How Palmetto Health Doctors Defied the Health Information Technology (HIT) Productivity Paradox: Part 3

27 September 2013 | Dr. Dennis Schmuland, Chief health strategy officer, U.S. Health and Life Sciences, Microsoft

Part 3: The 5 Things Palmetto Health Did Right

#1: Right OBJECTIVE.  Most practices mistakenly assume that what they need to compensate for their post-EHR productivity drop is a lite or virtualized version of their EHR on a companion tablet to bridge the productivity gap while clinicians are mobile between workstations. The mistake in this approach is the outdated assumption that a tablet should be used as a companion device and can't serve as a fully functional mobile workstation capable of being the single primary device that mobile clinicians can use to run their fully functional EHR and all their core applications. Most physicians I talk to tell me that, while their iPadtm works well for accessing information and media, it falls short of the full functionality necessary for the tablet to replace the PC workstations or laptops they still use as their primary device. 

This companion tablet assumption and experience jibes with the 2012 Spyglass Consulting Group survey that showed 83% of clinician tablet users still using workstations "as their primary device for accessing corporate assets and patient data whether they were at the hospital, in their office, or at home."  But adding a companion device to workstations destines them to endlessly toggle between two devices--a tablet and PC or workstation--with entirely different platforms as they move between patients, rooms, facilities, labs, the office, and home.  The result is predictable device fatigue AND application (“app”) fatigue: the cost in time, productivity, communications, and team work that comes from juggling and constant switching between tablet, laptop, workstations, and phones each of which have unique UIs and run different apps.   Every minute spent logging on, logging off, rekeying, and switching devices and applications was a distraction and one less minute for patient care. 

To their credit, Palmetto Health physicians thought much bigger about solving their HIT productivity paradox and, instead of searching for a companion device for them to be more productive between workstations, they sought to fully eliminate the workstations in each room by equipping each physician with a single 3-in-1 device--a tablet, laptop, and workstation in one--that each physician logged into once a day and could continuously use from the start to finish of their workday.  The 3-in-1 workhorse device they envisioned had to adapt to the documentation and workflow needs of clinicians better than their existing workstation and without introducing the patient safety risks of first generation companion tablets.  By choosing a device that could match the first class jobs of a tablet, laptop, and workstation combined, they could eliminate the tyranny of endlessly logging in and off of workstations AND carrying a companion device with less than full workstation capabilities.

#2: Right FORM FACTOR. The Surface Pro is fully a PC that's usable on the move without the patient safety risks of consumer grade tablets.  In contrast to the iPad's 4:3 aspect ratio designed to be held in portrait mode, the Surface Pro's 16:9 aspect ratio and 10.6" display is designed to be cradled "like a baby" in landscape mode to make it easy and natural to write on.  This is very similar to the way physicians chart on paper records, where they still exist.  The high contrast, scratch and crack-resistant Gorilla glass display is both easy on the eyes and built to withstand the bumps and drops of a fast-paced clinical environment.

The built-in kickstand and optional magnetic snap-in keyboard cover enables physicians to go from tablet to laptop and work the way they want – touch, type, swipe, click, or write. With HD video out and full-size USB 3.0 ports it's easy to connect to peripherals, present with a projector, and transfer files with enforced encryption.  And if they need a full-size desktop environment they can easily connect a full-size Bluetooth keyboard and mouse and use an adapter to add an external monitor. 

With its Intel Core i5  processor and expandable memory, Surface Pro can take on full-PC workloads and connect to virtually anything that can connect to a PC: external drives, flash drives, bar code scanners, keyboard, mouse, speakers, cameras, etc. [1]  The Surface Pro is also ready with front and back facing cameras with the back camera angled to take advantage of the kickstand placement.  This means that a physician could easily aim the back facing camera at a patient while maintaining a full view of the EHR side by side with a view of a remote consultant. 

By running their full function EHR on the full size high resolution screen of the Surface Pro, Palmetto Health also circumvented two known safety risks related to the use of consumer grade tablets as companion devices for patient care recently highlighted in a research brief published by The Advisory Board Company.  They issued this caution on their website: “…using an iPad, iPhone, or similar small-form factor, keyboard-less mobile device to interact with EMR applications designed for a full-sized video monitor, external keyboard, and mouse invites a material increase in avoidable medical errors.”  First, when EHRs originally designed for full-sized video displays are run in virtualization mode on most consumer-grade tablets, some of the data intended for the clinician to see extends beyond the boundaries of the tablet.  This situation requires clinicians to manually scroll to view the vital portions of the record they need to be aware of before charting or acting.   Pop-up keyboards pose an additional safety risk because they can obscure contextual data intended for clinicians to be aware of when entering data or orders.    

#3: Right DATA CAPTURE CHOICES.  One of the unique value propositions of Windows 8 devices for health professionals is that it natively supports all five of the input modes that clinicians need to be maximally productive: Pen, Touch, Speech, Keyboard, and Mouse.  My colleague, Dr Bill Crounse, recently wrote about the seamless availability of these 5 data entry modalities as one of the last barriers to broader adoption of EHRs by “non-geek” clinicians, and made the case that every clinician has their own set of data input preferences. Each physician needs to be able to choose on the fly the data input mode that works best for them to document, illustrate, educate, share or project information, based on the clinical context of interacting with their EHR, the patient, or colleagues. 

Further, there are many clinical situations that are best served by specific modes of data capture.  For example, clinical process and patient safety forms may best be served by a pen or combination keyboard and mouse more so than touch or voice.  There are many bedside situations where physicians and nurses need a pen to quickly write down unstructured notes that can't be immediately entered into a structured EHR.  Clinicians often prefer to dictate their narratives that describe the present problem and the assessment but prefer a pen or keyboard and mouse to enter structured data such as physical findings, treatment plan, and orders.  In other words, for clinicians, native pen, inking, handwriting recognition, and speech support are all at least as important as touch and swipe. 

