Attending Rounds with the iPad – Hype or Hindrance?

12 08 2010

I recently completed a two week tour of duty on the wards in July with new residents, interns, and students.  Attending (serving as the supervising doctor for the team of residents, interns and students) in July can be challenging, but also one of the most rewarding clinical experiences as a faculty member.  The interns and residents are eager to learn and your teaching may have a more lasting impact as the residents and students are just forming the habits that will become the foundation of their clinical practice.  Over the last six years, I actually request to be on service in July for this reason.  Despite all the recent concern about the ‘July effect’, attendings are often hovering closer and more involved in patient care than in other months.  This July, I also took that opportunity to test the iPad on the wards to experience firsthand how it stacked up. 

Well, it certainly lived up to the hype!  Here are some of the powerful examples of what I was able to do with the iPad while I was on service.

  • Point of Care Teaching –On rounds, I was able to use MedCalc to show my team and calculate Ranson’s criteria for a pancreatitis patient, the San Francisco syncope score on a patient in the ER, and to correct the sodium (pseudohyponatremia) for a patient presenting with DKA.  I also used UpToDate (institutional subscription) to review the ARA criteria for lupus and rheumatoid arthritis for patients with these conditions.  (of course I did not do this on post-call days when the clock was ticking). 
  • Preparing for Teaching Rounds – At home in the evening, I could look up an article that was relevant to a specific patient and bookmark it on the iPad.  Then, the next day, instead of wasting paper and time on the time-honored tradition of photocopying articles before rounds, I could pull up the bookmark for community-acquired pneumonia and show the team the relevant graphic or passage in a paper.  Then, with one quick stroke, I could email the team so they had the link to review later that day.    
  • Immediate Access to a Computer – One morning, I found all the workstations occupied and I needed to text page my team.  From the hall, I simply opened my iPad and used the ‘shortlink’ to the paging system to let my residents know where I was.  Likewise, at a multidisciplinary case management rounds, I made use of the time waiting my turn by completing my billing through using the STAT-ICD9 coder app.  I also looked up narcotic dosing in Epocrates for a patient’s prescription (in Illinois only physicians with permanent licenses can write narcotic prescriptions in case you’re wondering).
  • Access to the medical record  – Our hospital uses Epic, so using the Citrix iPad client, I could access the medical record from anywhere on the hospital wireless.  However, the Epic interface is often clumsy if you don’t have tiny fingers making me wonder what my male counterparts would do!  We’re currently working on getting a stylus to try to improve use of Epic.  
  • Stay in touch with my team throughout the day –In the middle of a late afternoon workshop that I teach in, I was listening to a presentation when I got a text page. I just opened the link to our paging system to answer the question which averted the need to go hunt for an open phone.
  • Balancing clinical work with your academic work – Unfortunately, email for an academic physician does not stop when you’re on service… it just accumulates, resulting in stress and delay.  With the iPad, I stayed on top of my inbox while walking to and from the wards or during idle time on the wards waiting for my team or for patients to return from tests.  My research project manager also noted that I was not as behind on her emails.  In today’s email game, anything to improve your email is worth it!
  • Leisure and relaxation – For any healthcare worker, relaxation to unwind and be well rested for the next day is key.  When I got home from work, my iPad turned into the quintessential leisure tool.  I could use Flipboard to catch up on my Facebook friends or Twitterfeed that I missed through the day.  I could catch up on news ranging from the latest in the Gulf oil spill to Lindsay’s jail sentence so that I did not feel like was in ‘the fog of wards’.  I also used UrbanSpoon to find a restaurant for our off-service dinner and then Maps to figure out how to get there.

However, before we embrace the iPad as the panacea to all of our technology woes in healthcare, there are some hindrances that we need to think about.   

  • Security – Unlike my trusty clipboard, you cannot leave your iPad on the workstation or counter as you go into the room.  Then, when you go into the room, it’s a challenge finding a location for it while you examine patients.  For this reason, I did not carry the iPad with me every day and only used it on days that I knew I wasn’t going to be overwhelmed with new admissions.  Contrary to this post, the iPad does not fit in our white coats.  After some thought (including buying new coats), the most ideal solution was to use a shoulder strap.  My personal favorite is a fashionable tan leather stitching that was on overstock.com.  Now, I can take my iPad with me every day. 
  • Infection risk – As one tweeter put it, will your iPad (or iPhone) become the iGerm?  It is important to use a disinfectant to keep the iPad clean.  After a few days on the wards, my iPad was covered with fingerprints carrying who knows what… so I wiped it down with some disinfectant cleaner and it looked new and shiny again.  The shoulder strap also works here since I would wear the iPad and put on my contact isolation gown on over the iPad keeping it protected.
  • Multiple windows – Currently, the iPad does not have the ability to have multiple windows open.  This is the most disabling feature of the iPad.  If you are in medical record, you have to log back in if you decide to access UpToDate.  While you could access all of the hospital intranet on the Citrix client, it is slower than the iPad’s native apps and not as nice. 
  • Wireless access – Fortunately, our hospital has a very good network.  Unfortunately, it does not work in all areas of the hospital (my office, spotty in stairwells) and sometimes I have to switch to the University wireless which requires a log in each time I access it which can be somewhat challenging.   

While this is my n of 1 experience, we are currently piloting the iPad with 5 residents to ascertain its value as a point of care clinical and educational tool.  We provided the residents with fully loaded iPads with a variety of apps for our residents to test.  Apparently, we are not the only ones with this idea.  Last week, Stanford University School of Medicine announced that every entering student would receive an iPad.  Time for iMedSchool & iResidency?                                                                            

-Vineet Arora MD

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18 responses

12 08 2010
Tweets that mention Attending Rounds with the iPad – Hype or Hindrance? « FutureDocs -- Topsy.com

[...] This post was mentioned on Twitter by Vinny Arora and Rajiv Kumar, Henry Duong. Henry Duong said: RT @FutureDocs: New Blog Post: Attending Rounds with the iPad – Hype or Hindrance?: http://wp.me/pxRkH-7S [...]

