Nancy Luo didn't expect an answer when she e-mailed Steve Jobs one Wednesday evening two summers ago. But less than a day later, an Apple emissary knocked on her door at the University of Chicago Hospitals.
It was Aug. 25, 2010, the last day of a long heatwave in Chicago. Luo -- a second-year resident at the hospital's internal medicine department -- had been assigned the tricky task of figuring out whether a pilot program that put iPads in the hands of the hospital's residents was working out. So she sent a note to the CEO of Apple.
The iPad had hit the market just four months earlier, but the young, tech-savvy residents at the hospital were already using Apple's tablet to access medical data on the go. Luo thought that with some internal tweaking, she could measure whether the students were actually saving time with the iPad. "I just wanted to see if maybe Apple wanted to help us out," she remembers.
Jobs didn't get back to her, but at 5:21 a.m. the next day, she had an answer. Luo didn't even read the e-mail at first, assuming it was some sort of automatic response. But when she did, she was amazed. The note was from an Apple employee named Afshad Mistri, who offered to swing by the hospital later that afternoon -- he just happened to be in Chicago that day. "Your e-mail was forwarded to me for follow up from Steve," wrote Mistri, Apple's medical market manager, the company's go-to guy for the medical industry.
Apple is a company that builds stuff for consumers. Macs. iPods. iPhones. iPads. Though these devices may show up inside businesses, the company rarely promotes them for corporate use, and it has slowly pulled away from the few products it does sell to businesses. Its XServe servers died a premature death this past January. But for some reason, Apple is pushing the iPad into hospitals, playing against its well-polished image as the world's most successful consumer gadget company.
Afshad Mistri is Apple's secret weapon in a stealth campaign to get the iPad into the hands of doctors. And it's a campaign that seems to be paying off.
Meet the iPad Lab Coat
Landau Uniforms started getting e-mails about three months after the iPad went on sale. They were from doctors across the country, complaining that they couldn't squeeze an iPad into Landau's lab coats. The iPad was just too big to fit into the pockets. So, for the first time in its 50-year history, Landau redesigned its lab coats to accommodate a gadget.
Darryl Williams, the company's vice president of sales and marketing, thought at first they'd sell just a few items, but he was wrong. A year and a half later, Landau has three models (including the 7635 model) and the iPad lab coat is one of Landau's top sellers.
Next fall the company plans to introduce "more fashion-oriented coats" for iPad users. That means the same old white lab coats, but with some tapering to make them look a little more shapely on curvy bodies.
If you talk to technical staffers at any large hospital that is using -- or even thinking of using -- iPads today, Afshad Mistri's name is pretty likely to come up. Earlier in November, he organized a cross-Canada series of invitation-only conferences for medical professionals in Vancouver, Calgary, Montreal, and Toronto who are looking at using the iPad at work.
He's also the guy who in September launched a special iTunes room for healthcare, and promoted it to a select group of healthcare app developers.
Everybody who's met him seems to like him. Luo describes him as "super friendly, super charasmatic, down-to-earth guy." True to his name, and Apple's inscrutable public relations practices, Mistri declined to comment for this article.
He can't talk to us because Apple fires employees who talk with the press without permission, but also because the company must walk a fine line in the medical arena. Right now, the U.S. Food and Drug Administration seems set on regulating the software that runs on the iPad, not the device itself, but if the FDA were to decide that Apple is marketing the iPad for regulated medical uses, it could unleash a regulatory nightmare on the company.
Apple has to carefully watch what it says when it talks about the iPad in medicine, says Bradley Thompson, a partner with the law firm Epstein Becker Green and an expert on FDA regulations. As long as they promote it as a general-use computing device, Apple should be fine. But "if they were promoting it for specific medical device uses," he says, "they would cross a line."
Mistri isn't new to the medical profession. According to his LinkedIn profile, he got a bachelor's degree in computer science and then cut his teeth as an engineer on the Tomahawk Cruise Missile Program during the late 1980s. He got into using computers to display 3-D images, including an x-ray technology known as computerized tomography (CT) during a 15-year career at Silicon Graphics before jumping ship to Apple five years ago.
