Mobile health and EMRs

Mobile Health (mHealth) is an emerging hot topic in Health IT, and was certainly one of the buzz items at the recent HIMSS conference in Orlando. Mobile devices, such as smartphones, iPads and other touch-tablets are entering the market, and by their sheer popularity are changing the market.

Where do these devices, with small touch screens and (generally) no keyboards, fit in to the overall picture of healthcare? Will they be what physicians use in the exam room while seeing a patient, or will they be auxiliary “satellite” applications that address a sub-set of functions that need to be more mobile?

To understand what kinds of things belong on these smaller devices, and what kinds of things don’t lend themselves well to this, let’s take a step back to look at how Electronic Health Records (EHR) systems are designed.

A little bit of technical stuff
The legacy EHR vendors were built with the idea that they would be installed locally in a clinic, or a hospital – they were thus dependent on the operating system (OS) that existed on the machines that would house the software. Therefore, in order to work, these EHRs required certain specific operating systems to be present on the server (typically, a Windows 2000 Server OS), and certain requirements on the workstations that connected to that server (typically, a Windows 7, or perhaps Windows XP OS – and usually needed the Pro version, rather than the Home version, in order to connect to the Domain that the server created).

Most such EHRs are built to run on a Windows platform, though there are a few systems designed to run on the Mac platform. However, with legacy EHRs installed in large settings (large groups, clinics, multi-site group practices), interested users have wanted to access their local server using a variety of machines – sometimes Windows-based laptops, sometimes Macs. The commonly-used solution for this has been to create a Citrix layer (similar to GoToMyPC, or GoToMeeting) that allows remote viewing of a virtual Windows-based desktop display, which can be viewed using Macs or Windows-based computers. This wrap-around allows Windows-based EHRs to be viewed remotely from a variety of machines using different operating systems.

As technology has evolved, and has moved away from desktop locally-installed applications and towards web browser-based applications, better remote access has been possible (without needing a Citrix layer for access outside a local area network). However, many of the tools embedded in web applications (ActiveX controls) rely on the Windows .NET framework, which means that they require the use of a machine running Windows.

AthenaHealth, for example, is an advocate of cloud computing and web-based access, but even though its application is accessed through a web browser, it requires Windows (XP Pro, Vista, or Windows 7), and even specifically requires Windows IE 7 (or higher) as the browser (not Firefox or Chrome).

How Practice Fusion is different
When we built the Practice Fusion EHR, we were aware of these limitations, and wanted to design a system that was both robust as well as truly platform-independent. We used a sophisticated programming language that created Flash files that would run on any browser that supported Flash. As a result, Practice Fusion runs on any platform (Windows, Mac, even Linux), using any browser (IE, Firefox, Chrome, Safari, etc.) that supports Flash. At the time, everyone supported Flash.

Along came the iPad
When the iPad was launched, it was viewed as a media-consumption device – a bigger version of its iPod. It was not envisioned as being a small computer – Apple had created the MacBook Air as the lightweight version of its Mac, with a keyboard and browser that had full Flash support (and therefore runs Practice Fusion just fine). Specifically, the iPad (and the iPhone) did not have built-in browsers that supported Flash – Flash was viewed as a power hog that shortened battery life. And, given that most Flash is thought of as small embedded windows in a web page that show fancy animation – passive content – the idea of Flash-based, interactive business applications (like Practice Fusion) was not taken into account when the iPad was developed.

The market, however, has adopted the iPad in droves, with 15 million such devices being sold in 9 months. Along with this, as can be seen from Practice Fusion’s Facebook page, many in the health field are clamoring for Practice Fusion to run on the iPad. Given Apple’s refusal to build Flash support into its iPad browser, we have had to create a wrap-around – LogMeIn – that allows a virtual view of Practice Fusion to run on the iPad’s browser (not too unlike using a Citrix layer for remote access to a locally-installed EHR, as described above).

What kinds of things belong on mobile devices?
EHRs themselves are complex, sophisticated systems that support many different workflows in a clinical practice – from front-office, to medical assistants, to clinicians. This main, core work really needs a full computer, with keyboard and larger screen size (not a 4” cell phone screen). These computers, of course, can be desktop machines, or can be wireless notebooks (like a MacBook Air, for the Mac enthusiasts). With platform- and browser-independence, Practice Fusion runs in all these settings.

However, certain types of needs are suited for more portable viewing. For example, viewing the day’s schedule from a cellphone before leaving for the office, or reviewing secure messages generated within the office, or looking at prescription refill requests along with outbound e-prescribing – these are all the clinician-facing workflows that would be welcome on mobile devices.

Patient-facing applications – things like weight trackers, blood glucose trackers, medication compliance prompts, secure communication with clinicians, access to health education resources, viewing one’s Personal Health Record (PHR), pre-visit forms completion (the list goes on) – are all things that are moving to mobile devices. Likely, most of the development efforts in the health field will be these kinds of patient-facing applications.

Mobile health – mHealth – is in its infancy, with great potential. From a technology standpoint, most of these apps are things that are downloaded from a marketplace (the iPhone and iPad App Store, or the Android Market), and are therefore locally installed on the device, and reliant on the device’s OS. They are written in the device’s native OS, rather than on a more ubiquitous platform like Flash. Therefore, vendors will need to build, test and support iPhone as well as Android versions of their apps. These apps need to be fairly small, so that download is not too problematic.

The future of mHealth is staggering. Large systems, including legacy EHRs as well as platform-independent web-based EHRs (Practice Fusion) will remain the “hubs” of data, and will need computer-based (rather than mobile-based) interfaces to use them. However, orbiting around these complex hubs of data, numerous mobile applications will extend the access to pieces of that data. The real key is for EHR vendors to build their “core” systems in open-architecture ways that allow external plug-ins to flourish (built by a variety of vendors). As we have seen elsewhere, true innovation comes from open platforms, rather than from the closed, “walled garden” approach that has characterized many of the legacy EHR systems.

Robert Rowley, MD
Chief Medical Officer
Practice Fusion EMR