EHR on the Move: Resident Physician Perceptions of iPads and the Clinical Workflow

Introduction

The electronic health record (EHR) provides access for physicians-in-training to complex clinical data and tools of documentation and order entry. As a result, physicians are tasked with spending significant amounts of time interacting with the EHR as opposed to time spent in direct patient care. With respect to resident physicians, in particular, the clinical workflow involving the EHR can supersede time spent at bedside or in educational pursuits.

The Department of Medicine at Columbia University Medical Center provided tablet computers (Apple iPads) to medicine housestaff to provide mobile access to the necessary tools of the EHR. The integration of tablet computers into the clinical workflow as well as obstacles to the use of these devices will be discussed.

Background

The typical clinical workday for housestaff begins with “pre-rounding” during which interns and residents receive signout from the covering overnight team, and housestaff visit patients on the service. Pre-rounds are followed by work rounds in which the supervising resident and intern review the service together and discuss the plan for each patient for the day prior to attending rounds. Each team ends the day in “hand-off” in which the primary intern will transition care to a covering service intern overnight.

The internal medicine residency program includes bedside teaching rounds with supervising attending physicians (“attending rounds”) as a priority in the development of clinical competence. Attending rounds bring together the entire team for the presentations of new admissions and for review of the care plans for each patient. Didactics, formal or informal, occur during attending rounds. Attending rounds remain the primary educational and patient care activities of the workday for resident physicians. As residents record changes in the care plan as discussed on teaching attending rounds, they regroup at workstations later in the day to implement those plans within the EHR. A duplication of work as well as risk of transcription error can result. Moreover, bedside teaching rounds are interrupted to review imaging, electrocardiograms, or laboratory results on desktop computers in the unit stations.

In the era of reform for the Accreditation Council for Graduate Medical Education duty hours, training programs have an interest in innovating with respect to fluidity of attending rounds to maximize time for teaching. By enabling residents with mobile devices armed with the electronic health record, the department of medicine sought to increase bedside teaching and to enhance clinical workflow.

Tablet computers in the clinical environment have been implemented and studied across a number of disciplines. A study within emergency medicine quantified a decrease in number of logins at a computer workstation in an emergency department in which tablet computers were deployed; a resultant change in time at bedside, however, was not specifically quantified.¹ Competency-based curriculum within neurosurgery demonstrated increased perceived study time and improvement in exam scores with the introduction of a study program enabled by mobile devices.² Patients have responded positively to care providers using tablet computers in an exam setting, and tablets have been used in home care.^3–6

Patterns of resident use of mobile devices in answering questions at point of care have been described.⁷ Those patterns demonstrated residents used mobile devices primarily to access drug formularies or for communication. Recent data suggests mobile tablet computers can increase efficiency for resident physicians in order entry.⁸ However, integration of tablet computers within the clinical workflow for resident physicians has not been described to our knowledge.

Methods

Apple iPads were deployed in the fall of 2011 to internal medicine housestaff at Columbia University. The basic Wifi-enabled model was supplied to each resident physician (iPad 2, 16GB, release date March 2011, retail cost at project launch $499).⁹ Required configuration profiles were installed on all devices. These profiles included a Security Profile that set a mandatory six-character strong password (letters and numbers) at device activation and at screen lockout. Secure wireless network settings at the hospital and virtual private network resources were also installed via a configuration profile. Similarly, secure hospital electronic mail settings as well as a collection of application icons to connect quickly to online program resources were also installed.

An internally developed iOS application known as the “Columbia Medicine App” (Figure 1) was installed at launch on each device. This application provided an iOS optimized handbook (coded by the author, Dr Walsh), which outlined protocols in the hospital, guidelines for documentation, and references for common housestaff tasks such as electrolyte repletion and glycemic control. The Columbia Medicine Application also provided a phone and paging directory including the ability to page clinicians at the hospital directly from the device. An antibiotic dosing calculator including renal dosing protocols and hospital-specific empiric antibiotic preferences is also a component of this application. Finally, a reference of commonly used IV drip medications is included in the Columbia Medicine App.

Figure 1:

Screenshot of Columbia Medicine iOS App

Access to the electronic health record (Allscripts Eclipsys) required the installation of the Citrix Receiver App on each device. This virtualization software permitted users to access the full-featured desktop version of the Eclipsys application on the iPad. A virtual keyboard could be accessed for data entry, and touchscreen input replicated mouse functionality. Because of the virtualization environment needed to serve the EHR, two logins were required (one login to access the server hosting Eclipsys and a second to initiate the application itself).

The Citrix-based user interface of Allscripts Eclipsys on the iPad was visually identical to that on desktop computers with respect to information density (Figure 2, displaying fake patient data). The entire tablet display was devoted to the Eclipsys user interface, and the user’s fingertip acted as virtual mouse cursor with single taps replicating a primary mouse-click (“left-click” in default settings) and sustained taps replicating a secondary mouse-click (“right-click”).