Like some rare subatomic particle, he's existential proof that Apple sees iPads in the hospital as a special phenomenon. "Just the fact that he exists, that there's a director for medical marketing, tells you it's different because Apple never does vertical markets," says Elliot Fishman a professor of radiology at Johns Hopkins. "The fact that two years ago they assigned someone to that position tells you there is a difference."
The Doctor's Best Friend
Fishman is one of a growing number of doctors who look at the iPad as an indispensable assistant to his medical practice. He studies 50 to 100 CT scans per day on his tablet. Recently, he checked up on 20 patients in his Baltimore hospital while he was traveling in Las Vegas. "What this iPad does is really extend my ability to be able to consult remotely anytime, anywhere," he says. "Anytime I'm not at the hospital, I’m looking at the iPad."
For some doctors at Johns Hopkins, the iPad can save an hour to an hour and a half per day -- time that would otherwise be spent on collecting paper printouts of medical images, or heading to computer workstations to look them up online. Many doctors say that bringing an iPad to the bedside lets them administer a far more intimate and interactive level of care than they'd previously thought possible. Even doctors who are using an iPad for the first time often become attached, Fishman says. "Their biggest fear is what if we took it away."
Apple's devices are especially popular with students and residents such as Luo. Patients at Johns Hopkins' pancreatic clinic get iPad loaners to track their treatment. At Stanford's catheterization and angiography laboratory, they're a way of giving patients something to do -- they can watch a movie or catch up on e-mail -- during boring wait times.
An iPad Infection?
Apple's advice for cleaning the iPad is pretty clear: "Keep liquids away from the product." But at the University of Chicago Hospitals, residents in the internal medicine training program have chosen to ignore that. And for good reason. They don't want their iPads to make their patients sick. "The transmission of infectious disease issue was one of the most significant challenges to deploying the iPad," says Christopher Chapman, a clinical instructor of medicine with the hospitals. But they've decided to stick on screen protectors and treat the iPads pretty much like a stethoscope or a necktie. They tell residents to use regular hospital disinfectants such as Cavicide spray between patient visits. At the Virginia Hospital Center, in Arlington, Virginia, doctors have tested out the iPad in the operating room, and come up with a simple but effective solution. Clamp a sterile plastic bag over the tablet.That helps doctors, too. Residents at the University of Chicago Hospitals have 28-hour on-call shifts and when things quiet down at night, it's often time to break out the iPad. Some will do their e-mail or even catch some video. Luo is partial to Fruit Ninja. "It helps pass the time a little," she admits.
And though hospital sterilization techniques might run slightly afoul of Apple's prescribed cleaning techniques, iPads have even been spotted in the operating room.
It's a story that's been repeated again and again in small-scale projects at hospitals everywhere since the iPad's April 2010 launch. Now, some of those hospitals are getting ready for some really big rollouts. In October, the Veterans Administration started soliciting bids from contractors to help them manage as many as 100,000 tablet users across its network of 152 hospitals.
The VA has just about 1,500 iPads in limited trials right now -- most of them in its Washington, D.C., hospital. But if things go as planned, the VA, with a staff of 315,000, could easily be managing many more devices in a year's time.
"We are the largest medical training organization in the country. We bring in 115,000 medical residents every year to help us provide care to veterans," says Roger Baker, the VA's chief information officer. "A large number of those folks come in with a mobile device and they want to know why they can't just use that."
It may seem strange that the same government organization that was rocked by a major league data breach just five years ago is now at the vanguard of mobile computing. But Baker thinks that he will help lock down the VA's data by being quick to allow the iPads, while simultaneously placing strict controls on how they are configured and used. "There's huge demand," he says. "We have to balance that demand with the information protection requirement."
Hospitals aren't speedy adopters of new computer technology, but the iPad has freed up doctors to read papers and look up information no matter where they are -- at home, while traveling, or doing hospital rounds. That's a big deal, says Iltifat Husain, an emergency medicine resident physician at the Wake Forest University School of Medicine in Winston-Salem, North Carolina, who edits a blog about mobile medical apps. "Initially hospital were saying, 'no, you can't bring the device,'" he says, "they were really discouraging their use. But if you look at it now, they realize that you can't just keep pissing off the physicians."
Canada's Ottawa Hospital uses close to 3,000 iPads, and they're popping up everywhere -- in the lab coats of attending physicians, residents, and pharmacists. For hospital CIO Dale Potter, the iPad gave him a way out of a doomed "computer physician order entry" project that was being rolled out hospital-wide when he started working there in 2009.
