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Horizons 

May 9, 2003 | AS A PRACTICING PHYSICIAN with 34 years of seeing patients, I have a keen sense of how workflow in an office setting may be either assisted or impaired by the introduction of new approaches to the "encounter" or visit.

Thomas E. Sullivan

As a technophile for many years, I jumped at the opportunity to "borrow" an evaluation Tablet PC made by HP/Compaq running Microsoft Windows XP Tablet PC Edition. I used the TC1000 on and off for about five days. Although I did not attempt to use the device in my actual patient care due to the short evaluation period, I did form some conclusions.

I liked the tablet's size and weight (about 3 pounds), and I liked the battery life compared to traditional notebooks, though I would need two batteries to get through my day. I was impressed by the pen functions — the digital ink and the handwriting recognition, and particularly the handling of medical words and phrases. For example, leishmaniasis, a subtropical parasitic disease, was easily recognized from my cursive handwriting even though the unit's software has no technical medical vocabulary.

I did not like the fit and finish. The pen kept falling out of the slot, the tablet screen and keyboard never closed correctly, and two small slots/doors were not adequately engineered or manufactured to close properly.

I did not work with the wireless version of the TC1000, although it would provide a great benefit in an office like mine. Doctors move quickly from one exam room to another and prefer to write their initial notes with the patient's paper chart resting on the exam table while looking directly into the eyes of patients. Eye contact and nonverbal communication are critical to the physician-patient encounter. Being able to use a pen is essential because typing on a keyboard in an exam room to record information would diminish vital interaction.

Some marketing experts believe physicians will carry these tablets on morning rounds in the hospital and then bring them back to the office. That's not going to happen. Wireless networks in most hospitals, if they exist (most hospitals don't have them yet for meaningful clinical data exchange), do not support this function. It's further complicated by the new federal HIPAA privacy and security regulations, which have been only partially implemented at this writing.

In addition, most hospital information systems have trouble connecting in an efficient way with the physician's office desktop and applications, let alone to brand-new tablet PCs. To be brutally honest, most physicians use office computers for administrative, management functions — not clinical ones like patient care — even though e-mail is making inroads.




The Software Component

Two companies developing software for wireless applications — Buffalo Technology and Linksys — have introduced early working products compatible with the new, though still uncertified, 802.11g category. This standard has potential throughput as much as five times faster than 802.11b, the current standard around which most wireless cards and transmitters are built. But easy, fast, and inexpensive wireless connectivity in hospitals and clinics is still down the road. Given the "need for speed" and the graphics-laden nature of medical data and images, I want to see which "WiFi" wireless attachments (e.g., Cardbus adapters versus integrated hardware) will work in a tablet before I lay out my hard-earned cash.

Amicore, a young medical software company, has standardized on the Toshiba Tablet PC. Amicore — backed by Pfizer, IBM, and Microsoft — held great promise about two years ago, when I was one of the physicians involved in surveys commissioned by Pfizer regarding the formation of the new company.

Amicore's product and service price points, and the design and functionality of the hardware and software, were supposed to bring an innovative workflow approach to the physician's office setting. I had high hopes for Amicore, but unfortunately have seen very little substantive progress within the time frame I expected. Perhaps this is impatience talking, but I thought the three founding companies had the expertise to have achieved more by now.

If Amicore is able to adapt its current PenChart medical records program to mesh with Windows XP Tablet Edition and build or acquire effective medical billing software, it should have a good chance to make its mark. The current environment is difficult for vendors targeting physicians, especially in small, cash-strapped practices.

I spent several hours a few weeks ago with my team at the Massachusetts Medical Society listening to and evaluating another software vendor, Greenway Medical Technologies. It has a browser-based integrated practice management system and electronic medical records program. Greenway recently standardized on Fujitsu's version of the Microsoft XP Tablet.

From my standpoint, Greenway is significantly ahead of Amicore in adapting its applications to the tablet. That's partly because it has the benefit of writing applications on top of the latest Microsoft SQL Server database and tools. Greenway has no complex legacy software to support, unlike Amicore, which must pull along and upgrade PenChart. To its credit, though, PenChart was the first really good pen-and-mobile-computer chart application I have seen adapted to the physician's habits and customs.

Sampling of Tablets and Software 


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One specific application that holds great promise for tablet computing is electronic prescription writing. A recent wave of health insurers has started to sponsor electronic prescription pilot programs primarily using the Pocket PC. Eliminating handwriting legibility problems and adding the ability to quickly check drug incompatibilities, allergies, and other potential problems improves the chances of getting medication dispensed safely and efficiently.

It's my sense that the Tablet PC, with its bigger screen (10.4-inch LCD), along with more features and power and the ability to handle comprehensive electronic medical records, is ideally situated over the long term to take this function away from the much smaller PDAs such as the Palm or the Pocket PC.

For readers interested in the hardware and benchmarking aspects of the new tablets, my favorite Web site is Tom's Hardware Guide. Its recent review of a Tablet PC rang true for me (www4.tomshardware.com/mobile/20030129/index.html).

Mobile computing has a great future in healthcare and particularly in physician, clinical trial, and ambulatory settings, although the same could have been said more than 10 years ago when pen tablets first started to appear. This time it's more realistic to say that wider adoption is "just around the corner," notwithstanding the usual danger inherent in that prediction.*



Thomas E. Sullivan practices medicine in Danvers, Mass., and is president-elect of the Massachusetts Medical Society.








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