Mobile Devices: EMR Integration Is Just Beginning
As the process to convert and integrate EMRs to mobile devices begins, here’s what the mobile-savvy CMIO should expect.

About 72 percent of U.S. physicians are currently using smartphones—up from 2009’s 64 percent—and the percentage should reach 81 percent by 2012, according to Manhattan Research’s 2010 “Taking the Pulse” report. No wonder a no-holds-barred, all-out war among vendors is on in the mobile technology market space. The prize: Clinicians’ workflow—and thus purchasing—loyalty.

In addition to Apple’s iPad, Research in Motion’s Blackberry and Google/Open Alliance’s Android, a stream of competitors is taking aim at healthcare. These include Dell, which in September announced it is integrating its EMR and mobile clinical computing (MCC) products into its 5-inch Android-based Streak tablet for medical applications. Verizon Wireless and Samsung Telecommunications America in November made available the Samsung Galaxy Tablet.

This influx of tablet/smart technology has not gone unnoticed by healthcare professionals. For example, John D. Halamka, MD, MS, health IT guru and CIO of Beth Israel Deaconess Medical Center and CIO at Harvard Medical School in Boston, opined in a blog entry in November that iPhone/Android smartphones, iPod Touch, iPad, Playbook, Galaxy and Streak “will become the platform for healthcare.”

That future may be now. Clinical users have already begun adopting creative solutions/applications of these platforms to suit their facilities’ mobile needs. In the third quarter of 2010, Android—an open-source platform—held almost 44 percent of the market, followed by Apple with 26 percent and RIM with 24 percent, according to technology vendor analysis firm Canalys.


Glen Geiger, medical director of clinical information services at The Ottawa Hospital (TOH), a 1,172-bed teaching hospital serving 1.5 million people in Ottawa and eastern Ontario, Canada, outsourced a developer to integrate TOH’s customized EMR for iPads usage to enhance the organization’s mobile capabilities beyond its computers on wheels (COWs). Out of the 1,183 physicians at TOH, 100 are piloting a native iPad app with plans to deploy 500 iPads to clinicians this month, Geiger says.

“Preliminary feedback is very good,” he adds. “Clinicians are anxious for us to deliver the full linkage to the image viewer but the initial rollout has been a good down payment on future functionality.”

The EMR app took three months to design and build, and contains an ED-patient tracking module as well as the primary clinical viewer that provides access to patients’ clinical data. The mobility of the iPad and its native EMR app will improve patient/physician interactions, Geiger says. Physicians will be able to access up-to-date information such as x-rays or consultation reports at the bedside.

TOH is currently determining the iPad’s optimal place in the workflow within the organization, says Geiger. “We’re trying to figure out basic stuff like if clinicians want lab coats with big pockets to carry them around or not, and how to sterilize the devices.” He expects the iPad technology will be a huge asset for e-prescribing, especially at the bedside.

The iPad’s lack of an internal microphone or camera has garnered some criticism from healthcare professionals that the device is not the best fit for healthcare. Geiger acknowledges that the device is not the end-all, be-all of mobilization/functionality/efficiency.

However, “we’re not done by any means in terms of improving mobility and efficiency,” Geiger says. “We recognize that better technology might come along later and if it does, we’ll consider the options, but for now, we’re hitting the ground running with this initiative.”

“Our strategy is to develop our mobile EMR once instead of moving across multiple platforms,” he says. “For us, this is a better investment than going after every single tablet.”

It’s about the patient …

Without patient engagement, mobile platforms are useless, says Henry J. Feldman, MD, chief information architect, Division of Clinical Informatics at Harvard Medical Faculty Physicians, and a hospitalist with the Division of General Internal Medicine at Beth Israel Deaconess Medical Center (BIDMC) at Harvard Medical School in Boston.

Feldman uses an internally built, web-based EMR platform from his iPad to engage patients at the bedside via devices like electronic anatomy textbooks to show and compare reference images to a patient’s x-ray. As a hospitalist, Feldman appreciates that the technology allows him to become familiar with patients within minutes by accessing records quickly.

Feldman typically writes 85 percent of an admission note on a desktop computer because “iPads aren’t great for writing big documents,” he says. However, the other 15 percent of input is done on iPads because it’s easy to clarify the patient’s story/history and reconcile data on the iPad at the bedside.

The EMR technology is web-based, enabling Feldman or any other clinician at BIDMC to access a patient’s EMR information via any web browser. “Since our web-based system is for everyone [nurses, psychologists], it has thousands of users who can access this,” says Feldman.

“Anyone who has a client has already failed in my eyes,” says Feldman, “because you have to keep up to date 10,000 to 20,000 users; creating significant support burden. From a user standpoint, I’m not locked into [one vendor’s] technology.

“Make [EMR integration applications to mobile devices] web-based and platform agnostic,” advises Feldman. “A web-based app will lower support cost and makes users happier because apps can run on a multitude of platforms.”

But it’s also about the network…

Practitioners must make sure their EMR applications are flexible enough to be pushed out to any mobile devices. “It’s best to assume clinicians will be able to pick whatever mobile device they need moving forward with clinical care, but what they will be able to do on that EMR is dependent upon how that EMR is structured and whether it was created specifically for someone to interact with it in a mobile manner,” says Andrew Barbash, MD, medical director of neurosciences and virtual care services at Holy Cross Hospital, in Silver Spring, Md.

“Mobile devices depend on what best fits a form factor. And since organizations will be able to run the same applications on most devices, the biggest limiting factor will be the network’s bandwidth.”

Using unrestricted devices, clinicians are no longer limited by a hospital IT department: “That is the breakthrough,” says Barbash. However, he notes that some platforms, like Apple, are more restrictive with applications running on their software. “iTunes is too tightly controlled. Nothing against Apple, but that tightly locked-down funnel is problematic in a world where, if anything, we need to free up individuals from constraints,” he says.

“The day of a practicing group saying ‘We only support Product X’ has set sail,” agrees Russell P. Branzell, FCHIME, vice president and CIO at Poudre Valley Health System (PVHS), in Fort Collins, Colo. PVHS, a health system serving northern Colorado, southern Wyoming and western Nebraska, uses VMware to emulate and stream patient data from its Allscripts ambulatory and Meditech inpatient EMR systems to clinicians’ mobile devices via web-based viewers.

Branzell says his organization’s view is that clinical care shouldn’t be application-driven, but rather the mobile world should be “flatter,” so users can access clinical data from mobile devices in the same manner as a traditional, stationary working environment.

VMware creates a virtual desktop for any device the clinician is working from, says Branzell. “The concept of cloud computing is going to revolutionize healthcare and remove a lot of the administrative burden that we have today with big applications, big data centers and big hardware.”

As more applications are deployed on an ever-wider array of devices, CMIOs will have to keep their eyes on the entire mobile application prize, including mobile network developments, integration with EMRs and hospital information systems, and changing device footprints.

But the basics won’t change: “We’ve told our doctors to buy whatever they want,” says Branzell. “I don’t care if they have an iPhone or an HTC EVO 4G, it’s my job to support that device.”