How might the iPad change healthcare?

Mainly conceived as tools to support the consumption rather than the production of information, wireless ‘media tablets’ such as Apple's iPad provide a delivery and visualization medium for stored and online documents, images and video, as well as a portal to a vast array of downloadable ‘Apps’ serving a variety of purposes. They share characteristics with both mobile phones and laptop computers, but typically offer a larger and more intuitive interface than the former whilst being more portable and simpler to operate than the latter.

Although e-health applications are not unique to wireless media tablets, there are unique reasons why they may be well placed to facilitate e-health. On a general level, these are technologies, which have attained almost unprecedented levels of diffusion and adoption since the iPad was launched in early 2010 (around 18 million units by the end of that year alone, Figure 1A). Apps are being developed to suit a range of operating systems, notably Apple's iOS, Google's Android and Blackberry's QNX.^1–4 The controlled ecosystem that prevents non-authorized code to be run on the platform and the greater availability of controlled Apps for the iPad seems to secure Apple's dominant position for at least the next two years, although other providers are gaining market share (Figure 1B). The Apple Store so far contains around nine thousand examples of software in the ‘medicine’ category and fifteen thousands in the ‘wellness’ category.⁵ The ‘appidemiology’ of this market suggests that health maintenance is of interest to more users than illness management, arguably reflecting both the needs of an affluent user demographic and a more widespread desire for eHealth applications that support healthy lifestyles and wellbeing, although, as yet, it remains a luxury accessory, rather than a core technology.^6,7 (Figure 2)

Figure 1A.

Media tablet market forecasts: number of devices sold. (Source: adapted from Gartner: http://www.gartner.com/it/page.jsp?id=1626414)

Figure 1B.

Media tablet market forecasts: market share. (Source: adapted from Gartner: http://www.gartner.com/it/page.jsp?id=1626414)

Figure 2.

iPad App for diagnosis of skin diseases. (Source: http://www.knowabouthealth.com/ipad-version-of-visualdx-mobile-app-released/5538/)

Whereas the potential of iPads for supporting clinicians has been clear from an early stage,^8–10 their use by consumers for health purposes was anticipated to a lesser degree and warrants further exploration. As such technologies become mainstream, we may soon face a situation in which patients and their physicians have the same mobile personal computing device, offering access to the same sets of information and tools for healthcare decision-making and leading to a more horizontal alignment of knowledge between the two. Greater synchronization across personal computing and media devices (e.g. iPad, iPhone, iPod, Apple TV) will increasingly enable users to interact with their eHealth applications in a flexible way and as part of a holistic ‘ecosystem’ for self-management that includes financial transactions, entertainment, gaming, social networking and video telephony. This also offers a cost-effective alternative to bespoke hardware devices for health; for example the iPad includes an option to connect biomonitoring devices via USB. (Figure 3) In addition, the emergence of Cloud Computing presents future opportunities for these devices to act as mobile platforms for personal information management and virtual desktop computing, whilst avoiding the need for mobile storage of software or data.¹¹

Figure 3.

A blood pressure monitoring device now available for the iPad. (Source: http://www.ihealth99.com/)

We now offer a few examples in order to illustrate the various ways in which such technologies may support different actors in healthcare and to give a pointer to possible future scenarios. Table 1 describes a selection of medical Apps that have attracted particular attention in recent months. However it is important to note that there is, as yet, no consensus on methods for classifying the quality of medical Apps and sources claiming to highlight the ‘best’ medical Apps are largely based on popularity (numbers of downloads) and anecdotal user reviews, rather than formal evaluation of usability, utility or applicability.¹²

Table 1.

Selection of medical Apps that have attracted particular attention in recent months.

