Technology in Medicine

[ Introduction and Background ]

Previously, I discussed the merits and problems of my first keyboard case for the iPad, the ClamCase. While it still remains one of the best options available, a few factors have prompted me to search for an alternative case.

Just as a reminder, I am a Neurology resident at a training program at a large academic hospital that has three Neurology primary services and three consult services as well as a smorgasbord of general and subspecialty clinics. This hospital has a browser-based online medical record and order entry system that makes it very easy to use an iOS or Android device (or a laptop) to perform digital tasks to contribute to the medical care of patients. For the second year in a row, the program is issuing iPads to its incoming junior residents. Our program, in particular, generates massive amounts of admission, consultation, and progress notes (which include “accept notes” for all junior residents assuming the care of new patients, even if another admission note is available, and “chief accept notes” for chief residents in a similar position). Accordingly, having a method of performing actual word processing on the iPad is an attractive objective.

In the setting of my wife (also a Neurology resident) researching cases for her new iPad which her residency program is issuing to her for a similar purpose, I have sought out alternatives to the ClamCase. In particular, my desire was to find a solution that matched these criteria:

1. Battery Life – Perhaps the most important factor is that the keyboard case should have a very long and stable battery life. In my line of work, I can’t afford to sit down and plug in when I might have to respond to a Code at any given moment.

2. Weight – The ClamCase essentially doubles the weight of the iPad and adds considerable heft to the standard Neurology bag. I would prefer a lighter case if possible.

3. Comfortable Keys – Many of the iPad keyboard cases have relatively poor quality keys or oddly arranged keys that provide an unsatisfying experience that ultimately slows down the typing process, and hence, reduces productivity.

4. Protection – I would want a case that offers sufficient front face and rear encasing protection for the iPad. Sadly, I previously dropped an iPad in the line of duty (running to the Emergency Room to respond to an emergent consultation for a life-threatening traumatic head bleed). At the time, I was using the standard Apple “Smart Cover” which offered no front screen protection, particularly when it slipped out of my hand and landed glass-side first on the tiled floor!

[ Hypothesis ]

There must be a keyboard cases that provides a suitable balance between battery life, light weight, keyboard layout, and protection.

[ Results and Discussion ]

After viewing and trying out several cases in a local store including the Zaggfolio, Targus Versavue, and Logitech Solar Folio, I have recently settled on the Logitech Ultrathin Keyboard cover. The Zaggfolio and Versavue keyboards lacked a good typing feel (lack of spring in the keys). The Solar Folio is a nice option, but it lacks any backup method of charging besides the six hours of natural or incandescent lighting required to charge the keyboard battery. Nonetheless, I also had a lot of reservations about the Ultrathin Keyboard cover initially including the following:

1. It offers almost NO protection. – This is not actually a “case.” It is essentially a svelte version of the Apple Smart Cover with a built-in “chiclet” keyboard. It connects to the iPad with a magnetic hinge, providing a cover for the glass screen when closed but otherwise not contributing any protective benefit, particularly to the rear of the case. It additionally will do nothing to protect the glass screen when opened.

2. It cannot be flipped 360 degrees. – Unlike the ClamCase, the cover has to be detached in order for one to use the iPad comfortably. In other words, the cover cannot be flipped across the rear encasing of the iPad: the hinge will not allow for that much rotation. Fortunately, the cover is extremely easy to detach, but this is somewhat disappointing feature of the design.

3. It has few viewing angles. – Unlike the nearly 360 degrees of viewing angles offered by the ClamCase, this cover only allows for a single viewing angle which is approximately 60 degrees from the table. It is a relatively steep angle that makes typing on one’s lap potentially awkward when sitting upright.

4. It was not clear whether or not other protective encasings would be compatible with this device. – Some user reviews described being able to encase the iPad in a plastic shield whereas others vehemently denied this possibility.

5. Several users described not being able to type on their laps with this keyboard. – Since the keyboard is very light, some users expressed concern about the possibility of the top-heavy iPad toppling over their knees and onto the floor when trying to type on their laps.

Nonetheless, I decided to take the plunge and attempt to fit a Belkin Snapshield onto the iPad 2 and then see if this would be compataible with the Logitech Ultrathin Keyboard cover. Fortunately, this gambit paid off, and the finally result can be seen in these pictures.