Figure 2:

Screenshot of Allscripts Eclipsys User Interface in Citrix on the iPad

Keyboard input in the EHR was conducted using a virtual keyboard within the Citrix App (Figure 3). To enlarge one area of the interface (display “zoom”), two fingertips could be spread apart on the touchscreen; conversely, two fingertips could also be pinched together to enable reverse zoom. This feature is common to many iOS applications including the native web browser on the iPad and iPhone.

Figure 3:

iPad Citrix Interface Demonstrating Virtual Keyboard

Yearly at Columbia University Medical Center, interns completing their postgraduate year one (PGY1) update the Columbia Evidence-Based Medicine Manual (EBM Manual). This resource is a compilation of seminal literature organized by monthly rotation including ward, intensive care, and outpatient months.

The iPads provided a new interface to browse, search, and download these articles. This application was also deployed on devices at launch.

A subjective survey was administered six months after provision of the Apple iPads on the housestaff service. Residents were invited to participate via email and announcements at educational conferences. Written consent was obtained prior to the completion of the online survey. The Institutional Review Board approved this study. The survey was administered electronically via SurveyMonkey and was accessible on either personal computer, iPad, or other mobile device.¹⁰ Participants were permitted to use any device to complete the survey.

The survey comprised multiple domains of question content types. The first domain determined whether users integrated the iPad into clinical work and collected usage patterns (frequency of use, areas of use [e.g. note-writing, order entry], setting of use [e.g. pre-attending rounds, during attending rounds, at hand-off of care]). Participants were also queried with respect to obstacles to integrating iPads into clinical work including interface issues and practical concerns. Finally, residents were asked to comment on the iPad as related to patient safety including order entry, adverse event reporting, and time at bedside with patients.

Results

Sixty-two residents completed the survey (48% response rate). Fifty-five residents (89% of respondents) reported integrating the iPad into clinical work at any point. Forty-three residents (69% of respondents) reported continuing to use the iPad in clinical work at the time of the survey, six months after initial deployment. Thirty-six residents (58% of respondents) used iPads to answer clinical questions at point-of-care.

Of the sixty-two respondents, 18% used the iPad daily and 39% used the iPad more than once per week in clinical work. Most respondents used the iPad daily for any reason, work-related or not (Figure 4).

Figure 4:

Frequency of iPad Use

Documentation review (95% of respondents) and laboratory data review (86%) were the two most common tasks accomplished using iPads. Order entry and review of imaging studies were common tasks for roughly half of respondents (Figure 5). “Presenting on rounds” in Figure 5 refers to using the iPad in place of paper notes during oral presentations of patients and does not refer to using iPads during rounds in general.

Figure 5:

Clinical Tasks Accomplished Using iPads

Housestaff were most likely to use iPads during attending rounds (90% of respondents to this question) for review of documentation, laboratory data, and imaging, and for order entry. They did not report using the iPad to replace the paper notes that were used as references in presenting new patients. iPads were used infrequently at hand-off (12.5%); general practice remains that paper hand-off summaries are created and printed from the EHR for review with the physician taking responsibility for care of the patient list.

The virtualized electronic health record was the preferred application for use on the iPad (70% of respondents to this question). UpToDate was the second most popular application (48%). The next most popular application, AMiON (24%), provided easy review of clinical rotation and call schedules. The internally developed Columbia Medicine App and Evidence-Based Manual were also preferred (20%). A summary of these results is shown (Figure 7).

Figure 7:

Preferred iPad Applications (percent of respondents shown, multiple selections permitted)

Protective cases for the devices were recommended but not supplied. Similarly, Bluetooth keyboards for text entry were suggested but not required nor supplied. 46% of respondents reported using a keyboard and 69% reported using a case for their devices. The current iteration of the iPad did not fit into the standard white coat pockets supplied to housestaff by the Office of Graduate Medical Education.

Resident physicians were asked about obstacles to using iPads for clinical work. Portability was the most common obstacle cited by respondents (67%) to using the iPad in regular clinical work. Half of those respondents who reported using a carrying case for their iPads also cited portability, so it was not felt that this obstacle was case-specific. The virtualized EHR interface on the iPad was the second most commonly cited obstacle (61%). Difficulty in typing text on the device and concern for misplacing or losing the device at work were the next most commonly cited obstacles to iPad use (54% of respondents for both concerns). Thirty-two percent of the twenty-four respondents who reported using a keyboard also reported difficulty in entering text as an obstacle for iPad use. The subgroup of residents who denied using iPads for clinical work at any point (11% of respondents) cited difficulty typing on the device (100%), lack of portability (86%), and dislike of the EHR Citrix interface on the iPad (71%) as obstacles to use of the tablets. All of the eleven percent did report using the iPads for activities unrelated to clinical work.

Twelve resident physicians reported discontinuation of iPad use for clinical work. There were no notable differences between the coded responses to obstacles to use with this group of residents compared to residents who reported continuing iPad use. Within the open-ended responses of these residents explaining obstacles to use, one resident noted technical difficulties in initiating the EHR on the iPad and “not taking the time” to seek technical support. This resident stopped using the iPad at point of care for this reason. A second resident felt that the dynamic, interruptive nature of patient care coupled with automatic two-minute lockouts made the iPad “too cumbersome” for continued use.