Last but not least, there are two special clinical situations where detailed, pressure sensitive drawing and handwriting are essential and are served poorly by the blunt, capacitive pen of most consumer-grade tablets: instructive bedside drawings sketched by physicians or nurses or marked up pictures or diagrams to help patients understand their conditions and treatments and the capture of patient signatures for procedure consent.  Not surprisingly, the Surface Pro pen brings several unique data capture advantages and choices that clinicians can't get on their consumer-grade tablets today: 15 years of collective discoveries and insights within Microsoft Research. 

#4: Right PRECISE, PRESSURE SENSITIVE PEN & PALM BLOCKThere’s a reason that practically every EHR designed to run on an iPad is a light version of the same full EHR designed to run on a full workstation.  As a user interface, touch is far less precise than a mouse or digital pen--which means that only a fraction of the information on the iPadtm that can be viewed on a full size screen can be displayed.  Less information per screen means that clinicians have to scroll, swipe, pinch or zoom multiple times to view the same amount of information they could view on a full screen.  More scrolling and swiping takes time, tanks productivity, and introduces unintended patient safety risks (covered in the last paragraph)

The unique Surface pen brings a high level of precision to the touch screen and several major advantages for clinicians over the blunt capacitive touch and stylus experience of the iPad. To achieve highly precise pen inputs, the pen digitizer system in the display produces a weak electromagnetic (EM) field, which induces a current in the otherwise passive pen, which in turn impacts the EM field.  The Surface touchscreen reads the presence of the Surface pen tip when it gets close to the screen, and responds by displaying a small dot on the screen.  The EM field allows the system to detect the position and angle of the pen starting at a distance of 1 inch (2.5 cm) from the display. Applying pressure to tip of the pen thickens the line in apps that support pen pressure.  In contrast, while the iPad’stm capacitive touch screen readily responds to the touch of a human finger, using many styluses on an iPad feels like drawing with the flat bottom end of a crayon. 

The Surface Pen gets even better because it also serves a dual purpose: it's not just an extraordinary digital pen but  also as a highly precise mouse replacement.  The latter is critical for clinical scenarios where it's impractical for clinicians to use a mouse because there are so many settings in which they must work that lack a flat surface to operate a mouse. A pen button allows quick access to right-click menus. Pen flicks are quick pen strokes to scroll up, scroll down, move forward, move back and do other shortcuts.

Right PALM BLOCK.  But beyond the advantages of the highly precise Surface Pen that doubles as a mouse, the advanced pen digitizer system includes an amazing Palm Block technology that enables Palmetto Health clinicians to rest their palm on screen while writing, clicking, and drawing.  When the touchscreen senses that the pen tip is close, Palm Block technology deactivates touch so you can write comfortably and even more precisely with your hand resting on the screen.

When Palmetto Health physicians realized how precisely the pen performed with Palm Block and that the same pen could double as a full mouse replacement, they realized that they could get more out of their existing EHR by replacing fixed workstations with the Surface Pro.  Because the Surface Pen can be used as a precise mouse to click on, strike, or check small items, as a pen to write naturally and steadily with while resting their palm on the display, and even flick to scroll up or down or move forward or back without using a finger, the Surface Pro pen uniquely enabled them to switch between touch, pen, mouse, and keyboard on the fly without the inconvenience of adding a mouse.  For Palmetto physicians, it was this versatility of the Surface pen that made documentation on the Surface Pro faster and easier than using workstations with mice.

#5:Right APPS.  While Palmetto Health physicians knew that running a scaled down light version of their full function EHR on iPads could provide limited access and data entry to their EHR while on the move, they recognized that iPads could not replace the workstations they needed to access their full EHR, core IT applications, imaging applications, run multiple apps side by side, and take advantage of larger screen displays.

A key feature of all Windows 8 devices that’s often missed is that these all these devices don’t just run Windows 7 applications, but those Windows 7 applications also work with touch and pen as well as the standard keyboard and mouse. By running the very same apps on their Surface Pros as they now run on their workstations, Palmetto Health physicians are able to achieve better productivity and a patient experience with the EHR app they already owned, without additional software and support costs.  The ability to run the same apps on every device in the organization also eliminated app fatigue--the productivity tax that comes with forcing clinicians to endlessly switch between devices to access different apps. 

An HIT Productivity Paradox Defying Act

While many healthcare organizations are spending more but getting less for mobility, Palmetto Health appears to be defying the HIT Productivity Paradox by spending less and getting more productivity out of their existing EHR investment by leveraging Windows 8 powered Surface Pro 3-in-1 devices that combine the best of a tablet, laptop, and workstation.  With all the apps they need on one no-compromise Surface Pro tablet, plus the full range of data capture modes--touch, digital pen with palm block, voice, keyboard, and mouse, Palmetto Health physicians may very well be leading the way in overcoming some of the last obstacles standing in the way of physicians delivering better care at a lower cost and, in the process, restoring the joy of practicing medicine for many beleaguered physicians.


How Palmetto Health Doctors Defied the Health Information Technology (HIT) Productivity Paradox: Part 1

How Palmetto Health Doctors Defied the Health Information Technology (HIT) Productivity Paradox: Part 2

[1] Compatible with peripherals certified for Windows 8. Review port availability at

Dr. Dennis Schmuland
Chief health strategy officer, U.S. Health and Life Sciences, Microsoft