Considering the tradeoffs
As with any new technology, there are some tradeoffs that accompany the tablet and mobile device upheaval. For the vast majority of clinicians, saying hello to tablets means saying good-bye to keyboards, which opens up a host of issues, not the least of which is the tendency of longtime clinicians to narrate their way through their notes, rather than enter them in a more structured format.
"It's really hard for people to get used to the typing on an iPad, the feel of it, so that there's still stronger preference for a keyboard when you're doing order entry or doing any kind of heavy input that would require a lot of typing," Moroses says. "We're hoping in 2013 to focus a couple of different pilots around EMR use when the EMRs are customized for that device, to have less typing and more point and click."
The keyboard gets its share of vilification as a source of germs in hospitals. "A smooth screen is inherently easier to remove bacteria from than the difficult topography—the nooks and crannies—of a keyboard," Perlin says. "So they're cleaner, with the proviso that one appropriately cleans the device."
Holston notes that when clinicians are touching a keyboard, they're usually "in a pretty clean state. Of course, we try to use a lot of barcoding to put in a lot of information along the way so they're not spending a lot of time typing on it; and then for most physicians in our world, I don't see them doing their notes in the room. They tend to go out to kind of a nursing station or a pod to finish those things up."
Elsewhere, such traditional charting habits haven't stopped clinicians from dumping their keyboards as fast as possible as the tablet revolution gathers steam.
"The patient-physician interaction is much less disrupted by the tablet," Velasco says. "It's much more like the clipboards that some physicians used to have to take notes or to refer to information when they saw patients, either in an exam room or at the bedside, and so it does really lend itself to a much more appealing interaction, and the iPad Mini may prove to be a more attractive form factor because of its smaller size."
Some patients actually like having a doctor typing away during a consult, thinking that when the clinician types something in, the information has been entered properly, Holston says.
Organizations such as Intermountain still haven't completely bought in to the BYOD trend. Only the iPad and iPhone are approved as BYOD, and they must remain off the internal Intermountain network and use the guest network instead, Holston says. Intermountain also gets each employee's agreement to allow remote wiping of the device, including all personal information, should it be stolen or lost, he adds.
While the keyboard debate continues, the growth of tablet-friendly EMR systems, plus alternate forms of input such as speech, will further whittle away the virtues of keyboards, clinicians say.
"The challenge will be for app developers to optimize the entry of information that minimizes the keyboard paradigm, maximize the use of template-driven documentation, and therefore keep free text to a minimum, and perhaps support the need for free-text narrative using dictation and voice recognition," Velasco says.
"The more we move to coded data," Holston says, "where you're selecting very distinct values of things that have well-understood codes that all come together to tell a story the computer can act on, I think, is a powerful platform for touch." But if the industry continues to have a box for extensive open text "and you type whatever you want, even if you try to format it the same every way or we put some form in there that you fill in the blanks but it still ultimately kind of poops itself out as a big text blob, I think it's tough on touch."