From platforms to performance to security concerns, leading vendors discuss what’s needed in the next generation of mobile apps for diagnostic imaging.

While mobile devices have long been part of everyday life, their use in the world of health care—particularly medical imaging—is really only in the beginning stages. And once institutions decide to implement the technology, there are a number of different directions they can go, and a variety of applications they can adopt.

“The technology is clearly on the rise,” said Jonathon Dreyer, senior manager, mobile solutions marketing, healthcare division, Nuance Communications. “It’s practical, valuable, cost-effective, and sexy. And as everyone becomes more comfortable in this environment, the benefits will be clear—for us as patients who will see our doctors use these devices, and as patients who will be able to use them to access our own health information. This is going to be a very fast moving environment.”

New Wave of Mobile Applications

After the FDA approved MIM Software Inc’s mobile diagnostic radiology application—called Mobile MIM—almost 2 years ago, a lot of medical imaging-related applications hit the market, many of which failed, according to Dreyer. Some tried to do too much, some tried to be too simple and not do enough, he says. “Now we’re seeing a second generation of applications that are much more tailored and focused on specific tasks.”

Which, he says, is one of the things Nuance has done with the recent release of its application, PowerScribe 360/Mobile Radiologist. The application is designed for medical imaging users to utilize on tablets or smartphones to voice search for radiology–specific content to help with a diagnosis, or to sign off on reports.

“Radiology is an interesting space because traditionally radiologists have kind of been the guys in the basement—the least mobile of clinicians,” said Dreyer. But now, he adds, radiologists are increasingly using mobile devices, whether as a companion device at their workstations, or to access report data or other information when they are away from their stations.

Nuance is working with developers who are developing image sharing applications, said Dreyer, “which is a huge market where we are seeing growth in the mobility space and where we will be able to use these mobile image viewing platforms and add dictation layers to them, so that not only will you be able to view the images on those devices, but you’ll be able to create input as well, using voice.”

And that is important, Dreyer says, because what Nuance hears from physicians—both radiologists and nonradiologists—is that while they have been able to access information on mobile devices, the devices really have not been that great for inputting data.

“I’ve had an iPad for a couple of years now, and I read a lot off of it, and I consume lots of data and information, but inputting data is a little bit of a pain,” he said. “And that’s even more so in the health care space where you have to do more narrative, dictation, and data input.” Creating the ability to add speech to a mobile device makes it that much more valuable, he says.

Jonathon Dreyer, Senior Manager, Mobile Solutions Marketing, Healthcare Division, Nuance Communications

Diana Nole, President, Digital Medical Solutions, Carestream Health

Differing Approaches

This past June representatives of several vendors talked about what’s going on with new mobile medical applications at a session of the meeting of the Society for Imaging Informatics in Medicine (SIIM) in Orlando, Fla.

What became clear, says Diana Nole, president, digital medical solutions, Carestream Health, is that vendors in the mobile application space are taking different approaches as they enter this market, and that there are advantages to each approach.

Nole says that Carestream decided to take into account who is actually going to use the technology, and the environment in which that technology is going to be used—and from there the company decided what kind of approach made the most sense.

Carestream’s Vue Motion Medical Image Viewer was developed for use across the enterprise, so, Nole says, there is a large community of users who will be accessing it. “So the question is, do you develop an app—a dedicated iPad app—or do you do something that’s a little more agnostic?” asked Nole. “It’s easy to think that everything will just be on an iPhone or iPad, but you will have users who are not using an Apple platform.”

So Carestream elected to forego the idea of a dedicated application, and went the HTML5 route, which means its Vue Motion Medical Image Viewer can be used on any operating system. “We do feel we have a broad enough user base when you think about who is using the application,” Nole said. “And we think the HTML5 route will continue to show progress.”

A big consideration in the decision, says Christine Kao, marketing manager, global healthcare IT, Carestream Health, was the issue of workflow. Clinicians working within a health care enterprise are more than likely going to access clinical results and information through an EMR, so “we wondered whether it was reasonable to ask them to download multiple applications so that they always have to remember where they have to go to find information.”

Instead, since EMR companies are already developing their own applications, Carestream links into the EMR as the image enabled piece. “There’s really no rationale for us to do a dedicated application, because we aren’t the entry point into the EMR,” Nole said.

Another SIIM session participant, Mark Cain, chief technology office, MIM Software, points out that when MIM began development of a mobile diagnostic radiology application in 2008, it chose the iOS platform, since there were not many other options available at that time.

“We approached this as a full-fledged medical device,” Cain said. “Not like a clinical utility for records, but a true diagnostic tool.” That objective was based on feedback MIM received from physicians who told MIM they wanted the option, if necessary, to access a portable device to make medical decisions.

Mobile MIM is a thick-client application, which means, Cain says, that data—such as multiplanar reconstructions—are manipulated on the device, as opposed to a thin-client application where the data are continually streamed to the device.

“Having all the data on the device allows for fast manipulation,” he said. “So you’re not dependent on a network connection.”

Cain says that MIM is overcoming some original skepticism about the diagnostic usefulness of the application, particularly with the introduction of the newer iPad, “where the resolution is fantastic—x-rays on that device look remarkably good.”