Residents were also asked their perceptions of the iPad as it affected the patient safety environment. Respondents felt that it was easy to stay up-to-date on their patients using an iPad. They also reported using iPads in prescribing medications to check drug dosages, drug interactions, and pharmacology. They did not report perceiving order entry on iPads as more error-prone. Housestaff denied being more likely to report adverse events using an iPad than through other means. Impressions were neutral to negative that residents spent more time with their patients using iPads. They denied feeling distracted by iPads on rounds or in the clinical setting. They denied using iPads during conferences on unrelated tasks like checking email or browsing the internet. Figure 8 summarizes these results visually.

Figure 8:

Resident impressions of the effect of iPads in specific aspects of care

Discussion

Resident physicians at Columbia University Medical Center demonstrated good adoption of iPads in their clinical work. In particular, the residents were most likely to integrate iPads into attending rounds. This critical component of the workday brings together supervising attendings with the housestaff and medical student team. The preponderance of residents reported the electronic health record on the iPad as the preferred application on the devices. This result matches expectations that residents would be most likely to access the EHR on mobile devices if supplied with the resources to do so. Residents also reported that they were most likely to review documentation and clinical data (e.g. laboratory data) to stay informed on patient-specific objective data recorded in the EHR.

The educational model at Columbia emphasizes attending rounds at the bedside whenever possible. This data suggests that residents use iPads during bedside teaching rounds to access the most current patient data in the least disruptive manner. Teams are no longer required to move from patient room to unit station throughout the morning. Housestaff who use the iPads for clinical work do so frequently. Notably there was attrition of usage in the six months since project launch; twenty-two percent of those who tried to use the iPads subsequently stopped using them for clinical work. It is also worth noting that eleven percent of respondents denied attempting to use the iPads in clinical work though they did report using the tablets for non-clinical activities. The obstacles cited by that subset suggested strongly that difficulty in content entry was a factor in the lack of adoption of the device.

Obstacles to use were explored. Coded survey data and multiple free text responses underlined the desire for a simple, single sign-on process. This result is intuitive and emphasizes the need for application development that utilizes the unique interface provided by tablet devices such as the iPad. Intuition also suggests that this result is not unique to iPads and would be common to tablets or other devices with touchscreen interfaces. The Citrix interface to access the EHR provides all of the features of the EHR but requires multiple sign-ons. Of note, some resident physicians cited a brief inactivity window before automatic sign-out as an obstacle to use. Because of the sensitive nature of protected health information, automatic sign-out is a required component of information security policy at this institution and has been espoused as a best practice for mobile devices in healthcare.¹¹ The tension between usability and information security underlined here is an avenue for further investigation.

Portability remained a primary concern even for housestaff with carrying cases. While unit station computers are less accessible than a tablet computer carried in hand, combining a need to carry a tablet throughout the day coupled with an even mildly onerous sign-on process may be enough to deter adoption of mobile technology.

Strengths of this study of tablet computing in clinical workflow include a good response rate for an online survey and a broad range of use cases in assessment. The areas of evaluation were also chosen to be highly clinically relevant to the workflow of an internal medicine resident and were not specific to a particular postgraduate year of training. The devices were deployed to all residents and adequate adoption time was permitted prior to evaluation.

Weaknesses of this evaluation include a lack of objective usage statistics to correlate to the subjective data and a lack of serial assessment over time to better quantify attrition of device use or increasing sophistication of tablet users in the clinical environment. Data regarding errors in order entry or adverse drug events specific to iPads were not collected. Similarly, frequency and timing of actual order entry events on iPads (e.g. at bedside, during rounds, or at the unit station) were not collected; these limitations prevent analysis of use of iPads to enter orders at the time they are conceived rather than with a cognitive delay. Notably, the electronic health record at the study institution is accessed on tablets solely through a Citrix-based EHR environment. Comparisons to non-Citrix or web-based EHRs on iPads were not conducted. Anonymous data collection precluded correlation of responses to the yearly clinical schedules of individual housestaff.

The utility of the iPad and other tablets as content delivery devices defines use patterns among clinicians at Columbia University. As mobile interfaces for the EHR become more sophisticated, however, further attention must be paid to content entry to fulfill the potential for making the EHR truly mobile. Allscripts has advertised an iOS application called Sunrise Mobile MD for use on iOS devices, but it has not been implemented within our EHR to date and was therefore not included in this initiative. Documentation of this program suite emphasizes content delivery and communication over basic content entry, which was highly represented as an obstacle to adoption in this data.

The assessment of housestaff perceptions of tablets in the clinical environment suggests multiple directions for future work. Given the notably high rate of adoption of iPads on attending rounds, programs considering a similar initiative could consider service-based or team-based tablets with guidelines emphasizing use of the devices specifically for rounds. The expense of obtaining devices for all housestaff would be mitigated with this approach. The counterpoint remains the fact that purely educational endeavors on iPads were not studied here, and this benefit should be considered in evaluating the scale of a future tablet initiative. Similarly, an investigation of the types of orders and notes being entered on iPads in comparison to content entry on desktop computers may guide application development to areas of need. The tablet as a complementary instead of supplementary device for the EHR is another potential area of investigation.

Figure 6:

Setting of iPad Use