Beware virtual keyboards in mobile clinical apps

By Neil Versel
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Neil_Versel_LargeDon't look now, but there's another report raising safety issues about electronic medical records – and this one is focused squarely on mobile devices.

Remember the problems Seattle Children's Hospital had with trying to run its Cerner EMR, built for full-size PC monitors, on iPads? The hospital tried to use the iPad as a Citrix terminal emulator, so the handful of physicians and nurses involved in the small trial had to do far too much scrolling to make the tablet practical for regular use in this manner.

Well, there may be a greater risk than just inconvenience when tablets and smartphones stand in for desktop computers. According to a report from the Advisory Board Co., "[A] significant threat to patient safety is introduced when desktop virtualization is implemented to support interaction with an EMR using a device with materially less display space and significantly different support for user input than the EMR's user interface was designed to accommodate."

The report actually is a couple months old, but it hasn't gotten the publicity it probably deserves. We are talking about more than user inconvenience here. There are serious ramifications for patient safety, and that should command people's attention.

How many CIOs or even end users have considered another one of the unintended consequences of running non-native software on a touch-screen device, that the virtual, on-screen keyboard can easily take up half the display? "Pop-up virtual keyboards obscure a large portion of the device’s display, blocking information the application’s designer intended to be visible during data entry," wrote author Jim Klein, a senior research director at the Washington-based research and consulting firm.

Klein said that users have two choices to deal with a display that's much smaller than the software was designed for. The first is to zoom out to view the whole window or desktop at once, but then, obviously, users have to squint to see everything, and it becomes easy to make the wrong selection from drop-down menus and radio buttons.

Or, users can zoom in on a small part of the screen. "This option largely, if not completely, eliminates the context of interaction from the user's view, including possible computer decision-support guidance and warnings, a dangerous trade-off to be sure," Klein wrote.

In either case, the virtual keyboard makes it even more difficult to read important data that clinicians need to make informed decisions about people's health and to execute EMR functions as designed.

The Advisory white paper cited the November report from the Institute of Medicine, "Health IT and Patient Safety: Building Safer Systems for Better Care," that is sure to become another in a long line of seminal IOM studies on the quality of care in America. Among other things, that volume spelled out the risks associated with poor health IT user interfaces.

"It seems clear that running even a well-designed user interface on a device significantly different than the class of devices it was intended to be run on will lead to additional medical errors," Advisory's Klein commented.

What that means is that native apps, not virtualized desktops, will represent the future of mobile EMRs. Klein suggested that some organizations consider read-only applications for accessing clinical systems on tablets and smartphones, which would prevent errors in data entry on a keyboard that obscures half the screen. But how useful would that be?

Seattle Children's CTO Wes Wright told me last month that the hospital's inpatient EMR vendor, Cerner, has released a native iPad app that is read-only, but he is not interested because physicians there would like to be able to enter data on the iPad. Again, though, they would run into the keyboard issue.

Dictation and cloud-based speech recognition are good alternatives for documenting patient encounters from mobile devices, but not so much when it comes to order entry. Drop-down menus might work in that regard, but they have to be designed for a touch-screen interface, not a mouse/keyboard environment. But sometimes the pre-loaded, templated information is insufficient, so clinicians have to do some manual data entry.

Once again, up comes the issue of a virtual keyboard hogging the screen. And once again, we see that there still is no one "solution" – a term vendors love and I loathe – for clinical data entry on mobile devices.