Visage Imaging has taken a different approach in the sense that it takes a much broader view of what a mobile device actually is.

“When we talk about mobility, we talk about something that is reasonable and practical for someone to use,” said Bobby Roe, director of solutions architecture and customer experience at Visage Imaging, who also participated in the SIIM session. “It should be reasonably portable, so we don’t limit it to an iPhone. It could also mean a laptop, or something like a MacBook Air.”

And with the prevalence of high speed mobile Wi-Fi, Roe says, it is practical to use something like a laptop as portable medical imaging access point, so Visage has written its applications so they can be native on Windows, Macintosh, and iOS.

The Future—What Platform?

Dreyer believes the space seems to be standardizing around one platform—iOS.

“Users have these devices [iPhones and iPads] anyway, and they are comfortable with them,” he said. “And they are also very standard. An iPhone 4 is an iPhone 4, where in the Android environment there are various models and operating systems and that becomes a little bit of an administrative nightmare to support.”

The move toward one platform also helps in the overall adoption of mobile applications, Dreyer says, because it serves to reassure potential users when a lot of developmental work is done on one platform, and other facilities, in turn, begin adopting the technologies supported on that platform.

“We’re seeing that from the speech capture side,” Dreyer said, pointing out that a year ago Nuance was working with 50 developers and since then has seen a fivefold increase in that number. “The sheer fact that there are so many developers doing things in this space gives the end user a lot more options.”

Roe points out that the one platform Visage does not have an application for is Android. “We’re watching the market to see what happens,” he said. “Based on everything I’ve seen, that market for medical imaging is shrinking pretty rapidly, and iOS is already the de facto standard.”

While all of the vendor representatives quoted here believe the mobility application market will continue to grow, some barriers to adoption still remain, including the issue of information security.

“You are talking about health information on portable devices,” Cain said. “And that’s where the real problem comes in. Are facilities comfortable with this?”

Cain says he often talks to IT professionals and CIOs at facilities about MIM’s technology, how it works, and what MIM is able to do to secure it. One security feature MIM may provide in the future would involve the elimination of a patient’s health information from a device after it has been viewed.

“This will provide an extra level of security,” he said. “But we always encrypt that patient health information anyway—administrators just need to understand how this technology can be used in a HIPAA-compliant manner.”

Nole agrees that one of the issues preventing the full-blown implementation of mobile devices across medical facilities is the security issue. “But the nice thing about this space is a lot of people are really working on security applications,” she said.

One possible way of enhancing security could be the use of biometric authentication, says Nole, where use of the device could depend on something like face and voice verification. “We use iPads for our own sales force, so we know that these kinds of features are being developed,” she said. “So some institutions could be waiting to see whether these applications come out [before they adopt the mobile technology on a widespread basis].”

Another complicating factor, Christine Kao says, is the BYOD—Bring Your Own Device—issue. CIOs are probably going to be unable to dictate the kind of device that individual clinicians carry around on a daily basis, so the question becomes how to accommodate the use of these devices. “I think that validates the route we’ve taken of the nondedicated app,” said Kao. “So whether we’re talking about an HTML-based app, or an iPad or an Android device, we feel we have an advantage in helping [a facility] with a BYOD strategy.”

What Do Users Want?

Considering the size of these mobile devices as they existed a few years ago, MIM left some features out originally, says Cain, such as side-by-side comparisons. “How do you get two studies side-by-side on that little iPhone screen?” he said. “So that wasn’t a high priority.” The MIM mobile model, he adds, was based on getting physicians data as quickly as possible when access to a workstation was unavailable—not to do side-by-side comparison studies.

“But with an iPad 3, it’s much more feasible to do, because you have enough pixels,” Cain said. “So that’s something people are asking for. Now I don’t think it’s a terrible problem that people can’t do that, but with the advent of the iPad 3, you can legitimately see more than one study at once for comparison purposes, and that’s something we are working on.”

Cain also points out that there are users who would like to see the software integrate with existing systems, like a PACS. “The model we have now doesn’t allow for that simple an integration,” Cain said. “But that is something we are certainly considering, and we are talking to some PACS companies to see if there are ways to make that possible.”

Performance is another key issue, says Roe, noting that as users become more mobile, they still want immediate—and fast—access to information. Providers such as Verizon, Sprint, AT&T, and T-Mobile are helping to make that possible by rolling out more high-speed networks, he says.

“I was in the New York metro area recently and was testing my new iPad and got cellular network connections of a little bit over 50 megabytes per second,” Roe said. “That’s unbelievably fast—certainly faster than what I can get on my home network. The response time on the Visage application is pretty much instantaneous with anything faster than 2 megabytes per second, so this was 25 times faster than the baseline we hope to see when we do an installation.”

Nole adds that no matter what the mobile application is, users want it to be intuitively simple. “There is something implied in having a dedicated app, and that’s that it has to be easy to use,” she said. “All of us are familiar with the consumerization of these apps, so that anybody can learn them. They’re not intended to require heavy, intensive training.”

They need to be intuitive and should take advantage of those capabilities inherent in smart devices, such as the iPad touch screen that allows you to move around, pan, and zoom, she said. “It needs to be designed so that it’s simple regardless of the technical platform you use.”

Michael Bassett is a contributing writer for Axis Imaging News.