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I could list all the reasons I think the iPad + Citrix are a great fit for healthcare, but it may be more meaningful coming directly from Physicians and IT Pros in the heathcare industry. This is a sample of what has been shared on the blogs when we asked what would Citrix Receiver for iPad be used for.
Dr. Paul Altmann says:
” Chris, the combination of Citrix and the iPad will, I am sure, be a huge success in the healthcare setting where the form factor of the iPad makes it the best all round device to access medical records in real time as clinicians care for their patients.Specifically, I am looking forward to showcase this for Cerner Millennium users who routinely access the application over Citrix.
There will be many other settings where the iPad, which is the first really decently sized, light, with good battery life “thin client”, will become very popular.
Dr Paul Altmann
Clinical Director – Health Informatics – NHS South Central & Oxford Radcliffe Hospitals NHS Trust
Consultant Nephrologist – Oxford Kidney Unit The Churchill – Oxford OX3 7 “

.. says:
“I would love to be able to use citrix on an iPad.  I currently use Citrix to log into our hospitals EMR, Epic, from home.  Being able to do so both at home and even in the hospital would be awesome. “

“So Are you saying that I would be able to use my GE Healthcare Centricity EMR Application from the Ipad? We connect to it using XenApp. This is really the only thing holding me back from getting an iPad is that whether I would be able to run my EMR for work.

“Please tell us you are working on a citrix client for the IPad.  It will be so “revolutionary” if you have one ready by the time the IPad is available. Physicians will love to use an IPad to handle their Electronic Medical Records at bedside, exam rooms.”

“Chris Smith says:
Yes, I think this would be fantastic. Many EHR (electronic health record) applications have developed stylus-driven interfaces for slate PCs (tablets with no keyboard option), so touch interface is a natural easy win for those already developed applications. Many of the EHR applications are also already deployed via Citrix, so this is a serious WIN WIN for Citrix to pursue… and as you mentioned, Citrix has already done quite a bit of work on the Citrix Receiver for the iPhone. This really does have so much more capability, now that you have the larger screen.
Also, multi-touch is supported in Windows 7, so it will be interesting to see how the XenReciever can interact with the Win7 host operating system environment, or even hosted application environment, but having the Receiver bridge that gap in the user experience via the iPad would be amazing!”

“I work for a health care provider and this could be huge. It turns the iPad from an interesting toy, to potentially powerful tool for business”

Todd Bruni says:
“Being in a large Healthcare environment I also see this device as having huge potential. First for ARRA/Hitech initiatives such as CPOE, BMV, Physician Documentation, etc physicians, clinicians, and/or nursing are going to want, need, demand mobile devices. As multiple people have pointed out one of those devices are tablets. The cost of those devices intended for Healthcare are extremely expensive (Motion Computing, etc).  Second, as people have pointed out protecting patient data is a requirement.  That is one of the beauties of desktop virtualization whether its hosted shared desktops or hosted dedicated desktops that data stays in the data center.  Finally organizations need to hit meaningful use in the not so distant future. Most of the large EMR vendors are not web-based today and organizations have to start taking steps now to meet the meaningful use timelines. That means these applications are client based today which is another reason to do desktop virtualization now until the ISVs solutions are ported to the web.
So how does this wrap back around to this device? Any device that is going to help healthcare organizations start taking steps now to adopt desktop virtualization, mobility, extend battery life, and move data into the datacenter without having to spend $2k on a tablet, $3k on cart solution is a great candidate. Being able to purchase 4 or 5 of these devices at the cost of one tablet makes it very intriguing. Add a docking station with keyboard and mouse for $40-50 in key locations and now you don’t have to worry about real estate on the floors (another huge healthcare issue) and the device becomes easy to stop and make updates to your EMR.
Finally, I don’t remember who said it but I completely agree with whoever said that we won’t know any of this until we get these devices into the clinicians hands we won’t know.”

“Already have XenDesktop environment pushing around 20 desktops using Nextgen out to several medical clinics in my area. Was able to get budget money for purchasing 5 iPads as a demo in less than 2 minutes. Will be an interesting demo as I have connections to several hospitals that are all looking into the EPIC Haiku Application also being developed with Keiser Medical Group in mind. A current rolling wireless cart with a WYSE Thin Client typically costs a Hospital in Oregon $20,000 after we did our full ROI 2 years ago. Interesting what happened in 2 years! “

Checkout the Heathcare IT Community site http://community.citrix.com/p/healthcare

Learn how to make the iPad work for your healthcare organization at Citrix Synergy