App Name	Reference	Short description	Price
Personalized e-health
CapzulePHR	http://www.capzule.com/phr/	Personal Health Record, universal for iPad and iPhone, sharable among different devices (including PCs), and allowing users to create their own personal sets of customizable health monitoring templates to record variations in health conditions, progress of health goals, and other observations.	1.99 $
Nike + Fuelband	http://www.nike.com/fuelband/	Wrist-worn tracking device connected with iOS devices that uses oxygen kinetics to track and differentiate physical activities, to be compared with target activities set by the user.	149.00$
Parents Diagnostic Aid	http://itunes.apple.com/sn/app/parents-diagnostic-aid-pda/id401604767?mt=8	Quick and easy layman's medical insight into a few common problems in children. It is primarily designed to allow concerned parents to quickly gauge the seriousness of their child's illness	0.99$
NHS MobileSymptomChecker	http://www.nhsdirect.nhs.uk/About/MobileApps	Direct-to-consumer App providing tailored advice through protocol-driven decision support alone	Free
Pulse Track	http://itunes.apple.com/us/app/pulse-track/id380804732?mt=8	Pulse rate tracker. It can be used to record heart rate along with notes that describe the type of activity performed prior to recording heart rate	0.99$
MyMedSchedule Mobile	http://www.mymedschedule.com/home/about_mms_mobile.asp	For iOS and Android, to schedule medication reminders	Free
Research
Trackyourhappiness	Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind. Science 2010;330:932	iPhone App developed in order to test a hypothesis about the impact of ‘wandering thoughts’ on experienced mood	Free
Education
Visible Body	http://www.visiblebody.com/mobile_overview	App to explore Human anatomy, with available 3D options	23.99$
Essentials of Clinical Anatomy by Inkling	https://www.inkling.com/store/essential-clinical-anatomy-keith-moore-4th/	Interactive App to learn human anatomy on the iPad. Self-tests of knowledge gained available stripping away the labels on anatomical diagrams	64.99$
PodMedics	http://itunes.apple.com/us/podcast/podmedics/id262862893	Website, available as App on mobile tablets containing a vast range of podcasts for medical students and junior doctors	Free
Dermoscopy	http://itunes.apple.com/it/app/dermoscopy-an-illustrated/id453996300?mt=8	A case-based visual guide to learning dermoscopy complete with self-assessment cases (from McGraw Hill)	74.99$
Supporting healthcare delivery
eFilm Mobile	http://itunes.apple.com/us/app/efilm-mobile/id354502755?mt=8	Image viewer (declared as not for diagnostic use), companion app to eFilm Workstation, a diagnostic workstation that connects to any PACS in use.	Free
OsiriX	http://itunes.apple.com/app/id419227089?mt=8	DICOM image viewer for iOS. It supports standard DICOM communications	29.99$
ResolutionMD	http://itunes.apple.com/it/app/resolutionmd-mobile-lite/id398740007?mt=8	Delivers anytime, anywhere full-functionality advanced visualization of medical images to mobile devices, through a client-server architecture that does not require DICOM image data or confidential patient information to be retained on the device	Free
DRChrono EHR platform	http://itunes.apple.com/it/app/drchrono-ehr/id369191782?mt=8	Certified complete Electronic Health Record App	Free
ACS trials Free	http://itunes.apple.com/us/app/acs-trials-free/id480567696?mt=8	App to navigate clinical trials (design, outcomes, …) on Acute Coronary Syndromes	Free
HCV Care & Guidance	http://itunes.apple.com/gb/app/hcv-care-guidance-hepatitis/id461838768?mt=8	Hepatitis Virus C reference for clinicians, nurses, and healthcare professionals	Free
Health Stroke Scale Scorer	Josephson CB, Al-Shahi Salman R. Can an iPhone App help stroke physicians? Lancet 2010;9:765.	Stroke Patient assessment	Free
Mini Mental State Exam	http://download.cnet.com/The-Mini-Mental-State-Exam-MMSE/3000-2129_4-75498205.html	App for the cognitive assessment for dementia	9.99$

