A few more iOS 5 considerations, for EM

I've been using my iPad in the ED, with my white coat's sewn-in iPad-sized pocket, for some time now -- mostly for patient and resident education, and to look up dosages or rashes. Hitting up my Evernote database or Dropbox documents is also useful. Occasionally I'll use my iPhone, for its LED light (when the otoscope can't reach to where I need to see) or rarely, its camera (in compliance with my hospital and department photo policy, naturally).

Our ED's EHR isn't quite accessible enough via iPad for me to quickly check results or place orders at the bedside -- right now it's just too cumbersome. But there's been progress -- enough so that I start to wonder about the flip side: instead of reviewing iOS medical apps and pining for an optimized EHR experience on the iPad, what if there are features of the iPad that could limit the utility of medical apps?

Well, there are some product design issues, like impact resistance and bacterial colonization, that have been discussed. But the operating system, iOS 5, has some quirks, too. Some have received a lot of attention. Some are maddening in their capriciousness.

But if you're an administrator, or an app developer, working on healthcare apps for folks with iPads, there's got to at least a few special considerations on your plate that you've never had to worry about, before (beyond the whole portrait/landscape issue). I've listed a few that seem novel to me, below:

1. Photostream, and iCloud. The other day, a colleague asked me to take a picture of an area behind her ear, to see how a lesion was healing. The next day, when I was home, polishing charts and playing tunes, my Apple TV's screensaver activated, and I found myself staring at my friend's ear, blown up to alarming proportions. My iPhone had sent the pic to the cloud, where iTunes found it and shared it with my set top box.

This is a separate issue from security, which I think Apple's iOS handles well enough. iPads can be locked and remotely wiped of data, if stolen. Facetime is HIPAA-compliant. But photostreaming is something that happens quietly, behind the scenes, and without much fanfare, until that pic your patient consented to is suddenly shared on all your devices and the cloud. Oh well -- hopefully your consent form has this possibility baked-in. And fortunately, Apple's finally made it possible to delete individual images from one's photostream.

2. My iPad knows when I'm sleeping. When I first pick it up after it's been laying dormant for a while, all the alerts and notifications that have been building up come tumbling out. In other words, iOS 5 is smart enough to know not to fire alerts when it's been off for hours and hasn't moved, and to let them build up and fire when I'm good and ready for them.

This is especially noteworthy, given my erratic sleep schedule.

I'm sometimes tempted to just pick up my iPad abruptly and unpredictably, hoping to catch it in the act of updating a Newsstand subscription or wireless sync. But if I've ever interrupted it, the iPad's never complained with any sluggishness or warnings.

It's a smart feature, but in healthcare there are some warnings that need to break through. And as iOS gradually replaces pagers and other communications systems, there are a few sleeping doctors that will need to be woken up -- instead of letting all alerts wait until the iPad's on.

3. Where's Save? When you've written a note in most iOS apps, it's just done. Automatically, quietly saved. In fact, it wasn't until I used the new Gmail app for iPad that I realized how incongruous the classic "Save" disk button looks in iOS.

But when you've finished a long draft in, say, Papers, and want to move on, it's a little unsettling to assume everything "just works" and your efforts are saved and retrievable. I've been burned too many times, in the past few decades. And frankly I think most of my colleagues would be paralyzed with fear if they'd written a patient note and there's no clunky, inelegant way to mark it as saved.

Hopefully this is only a problem we dinosaurs from the 80s will have to deal with. Perhaps we could get used to Apple's elegant solution, and maybe younger users will never feel weird about relying on the OS to act responsibly. But so long as developers like Google keep offering Save buttons, the iOS paradigm won't fully catch on (and a part of me will be relieved to click Save).

I've highlighted a few (relatively minor) quirks that may drive administrators, or users, crazy. There are undoubtedly others. Apple's innovations with tablets and iOS have led to great consumer products. But compromising for business uses has never been their strong suit. Getting these devices into hospitals, where they can make a big difference, will unfortunately require either administrators to be flexible and creative, or Apple to compromise. Immovable object, meet immovable force.