Earlier this week I attended “The New Wave of Healthcare IT Virtual Seminar” from SearchHealthIT.com. Unfortunately, I had to leave for the airport, but I did catch one of the first sessions on mobile health by Claudia Tessler and C. Peter Waegermann of the mHealth Initiative, Inc.
mHealth is basically the area where electronic medical records (EMR), mobile computing, social media and direct patient / doctor communication intersect.
The vision is clear: Patients and their doctors communicate via all the modalities we’re already enjoying as consumers: eMail, text messages, and sometimes social media. The obvious challenge is that the desire for convenience must be carefully balanced with the mandated need for privacy and security.
Application and Desktop virtualization can confine the protected data to the datacenter, while enabling clinicians to interact with the data securely over any device without the need to re-write the application. Application vendors sometimes offer secure patient portals that allow for direct communication between patients and doctors and nurses. With app and desktop virtualization, even the relatively new iPad is supported out of the box through Citrix Receiver.
The following resources provide a best-practices based approach to designing virtualization environments based on Citrix XenApp and XenDesktop technologies:

  • Windows XP Optimization Guide for Virtual Desktops
    Description: If Windows XP is still your desktop operating system of choice and it is going to be used within a virtual desktop environment, you need to optimize it appropriately. The optimizations will help deliver a better user experience and greater scalability on the hypervisor of choice (XenServer, Hyper-V, or ESX).
  • XenDesktop Modular Reference Architecture
    Description: The architecture explained within this white paper is a recipe for creating a scalable XenDesktop environment using any required FlexCast option. This reference architecture discusses how to configure the controllers, imaging layer, application layer and the desktop layer.
  • High-Availability for Desktop Virtualization – Reference Architecture
    Description: In environments where desktop virtualization is a critical business resource, it is imperative that the solution remains available even if a component or data center is lost. This reference architecture looks at all levels of the entire XenDesktop solution, and provides an architecture for creating a highly-available solution.
  • High-Availability for Desktop Virtualization – Implementation Guide
    Description: Implementing a desktop virtualization solution oftentimes requires an investigation and implementation of the high-availability options. This white paper provides step-by-step instructions for enabling high-availability in XenDesktop within a single site and across multiple sites.
  • Virtual Applications or Virtual Desktops
    floirDescription: Trying to decide between virtual desktops and virtual applications is oftentimes challenging. By understanding the core expectations and requirements for each delivery method helps make this decision easy. This white paper focuses on the decision and how to identify the most appropriate type of delivery solution.
  • Networking topics, including Global Server Load Balancing- it’s like never having to worry about datacenter failures again.

These and many other good nuggets on real world implementations of virtualization and networking practices can be found at the Ask the Architect sites.

Florian Becker
follow me on twitter: @florianbecker

The HiMSS group on LinkedIn features some interesting discussion. One of the longer threats evaluates why EHR/EMR implementations fail
Well, I must ask – please define failure! And this questions goes right to the heart of the matter. Defining success is probably one of the most prominent things any project management and executive steering committee must accomplish at the onset of the project – even before a vendor is picked.
I am well aware of the challenges associated with the technical implementation, workflow definition, workflow standardization and Computerized Physician Order Entry (CPOE) and much has been written about this topic.
A key point of any successful EMR is that the physicians and nurses accept the system and want to use it. Honestly, what’s in it for them?
Thus far, physicians in larger organizations had the luxury that someone would transcribe their scribbled notes and mumbled dictations, so that they could focus their time on patient interaction. The fact that healthcare administrators want to reduce errors and establish audit trails of clinical decision making has often been perceived as being of little value to the physician – especially if viewed in comparison to the perceived hassle of learning a new system and having to type patient notes. In a litigious society such as the one in the United States, some physicians may be more comfortable without any trail of clinical decision making that could potentially used against them in trial.
So, for EMR implementation success, a few key principles must be considered:

1. Define clear success criteria. Administrators, tech experts and clinical staff must work together to jointly arrive at a common goal.
2. Workflows. Pay close attention to how much hassle it is for the clinician to complete a workflow. Software must support users, not the other way around. When I was at a major EMR vendor, we actually counted the number of required clicks to complete a task as a key performance metric of the system. In the development cycle, no workflow could execute slower or with more clicks in a new version.
3. Access. This is at the heart of the matter. Organizations should establish clear metrics on how a physician accesses the system. Set an aggressive goal – such as “no more than 15 seconds for the first interaction of the day, no more than 3 seconds to log on to any terminal and get the session back”. This can be achieved through virtualization technology and session roaming with Citrix XenApp and XenDesktop. The use of two factor authentication such as proximity sensors in the user’s security badges or certificate carrying smart cards negate the use of typing in passwords. Think about the access modality as well – is it a thin client, a tablet, an iPad, a computer on wheels? How many hands will the physician have to care for the patient? Are cable or monitor arms in the way? Are there terminals in the hallways so that a note can be amended without disturbing the patient?