It sounds complicated, but computerized physician order entry really means something simple: replacing the clipboards at the foot of patient's beds with a computer, so that doctors can order tests, prescribe drugs, and check medical records using a computer rather than pen and paper. In theory, it's a great idea, but in practice, many of these projects have failed, in part because of the clunky and impersonal PC interfaces: Who really wants to sit down and start clicking and clacking on a PC, moving a mouse while visiting a patient?
The catalyst for his hospital's move to the iPad was Potter's own anxiety about this medical records project becoming a complete failure. Even if there were PCs in every room in the hospital, doctors probably wouldn't use them. Potter says that the typical doctor, "is not going to take the time to open up the health record, find the patient, find the appropriate document, fill it out, and push enter to enter an electronic order. They're going to scribble it on a piece of paper."
After an anxious 2009 Christmas break, Potter finally saw his ray of hope. He heard about a new tablet coming from Apple later in 2010: the iPad. Though the iPad wasn't even available in Canada, he picked up a pair of them during a spring trip to Las Vegas and brought them back to Ottawa for testing. To get one of them, he had to hand over an extra $200 cash to a student who was about to buy the last one in the store.
But it was money well spent; within a half-year, he had what he was after: an iPad app that talks to the hospital's medical records system.
Potter has rolled out more apps and iPads at the Ottawa Hospital since then, and medical staff has requests for another 100 apps in the pipeline. "The worst thing you could ever do is to try to take these iPads out of these environments," he says. "You'd be lynched."
Steve Jobs and the Pixar Connection
Doctors may like their iPads, but it's not entirely clear why Apple cares so much about them. After all, Apple likes to promote its products broadly as consumer devices. So why have a guy like Afhsad Mistri spending his days talking to doctors and medical software developers? Why is healthcare the one vertical market that Apple promotes on its iPad apps for business page?
As with so many questions about Apple, the answer links to the late Steve Jobs. Apple's founder was interested in medical technology long before he took ill. But one can't help but wonder whether all that time in hospitals during his final years had some effect. After all, this was a man who, deeply sedated and dying from cancer, once ripped an oxygen mask off his face, mumbling that he hated the design.
When Jobs acquired Pixar in the late 1980s, the company worked with Fishman and Johns Hopkins, trying to make a go of it in the medical imaging market. The project failed because Pixar's CT system cost a lot and took about a day to produce an image. Fishman remembers doing a demo with Bob Drebin, then a Pixar engineer, in the late 1980s. The patient showed up at 8 a.m. "It was a fracture," Fishman recalls. "Ten minutes later the surgeon came, and said, 'Where are the images?' I said, 'Come back tomorrow, same time.' And that was the end of the story."
Drebin went on to build the Nintendo GameCube graphics processor. He's now Apple's graphics processor guru.
Jobs took a personal interest in medical imaging back in the Pixar days, and he and Fishman stayed in touch through the years. In the late 1990s, Jobs sat in on a Stanford Grand Rounds lecture that Fishman gave on 3-D medical imaging. Fishman is one of the country's foremost experts on medical imaging and a polished speaker, but he was intimidated. "I'd given a lot of lectures at many, many places and that was the only lecture I was afraid of," he remembers. "I figured if I said something wrong to a bunch of radiologists on 3-D, they would never know the difference. He might."
In 2010, around the time Luo was writing her e-mail, Fishman and his daughter paid Jobs a visit in August 2010. Jobs invited him to do a demo for senior iPad execs of some iPad 3-D imaging software designed for Siemens by a company that Fishman co-founded, HipGraphics.
Fishman can't say if Jobs' illness made him more interested in helping out doctors. And Apple won't end up selling millions of iPads to hospitals. But it's not impossible to imagine that at a time when some are saying that Silicon Valley is no longer producing anything important, Apple believes that improving doctors' lives might just be the right thing to do.
There's an intangible appeal that comes from making things better for sick people who are seeking help. "People in computer science are always interested in medical imaging," Fishman says. "They always like to think that, you know, maybe Angry Birds is good but something medical might actually change the world."
Apple is subtle about promoting the medical uses of the iPad, but it does. Spot the two medical apps in this ad (AirStrip Cardiology and Mobile MIM).
