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Experts debate merits of virtualized vs native iPad EHR implementation

While native apps and virtualization both have their tradeoffs for iPad EHR implementation, health IT leaders agree: The tablet is here to stay in hospitals.

CAMBRIDGE, Mass. -- Among physicians and nurses, iPad adoption is expanding at a much faster rate than in the general consumer population -- and they want their electronic health records system to run on it, said speakers on a panel at the World Congress 3rd Annual Leadership Summit on mHealth. That leaves CIOs with a dilemma when it comes to hospital iPad EHR implementation: Run a native app or a desktop virtualized to the iPad?

Both have their tradeoffs. Virtualized environments offer unparalleled security -- and by extension, HIPAA compliance -- at the expense of speed and features tailored to the iPad and iOS operating system's touch screen.

Native iPad EHR systems, on the other hand, dovetail better with the iPad's design, with scrolling, page-turning and other features iPad diehards swear boost their productivity. However, these apps can also pose risks when an iPad is lost or stolen and therefore require more security safeguards. Native apps also may require in-house development or customization resources that many hospitals cannot afford.

Overall, if you can get employee buy-in for an iPad EHR implementation, said Dale Potter, senior vice president and CIO at Ottawa Hospital, it is quite economical. "These devices are six hundred bucks," Potter said. "Some medical equipment these physicians carry around -- [such as] a stethoscope -- can cost you much more than that."

Virtualization in Indiana EHR implementation

Before the "virtualization or native" decision can be made, Deaconess Health System CIO Todd Richardson said, a hospital has to decide if it will purchase iPads or let employees bring in their personal devices to use on the network. He took the latter approach for the six hospitals in his system, which serves western Kentucky, southern Indiana and southeastern Illinois.

His organization adopted the view that tablets, like cell phones, are a personal investment -- everyone who truly wants one already has one. Not only does that kind of thinking eliminate the capital outlay and need to track iPads throughout the enterprise. It also saves IT staff from policing devices for personal data and apps such as contacts and music. Furthermore, the policy prevents the "arms race" between physicians lobbying IT staff for upgrades when faster, larger-capacity iPads come to market -- users either upgrade themselves or they don't.

"As a CIO, it makes me sleep easier at night knowing it's a pain...I don't have to deal with, quite frankly," Richardson said. "And they're going to take better care of it."

That said, there's no one right way and one wrong way to do an iPad EHR implementation, said Richardson, who chose to use Citrix Systems Inc. to virtualize the hospital's existing Epic Systems Inc. EHR system. "Different health care systems have different cultures, and different ways of doing things. What works in one spot clearly does not work from Santa Fe to Evansville to Waterloo, Iowa."

With the virtualized EHR implementation, no patient data is stored on the iPads. This greatly simplifies HIPAA compliance. Richardson said the difficult challenge in getting the system to work was creating wireless connectivity throughout their facilities, which include lead-lined buildings that required creative positioning of access points so physicians would not drop off the network. It became especially thorny in difficult spaces such as stairwells. After that came the issues of securing the wireless network and giving physicians priority bandwidth.

While the transition has not been seamless, Richardson said physician affinity to the iPad is so great that they will take on the learning curve.

When you've got a neurosurgeon screaming at you that [he] can't connect through [his] iPad, you've won the war.

Todd Richardson, CIO, Deaconess Health System

"We had the experience of a neurosurgeon calling and screaming because he couldn't connect from Owensboro [Ky.] on his iPad to check orders and things," he said, sheepishly. "When you've got a neurosurgeon screaming at you that [he] can't connect through [his] iPad, you've won the war -- and now the battle is figuring out why it's not connected."

Canadians roll their own iPad EHR

Potter, CIO of the largest academic medical center in Canada, decided that the iPad's touch screen operating system offered such great efficiencies -- and at great savings compared to traditional computers -- that he bought into it, literally. So far, he's purchased thousands of the devices for his clinicians and hired 124 software developers to write apps porting his Oasis Healthware EHR system to the iPad.

That decision came after he witnessed several vendor demos of what looked to him like poor implementations of computerized physician order entry (CPOE). He told his board of directors he would not oversee a rollout until he saw what he considered a successful implementation.

That meeting happened to coincide with the iPad's initial release. He embarked on the current project after testing four iPads when clinical and IT leaders convinced him it would work -- and after he sunk resources into making it work better than the initial two-week tests that were run virtualized to the iPad.

"The physicians came back and said 'This is game-changing, absolutely game-changing,'" said Potter, adding that it was nonetheless "painful" to watch physicians struggle with the virtualized interface, even as they delighted in demonstrating how they were using the iPad to view medical images, charts and labs.

Ottawa Hospital -- spanning four hospitals and 1,300 beds -- has deep pockets for such a project, which went live on the first 1,000 iPads last January and will be tripling in size in the coming months. However, the productivity gains and inexpensive iPad hardware made it straightforward for Potter to convince the finance department that it was worth the capital outlay for in-house development and hardware purchase. That, and the fact that his development team can work faster and deploy apps tightly tailored to his hospitals' workflow.

So far, with the help of an ergonomics consultant who interviewed and followed physicians around to get an understanding of hospital workflows, the software development staff has finished a dozen custom iPad apps that page and scroll in ways iPad users are accustomed to.

An iPad EHR may not come to those who wait

For other hospital CIOs faced with iPad implementations, Potter agreed that tablet ownership is the first key decision to make. He felt it was easier to standardize development and security for a native iPad EHR implementation if the hospital bought them, and the IT staff wouldn't have to worry about developing apps for Android or BlackBerry operating systems. (The facilities do allow employees to bring their personal iPads to work, but, for iPad security purposes, they must agree to use software from MobileIron Inc. that gives IT staff control of an iOS device when needed.)

None of the iPads, by the way, have been lost or stolen yet. Users "cherish" the devices more than they do others, Potter said, adding that he's seen physicians return home at the beginning of a shift to fetch an iPad left behind; the time lost driving back and forth is worth not struggling with another device.

After that, the next key decision is deciding how fast you want to move. This can depend on whether you trust your vendor on two counts -- delivering an app, and delivering an app that will fit your hospital's way of working. Potter said that his EHR vendor probably wasn't going to be iPad-ready for 18 to 24 months after the device came out in early 2010.

That wasn't fast enough for Ottawa Hospital. "My intuition was…you have to go fast. I said to the board chair and the CEO, 'If you guys are serious, we've got to go fast,'" Potter said. One of Ottawa Hospital's goals is being recognized as a top-10 academic hospital in North America for patient safety and quality, and, Potter added, the board of directors saw the custom iPad implementation as a way to get there more quickly.

"Should a hospital be in the business of [mobile app development]? You could argue, probably no. But if we didn't want to stay in the middle of the pack and we wanted to move ahead in this mobility concept, we had no choice" but to develop without the EHR vendor, he said.

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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