12 08 2010
Blausen Group

Dr. Arora,

Congratulations on an excellent post and thank you for sharing useful tips from a talented educator of our future medical professionals. We’ll be anxious to hear more about your experiences with the iPad in Point of Care Education.

Blausen Group

12 08 2010
Today’s NewsStand (August 12, 2010) : Iowa Hospital Association Blog

[...] Attending rounds with iPad: Help or hindrance? There are some powerful examples of pluses for iPads coming along on rounds.  But before we embrace the iPad as the panacea to all of our technology woes in health care, there are some problems that we need to think about.  (FutureDocs) [...]

12 08 2010
Med School Odyssey

Interesting perspective on the iPad, particularly about the fact of it being in the way when you’re doing an exam. Having to log in to websites repeatedly is a pain on the iPhone which Apple really needs to look at. Two questions:

1) Does the lack of Flash have any impact on its utility?

2) Do patients feel awkward when they see it or do they seem to just take it in stride?

13 08 2010
futuredocs

Great questions. Here are some answers based on my thoughts…
1) Certain videos don’t play but several do esp if they are part of ‘apps’ like NEJM etc.
2) I think that if its in the case most patients don’t think about it. when I carried the regular case, it just looked like part of my clipboard. With the strap, its usually behind me and it just looks like I’m wearing a purse in the front. Wearing the strap is something you def have to get used to (and get over since others may make fun of you!).

13 08 2010
DrV

My question is how well does this fit with workflow. Like so many tools we like to believe that it fits when in fact we’re adjusting it to make it fit. I too was on the busy inpatient service at Texas Children’s Hospital in July and I think that I can envision perhaps half of you listed uses fitting in such a way that it would enrich our rounding experience.

I remember rounding with The Newton back in the day. We desperately wanted to make it fit.

At the end of the day I imagine that the iPad will fill some key niches in rounding. And I expect that these will grow as apps are developed.

Thanks for sharing your experience.

17 08 2010
Christopher

Hello, I read your article and was wondering if you were interested in helping me test a medical app for the iPad. Just your private feedback would be great in helping us create a better product.

Thanks.

19 08 2010
kgv

I would ask Apple what cleaning solution is appropriate and compare that to what your hospital uses for device cleaning protocols to find something that is safe for the device and effective enough for the hospital environment.

There are wipes sold to hospitals specifically for wiping down point of care medical devices such as Accu-CHEK blood glucose meters. But, not all wipes have the right bleach content to match hospital protocols for cleaning devices between beds which is just as important as washing your hands to control MRSAs and HAIs, and some devices can’t handle the cleaning solutions in wipes (some wipes can effect connectivity ports to the point that sparks fly when the device is connected again–there have been medical device recalls because of this).

19 08 2010
Kareena: Kareena unavailable for Milenge Milenge »

[...] Attending Rounds with the iPad – Hype or Hindrance? « FutureDocs [...]

20 08 2010
Elaine Schattner, M.D.

This post points, clearly, to some real perks and pitfalls in the iPad’s use on the wards.

A small note on the side – I can’t resist mentioning that the late Dr. John Ranson (as in the Ranson’s criteria for pancreatitis, which you mention) was my surgery attending when I was a med student. He stood out among my clinical teachers, and it’s kind-of cool to see him pop up in a future doc’s blog!

27 08 2010
Nayana Somaratna

I do believe that touch based mobile computing (Iphones and Ipads inclusive) will totally change how we practice medicine, both inside the ward and outside.

Aside from the points you mentioned above, I guess that residents would also find it an excellent learning tool – given the amount of textbooks, guides and videos available.

We all have these little intervals where we are ‘free’ (i.e. just after the clinic, or soon after lunch). While I would never consider reading through a textbook during this time, I might have more incentive to do a little reading on my Ipad.

27 08 2010
S. Ali

This is great read. We need more articles which covers this specific subject.

19 09 2010
New keyboard cases for the iPad could really add to usability on the wards | iMedicalApps

[...] and questions about security. Be sure also to check out Future Docs blog and Dr. Arora’s experience using the iPad on the wards to get more real-world perspectives on using the iPad on the [...]

19 02 2011
The Film Clerk, the Radiologist & Technology: Friend or Foe? « FutureDocs

[...] it has also become our worst enemy.   Today, I can look at images on the computer, even on the iPads that our residents carry on rounds, and eagerly await the ‘final read’ by the attending.  Ordering tests has also become [...]

17 03 2011
50 Best Blogs for Med Students | Master's Degree

[...] Future Docs: Read about issues related to medical education on this great news blog geared towards medical students. Recommended Post: "Attending Rounds with the iPad: Hype or Hindrance?" [...]

20 12 2012
Making the Most of the iPad Mini on Medicine Rounds « FutureDocs

[...] weeks ago, I was lucky to get an iPad Mini from my husband.  I already have an iPad and you have shared my experience.  In fact, we have all of our residents iPads (one of them contacted Steve Jobs and got a [...]

30 01 2013
Using the iPad Mini in the hospital: One doctor’s experience | Ossis: Notícias

[...] several weeks ago, I was lucky to get an iPad Mini from my husband. I already have an iPad and have shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), [...]

21 02 2014
Making the Most of the iPad Mini on Medicine Rounds - The Almost Doctor's Channel

[…] a few years ago, I was lucky to get an iPad Mini from my husband. I already had an iPad and had shared my experience. In fact, we gave all of our residents iPads (one of them contacted Steve Jobs and got a response), […]

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