The iPAD Experience

If you're reading this, you're probably a Baystate doc anxious to try out your new iPAD with CIS, or trying to decide if it's worth buying an iPAD to use when you're rounding. The good news is that it does work, with some limitations. The bad news is that there are still some glitches, most of which are going to require some programming effort to solve.

For starters, you need to have the free Citrix Receiver app installed - go to the iTunes appplication store, it's free. From the secure website, you need to access CIS from the CIS 4.5 upgrade folder. For some reason, the normal link doesn't work, and if you try to access it that way (and fail) enough times, eWorkplace may kick you out, and you'll need to call the Help Desk to get your password reset. I found it helpful to copy the link from the CIS 4.5 upgrade folder onto the desktop, which simplified repeated access. And, you may need to go in repeatedly because the iPAD is still not truly multi-tasking, although there is software promised to make this occur soon.

Battery life was good. I borrowed Dr. Talati's unit for the weekend without the charger. The device was 96% charged when I got the device on Friday around noon, and down to 56% by the end of the day with a lot of use. I tried to charge it with my iPod touch charger, and got a "not charging" error message, so I rounded on Saturday morning with 56% at the start of rounds (8:30 AM) and was down to 17% by noontime. I then discovered that if you turn the iPAD off, it will charge with a standard iPod charger, and was back to 100% by Sunday morning, and down to 70% by the end of rounds roughly 3 hours later.

Compared to the C5 tablets I've used before, the weight was no problem. Finding a safe place to put it, though, is a challenge. I've seen some Velcro wrist straps that would have made life easier, but frankly, what I really want is a lab coat with big enough pockets to accomodate the iPad. (Business opportunity??). I was rounding with housestaff, and there were lots of "oohs and ahs" from the audience. I do recommend locking the keyboard into Landscape position, especially if you're passing the device around or putting it down to avoid contamination when walking into a MRSA room. Otherwise, the constant rotation between landscape and portrait will make your head spin.

Some of the problems I encountered initially relate to where the keyboard display appears and covers up the Citrix signon box. Life is easier once you know the trick of the three-finger click to open and close the keyboard. Screen sharpness on the CIS default page (Inbox for those of us who are inpatient docs) was excellent, but it helps to zoom in a little if you need to reliably open up individual messages. Some of the other buttons (refresh, for example, toolbar buttons, the X to close a patient chart) work well without needing to zoom in or out, even with large fingers. It helps to keep the left side CIS menu closed to maximize screen real-estate. The scrollbar, though, is particularly annoying. The trick seems to be to touch and hold for a second before trying to scroll.

Patient lists loaded up immediately, at least as quickly as they do on a COW (Computer on Wheels - the Windows-based wireless thin clients that we use in the ICU). Web paging worked great.

The interactive flowsheets we use in the ICU (MICU and SICU quickviews) have left-hand navigation buttons, which is fortunate, because the scollbar is annoyingly slow. I suspect this is a wireless/Citrix/transmission issue rather than an iPAD issue per se, because scrolling on non-Citrix apps seemed to be OK. The horizontal scroll seemed even more difficult than the vertical scroll. By the end of the 2nd day, I had adapted to the need to slow down with scrolling, but still not pleased. (Patient people don't choose ICU as a career...) Other slowness issues: opening up radiology images (about 15-25 seconds on average). The right-hand side PACS menu was difficult to use, although two-finger tapping did bring up a useable menu for displaying multiple images. The images are not sharp enough for diagnostic use, and they will pixillate when you zoom. This may relate to Citrix settings on receiving graphics, and I need to investigate if there is a solution, because we saw this initially with wireless computers on wheels (COWS) when they were first deployed. I understand that some PACS vendors are now sending only the relevant pieces of an image at appropriate magnification, rather than sending the whole image, and hoping it doesn't pixillate when you zoom. We don't have that functionality yet. You can certainly see a portable CXR on the iPAD well enough to tell if an endotracheal tube or line is in proper position, but I'd still go to a high-resolution monitor to assess improvement in a pneumonia or ARDS. The iPAD is capable of such brilliant resolution on photos that it has to be able to do better with CXR and other films - I'm hoping this is a data transmission problem that can be fixed.

Scrolling through labs takes a little time. Graphing the trends was much more satisfactory than scrolling through the table, and my hope is that mPages or other technology would make it easier to access the information in the future. We have an ICU Safety Bundle report that runs from Discern Explorer, and that fit perfectly on the iPAD, allowing a quick check of all of the patients in the unit re: compliance with the "safety bundle" for VAP and CR-BSI prevention, DVT prophylaxis, glucose control, etc. Once again, having mPages or other quick access to data in customized format would seem to be the key to making the iPAD more useful. (For that matter, you could even envision using an iPhone if the displays were arranged for the screen size. I did get my iPOD touch to talk to CIS, but the scrolling was frustrating, and so inefficient that I can't recommend using a smaller screen than the iPAD). Patient lists (rounding lists, billing lists) intended for print looked like bad Xerox copies - ugly! That may have to do with the font chosen for these reports, and the black-on-white display.

Up-To-Date loaded up fine, but crashed when I searched for antibiotic information. The error message I received was "this operation has been cancelled due to restrictions in effect on this computer. Please contact your sysadmin". I blew through that warning screen and got a "Script error, Line 131, Character 3" and "Access Denied". Being persistant, I kept hitting "yes" to the question of "run script?" and eventually got it to work. But, this process had to be repeated each time. More room for improvement....

Should you try to write notes on the iPAD? I would say "Absolutely not". The keyboard covers up part of your templated notes, and it was difficult to go back and correct what you couldn't see while you were typing blind. Definitely not ready for prime time unless you have an external keyboard, or the display is adjusted to show only what you're typing. A templated note with radio buttons might work - perhaps clicking on findings while you're rounding, and then coming back to summarize on a real keyboard would be workable.

The bottom line is that the iPAD is useable for ICU rounds if you're patient (or impatient and gathering data for a blog) but needs a lot more customization within CIS before the average user would embrace it. Relative to carrying a C5 tablet or pushing around a COW, the iPAD is wonderfully portable, and has better screen sharpness. Xrays are still problematic. Scrolling is torture, and your efficiency would suffer when writing notes, or when reviewing a very complex patient due to the scrolling issues. I can see that mPages and some other customization would improve the experience immensely, and I do see a future for the iPAD as an ICU rounding tool. The question to ask yourself is: "Do I really want to be on the bleeding edge?"