promoting adoption of electronic health records. “They can expand access and they can reduce costs – and sometimes they can do both at once…. We’re going to see more and more of patient information being available remotely to clinicians.”

A few other such efforts are under way. Mount Sinai Hospital in Toronto has developed software called VitalHub that gives doctors access to certain medical information from their iPhones.

A University of Calgary spinoff, Calgary Scientific Inc., has developed software called ResolutionMD Mobile that can display medical images on any device with a web browser, including the iPad, the iPhone and the iPod Touch. ResolutionMD Mobile has received Health Canada approval for medical use, which means physicians can rely on it in diagnosis and treatment decisions. ResolutionMD Mobile is now undergoing clinical trials at the Mayo Clinic in Phoenix, Foothills Medical Centre in Calgary and other locations.

One scenario where such software can have a big impact is when a patient arrives at a small-town hospital after suffering a stroke, says Ross Mitchell, a University of Calgary professor and Calgary Scientific’s founder and chief scientist. Administered quickly, drugs that break blood clots mean recovery within days for one in eight stroke patients. But the drugs work best within three hours of the stroke, and when there is no specialist at the local hospital to decide whether to administer them, patients usually get transferred to a larger hospital, which wastes precious time. If a specialist can make the decision remotely, it can make a big difference to the outcome.

The health-care system has rarely been in the forefront of adopting new information technology, as Potter found when he came to the Ottawa Hospital from the private sector. That may be changing, and a number of hospitals see at least some role for mobile devices. Potter intends the Ottawa Hospital to be in the forefront. “We’re jumping in with both feet,” he says.





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