I’ve written about this topic in a previous blog as well.

Please provide your thoughts and comments.

Twitter: @florianbecker

There are two interesting trends going on in healthcare at this time (no, I am not talking about the current debate in congress). One is that we will see more and more healthcare providers use electronic medical records – a trend that is fueled by financial incentives through “stimulus money”. The other is one of the consumerization of IT – specifically healthcare IT.
We see this trend in other areas as well – like employees using their personal cell phones of choice to access corporate email, or even bringing their personal laptops to work.
In healthcare, doctors are already heavy users of mobile technology – cell phones, smart phones, the ubiquitous pager etc. But today we’re at a point where the consumer technology is good enough to be used for clinical purposes and can actually contribute to giving doctors a little bit of their free time and their personal life back.
Case in point: The patient calls their on-call doctor after hours with a rash or burn. In the old days, it would have required the physician to drive a possibly long distance to see the patient in order to recommend treatment. Today, she can simply ask the patient to take a picture of the ailment with a smart phone and simply email it over. In many cases, the image quality is good enough to recommend treatment and help the patient immediately.

This trend is obviously troublesome for healthcare administrators. Many actually recommend against their physicians employing “unapproved” avenues to make remote diagnosis out of fear of litigation and legal compliance violations. The dilemma is that both patients and doctors use technology out of convenience where it makes sense. It is against doctor’s nature to hold back care if it is obvious how the patient can be helped right then and there.
However, I stipulate that this is actually nothing new.

  • For a long time, doctors have consulted their patients over the phone and gathered enough information to diagnose and make a recommendation for treatment, so the digital information exchange actually reduces risk in many cases.
  • The patients are the only rightful owner (note that I am not saying the only legal owner, this would be a different discussion) of their medical data. If they choose to share some of it over less than secure connections with their physician, it’s their choice. In the age of social media and Internet-based commerce, people have become accustomed to giving up some privacy and security in exchange for faster and better service online.

So, can both groups – doctors and their patients on one side and privacy advocates, regulators, and lawyers on the other side be happy? Yes.
Some electronic medical record system vendors incorporate an internal, secure messaging feature that allows patients to communicate with their doctors and nurses directly, but through the established channels of an existing EMR implementation. In addition (or in lieu) of this capability, healthcare providers can use their smart phones, netbooks, tablets, home computers etc. to securely connect to their employers system to upload data, annotate patient notes in real time etc, check for potentially harmful allergies, etc. If the EMR implementation does not expose a fully functional web based user interface, both desktop and application virtualization technologies can make it so.
Instead of getting into the cold car and driving 50 miles through snow and ice to see a patient, the doctor on call can simply pause the movie on the living room TV, switch the set to the connected PC and securely connect to the patient’s medical record, review pertinent information, write a prescription electronically (a must have under the proposed “meaningful use” criteria) and finally go back to being a private person. More personal life for caregivers, faster service for patients – enabled through technology.

Follow me on twitter: @florianbecker

The American Recovery and Reinvestment Act of 2009 (ARRA) contains a whole chapter called HITECH. This catchy acronym stands for Health Information Technology for Economic and Clinical Health and makes you wonder if “they” construct the acronym before deciding on what information to convey. It basically mandates a number of fairly stringent disclosure requirements for HIPAA covered entities and their business associates  in the case of privacy  breaches leading to the disclosure of patient data. The act is intentionally aggressive in order to entice health care providers and insurance companies to be really cautious about patient privacy and record security.
I am at HIMSS in Atlanta this week and I notice that ARRA, HITECH, HIPAA and other related topics are front and center in many sessions and for many vendors on the floor.
Under HITECH, the burden of proof is on the side of the covered entity to prevent a breach, discover the breach, and then disclose the breach to the patients and – in some cases – to the secretary of health and human services. If the breach is affecting 500 or more patients in a state or region, the covered entity must notify the patients via public media and notify HHS immediately. 
So, let’s define what a breach really is, and then what you can do to never having to call your local newspaper for the disclosure ad.

Under HITECH, a breach is an “unauthorized acquisition, use, or disclosure that compromises the security or privacy of the health record”. There’s also something in the language that this must pose a significant risk of financial, reputational, or other harm to the individual. Note that I am not a lawyer, but I did stay in a holiday….. tonight. Kidding aside, I did listen to Gerry Hinkley and Deven KcGraw during their HIMSS session this week – both are legal experts in this field.