Personalized e-health

In the context of eHealth,^13,14 the term ‘personalized healthcare, concerns the use of Information & Communication Technologies (ICT) to assist people in managing their own health and to facilitate patient-centred management by healthcare providers. One example of an enabling technology for personalized healthcare, is the Personal Health Record (PHR); a piece of software, often in the form of an online portal, through which the individual can record their own health indicators and, in some cases, gain access to data held by their healthcare provider organizations (e.g. their electronic patient record, copies of referral documents, lab results etc).^15–17 Media tablets offer an opportunity to facilitate their diffusion and portability. Moreover, through enabling rapid access to applications such as medical dictionaries and drug databases, media tablets may help to enrich the usefulness of simple health management tools and data access (Table 1).¹⁸ PHR adoption has potential to complement the technological alignment referred to above, through providing a common platform for information sharing between clinician and patient, while the iPad2 includes a camera, enabling remote patient consultation.¹⁹ By offering a convenient medium for collecting symptoms and quality of life data, wireless tablets may also help to tailor telehealth support to user needs.²⁰

Engaging research participants

The term ‘crowdsourcing’ has been used to refer to the process of seeking information from a distributed network of technology users, typically via internet surveys or social networking.²¹ Researchers have recently come to recognize the potential of these networks in order to gather data for studies of health-related behaviours and outcomes.²² Apps may also be developed to enable health researchers to share and analyze data, and to support mobile disease surveillance, augmenting existing services that use crowd sourced data to track health trends and predict outbreaks.²³ The portability of such devices, and crucially their integration of Global Positioning Software, mean that live and geographically referenced information may be collected.

Medical education

Online learning is becoming an integral aspect of medical training and continuing professional development. Mobile phones offer opportunities to access educational materials on the move or in contexts where internet-linked computers are not available, such as in remote and rural healthcare, however limited screen size have restricted their ability to handle data-intensive content. Wireless media tablets offer an advantage in terms of their ability to import and display high quality images and multimedia content, possibly adding cognitive advantages, as in the case of 3-D digital images which can be navigated through ‘augmented reality’ tools.²⁴ The integration of videoconferencing has potential to support interactive learning.²⁵

Many Medical Schools in the US and UK have started giving iPads to their students as a means of enabling flexible access to e-learning resources.^26–28 The commercial Apps sector is also embracing opportunities in the medical education market (Table 1).

Supporting healthcare delivery

In the UK, clinical informatics tools, such as electronic health records and decision support, have proved harder to implement in secondary care than in primary care, where they are well embedded. One reason for this slow adoption has been a lack of access to fixed terminals in hospital settings, and the physical challenges presented by mobile ward rounds.²⁹ While handheld computers and cell phones have helped to address this problem, constraints associated with battery life, processing power and interoperability have hindered their adoption.³⁰

The potential of wireless media tablets to move things forward was recognized shortly after the launch of the iPad, with authors at the time drawing attention to its long battery life (lasting a full working day), powerful processor (able to handle data intensive applications), intuitive operating system and large 9.7 inch screen. When enabled by wireless access to relevant information and documents, these features can facilitate the delivery of care at the bedside.^31–33

To date, most experience of iPad use in hospitals has been gained in the US and, although relatively little research has been published, small trials indicate high levels of compliance and satisfaction amongst doctors, and hospitals are increasingly seeking ways to incorporate the technology.^34,35 Mobile access to patient data is a key requirement for clinicians on the move and whilst other technologies to enable this are available, new generation wireless media tablets offer enhanced levels of user-friendliness, with some enabling navigation of patient records via simulated natural gestures, such as leafing through a patient's notes. Their high resolution screens also provide a means of displaying data intensive clinical images.³⁶

Apart from the obvious financial challenges presented by device purchase, one of the major factors constraining the implementation of wireless tablets in settings such as the NHS, is the extent to which they are able to interoperate with core organizational information systems. A number of suppliers are coming forward with technologies designed to support this process³⁷ and secure integration with electronic medical record systems will undoubtedly be possible in the near future. More immediately, it is likely that most activity will come from a subset of enthusiastic and tech-savvy clinicians using their personal devices to access freestanding medical Apps, mindful of the fact that not all of these will be appropriate to every organizational context. A possible approach for the hospital setting is to create a ‘hospital App store’, similar to the private App stores that are being developed by some companies adopting mobile technologies.³⁸ A hospital App store could provide a package of clinical Apps accessible to members of the organization, such as software for viewing patient records, drug reference tools, mini-textbooks with protocols for disease pathologies, and systems to assist in e-prescribing,³⁹ or diagnosis.⁴⁰ This type of controlled environment may help to ensure the contextual appropriateness of the Apps on offer, whilst enhancing user confidence and safety, and ensuring that usage may be monitored. In the future, some doctors may be able to take advantage of iPads purchased for personal use in order to access clinical data, provided these data remain stored on organizational systems, and not the device, and are accessed via secure wireless intranet. (Figure 4) In the nearer term, the development of freestanding Apps for specific uses is likely to prove more cost-effective (Table 1). While creation of medical reports and discharge summaries via the iPad has been reported, it is likely that such devices will mainly be used to ‘pull’ information from other systems.⁴¹

Figure 4.

An EHR interface for the iPad. (Source: https://drchrono.com/products/ehr)

Notes of caution

While we have highlighted several potential benefits of wireless media tablets, the increased use of such devices for maintaining health or managing illness also generates potential risks. Amongst the most immediate of these is the risk to privacy, where the device is being used to store or exchange personal information.⁴² These are associated with technical factors (e.g. lack of encryption), organizational factors (e.g. where the data are processed outside the user's area of regulatory control), human error (e.g. leaving the device unattended), and human intent (e.g. malign unauthorized interception), all of which may generate negative consequences for personal privacy and opportunities for data to be misused. Legislation around the ownership and sharing of personal data using mobile devices remains unclear, hence the onus is on developers to ensure confidentiality and security and on users to exercise caution and respect privacy. In the meantime, however, consumers are relying heavily on trust, which may be mediated, in some cases, by the reciprocal benefits of being able to share information with a healthcare provider. Risks also arise through the potential for consumers to develop false expectations about the benefits of so-called ‘medical’ or ‘health’ Apps, many of which are of uncertain provenance and few of which have been evaluated. While it may be tempting to download a low-cost health risk calculator, a psychological support programme, or health self-management plan, users need to be aware that these may be ineffective or even dangerous. Thus while there is potential for Apps to enhance consumers' health knowledge and empowerment, it will be important to ensure that they are given appropriate guidance on choosing useful applications and to guard against unrealistic expectations of personal medical expertise that could jeopardize their willingness to seek professional help where this is necessary. Importantly, although many Apps are designed to support patients and professionals with healthcare decision-making, few are currently regarded as ‘medical devices’ requiring regulatory approval and, as already noted, there is no universally agreed framework for classifying their quality. Mindful of the potential risks to patient safety, agencies such as the US FDA have recently released guidance on regulating medical device Apps, and similar bodies in Europe and the UK are set to follow suit.⁴³ This is likely to improve the safety of medical Apps in the near future although it remains unclear how it will affect direct-to-consumer health and wellness Apps, many of which may not be regarded as strictly ‘medical’, hence other methods of assessing quality, safety and usability would be of value.⁴⁴

In addition to their potential for improving health, concerns have often been voiced that ICT may contribute to health inequalities via the so-called ‘digital divide’. A recent UK survey⁴⁵ indicates that while iPad ownership is spread across adult age groups, most users are above the age of 45 years,⁴⁶ although, as the technology diffuses more widely and its costs fall, the user demographic may become more inclusive.

DECLARATIONS

Competing interests

None declared

Funding

None

Ethical Approval

Not applicable

Guarantor

Francesco Pinciroli

Contributorship

All the authors wrote the paper, carried out the literature searches, and reviewed the paper

Acknowledgments

None