So, having a laptop with unencrypted, and personally identifiable patient information stolen would be a breach. If, however, the data is secured with federally accepted levels of encryption (and the security of the key is not compromised), OR the data does not include certain items such as DOB or the patient’s ZIP code, it’s not a breach.
As you can see, the devil is in the detail. So, how can you take steps to avoid that painful disclosure? For one, ensure that the patient information never leaves your data center. Leverage desktop or application virtualization and disable clipboard and local disk access on the client device. Many electronic health applications can only print through the server, so that client connected printers are not needed and can also turned off without compromising functionality. If mobile access to the data is needed, consider the Citrix Receiver for the iPhone or mobile access platform of your choice to deliver the information without delivering the data.
Even without HITECH, these are important considerations for any Electronic Medical Records (EMR) rollout. When done correctly, you could allow your doctors, nurses, and staffers to use the laptop, netbook, tablet, iPad of their choice without having to worry about IT managing the myriad of devices or any of them leaving the premises.

Now, unfortunately, this is only one aspect of HITECH. The other aspect involves the unauthorized access  of patient records by employees who have legitimate access to the systems, but are basically snooping around. HITECH covers privacy breaches, not just security breaches.  Looking up your own lab results, or the chart of your friend’s sick kid is an example of a well intentioned, but illegal breach. Looking up the local football player’s records to determine if that hamstring injury has healed before Sunday’s game is also an illegal breach, but not an innocent one.  Identifying those scenarios actually requires intelligent data mining to assess whether access was justified for a person to do their job or constitutes a breach. While you can’t fix the latter category through application or desktop virtualization, you can confidently use virtualization technology to prevent breaches through the loss of devices or data without restricting mobility. One less thing to worry about in the complex world of healthcare regulation.

Questions? Comments?
Follow me on twitter: @florianbecker

While most discussions on successful Electronic Medical Record (EMR) implementation and adoption circle around the proper implementation of clinical workflows, standard order sets, diagnostic codes, and the all important CPOE (Computerized Provider Order Entry), little time is spent on thinking about how the applications actually make it to the users. I have talked to CMIOs this week at HIMSS who mentioned that the improper application delivery actually constituted a significant roadblock or bottleneck towards adoption.
Healthcare organizations have tried anything from Computer’s on Wheels (COWs) to tablets to smart phones and iPhones. Each modality has its own merits and risks. Let’s have a look:

COWs: With large screens and full keyboards, using the system is as easy as using a desktop computer in the office. However, there are some distinct challenges associated with COWs: They are used by many different people. Although the carts are adjustable, users don’t adjust them in the interest of time on the floor and are therefore experiencing ergonomic problems. COWs are wireless, so the 802.11x infrastructure must be 100% reliable with good signal strength. Map out every patient room using the all familiar “Can you hear me now?” method of assessing signal strength in every place the COW might be used. Check with your facilities manager whether the COWs in the hallways would violate any fire security.

Tablets: Overcome some of the bulkiness of COWs. Same challenges with wireless networks though. Check with your users first. Doctors carrying the tablet in one hand and the stylus in the other hand don’t have a hand left to touch the patient. The success of tablets also depends on the specific EMR application you are running. Entering data via the virtual keyboard of the tablet is very time consuming and therefore prone to error. Applications that let users click through selection lists are much more tablet friendly. Consider specialized tablets for the healthcare industry that include scanners and interfaces to diagnostic equipment while maintaining the mobility.

iPhones, SmartPhones: Awesome. Barely larger than a pager with a user interface made for the device. Can’t replace a full application though as many apps are just for vitals, bedside monitor virtualization, results review etc. Smart phones are complimentary to other access modalities – not a full replacement.

iPad: It’s coming. I talked to several EMR vendors at HiMSS 2010 in Atlanta this year, who are already working on their user interfaces to make them friendly for user interaction sans keyboard. Of course, the Citrix Receiver will be able to deliver any windows app or desktop directly to the iPad.

Finally, there are the good old thin clients. These units combine the best of all worlds: Large screen, yet small form factor. Don’t require wireless networks and several incorporate a smart card reader to facilitate two factor authentication. Have one in each patient room, nursing station and several in the hallways (neatly wall mounted and tucked away while not in use) and you have a solution that allows doctors to use both hands on the patient and use a familiar keyboard for data entry. Use desktop and/or application virtualization so that you can eliminate the end point support team. Depending on the EMR application, consider generic windows logon and light or no profiles to speed up logon times to the windows environment. Authentication happens on the application itself in this case. Smooth Roaming capabilities are essential to cut logon time down to a few seconds and provides full mobility on the floor without carrying a device.

Some of the access modalities in your healthcare facility depend on provider preference (yes, doctors do prefer some devices over others and yes, please make your doctors and nurses happy). Use application or desktop virtualization wherever possible to avoid end-point support. Citrix XenDesktop can deliver remarkably high quality application fidelity and image resolution even over longer distances thanks to the bundle of HDX technologies.

What is your experience with EMR implementations and application delivery?

Follow me on twitter @florianbecker