This keyboard cover does have several key advantages:

1. It is very light. – Carrying my iPad and this keyboard in my bag feels almost weightless compared to the past several months when I was carrying the ClamCase.

2. The keyboard has a good feel. – While the keys do not have the laptop-style feel of the ClamCase keyboard, there is a slight separation between the keys that offers a good degree of spring. The feel is superior to most other keyboards incorporated into keyboard folio cases that I tried.

3. It is attractive and streamlined. – When attached to the iPad, it maintains a slim profile, approaching that of the MacBook Air.

4. It is compatible with the Belkin SnapShield. – At the very least, the iPad 2 with an iPad 2 SnapShield and the Logitech Ultrathin keyboard are compatible together (which has been corroborated by at least one other user). This may not be the case for the third generation iPad and associated SnapShield as the dimensions are slightly different. Having the SnapShield offers rear encasing protection for the iPad, attenuating the lack of protective qualities of this keyboard cover.

5. The cost is less than the ClamCase. – The Logitech keyboard is $100 while the SnapShield was an additional $30, making it slightly cheaper than the ClamCase.

[ Conclusions ]

Time will tell whether or not this combination of keyboard and case will be sufficient for the demands of the hospital, but at this time it offers a lightweight and attractive alternative to the ClamCase. Thus far, I have been using it for three days, including during noon conferences and lectures and during my continuity clinic for my clinic notes. My hope is that the battery is longer lasting and more stable than that of the ClamCase, and that the light weight does not come at too much cost with regards to reduced protective qualities.

Previously, I discussed the merits of the ClamCase, an innovative and useful keyboard case for the Apple iPad. Of all of the higher end and pricier keyboard cases, it definitively remains one of the best options available for the production of written content on the iPad. During the past seven months, I have written numerous admission, consult, and progress notes every day I have worked in the hospital, and I have additionally written weblog posts and numerous e-mails. I often had a hospital computer open to an electronic patient record while having the iPad open to a new word processing file which would allow me to type notes and read simultaneously. Unlike a laptop, the iPad with a keyboard case allows for instantaneous access for quick tasks at the bedside and while rounding (such as typing in an order in tablet form with one hand holding the device and the other hand tapping the screen and typing) while also allowing for comfortable word processing and reading. The combination of the ClamCase and iPad 2 essentially replaced my old laptop (a previous generation of MacBook of the black plastic variety) except for the occasional Photoshop task or for iTunes file synchronization and backup.

However, there are a few important disadvantages of the ClamCase which may or may not be generalizable across the product line. First and foremost, the battery life of the device is variable. Initially, I did not have to charge the keyboard for days at a time, but about five months into its lifespan I discovered that it was losing its charge during the course of a day’s work. After some weeks of experimentation, I have not found consistent behavior of the battery in response to overnight charging and roughly comparable usage each day, leaving me with some degree of anxiety as to whether or not it will keep its charge during a particularly busy day of consults and admissions. I suspect that this is the result of me not treating the battery correctly, but most people do not maintain good battery charging practices which makes me wonder how often customers have difficulty with the battery for this keyboard case.

There are a few other additional small and surmountable issues. The case is heavy: the weight of the device essentially doubles the weight of the iPad. The four protective pads on the keyboard side of the case which elevate the keys off table surfaces when flipped into a video viewing mode quickly lost their adhesive and tore off easily. The keyboard additionally has very nice laptop-style keys, but some do become slightly sticky with time, sometimes causing the keyboard to produce a string of repetitive letters which sometimes would require exiting from an app to interrupt. Over time, this has become a more frequent occurrence. Lastly, on a purely cosmetic level, my white version of the keyboard case very easily stained on the bottom surface within a week of ownership.

In summary, the ClamCase has been an incredible boon to my productivity on the hospital wards, but after seven months my particular device has aged and is starting to run into difficulties. Some user reviews have commented on issues with maintaining the battery’s charge and not being able to trust the green/amber indicator light. If I had assurance that the battery issues has been fixed, I would certainly purchase another ClamCase, but in the mean time, I have started to look into alternative options.

[ Introduction and Background ]
Tablet computing has grown at an incredible rate over the past year. Surprisingly, even physicians and hospitals have adopted this technology in relatively large numbers, considering that many hospitals and clinics continue to rely on paper-based charts, fax machines, and ledger-style appointment tracking. Some hospitals transmit blood draw orders by having them placed in a computer by a physician, printed out by a nurse, and dropped in a paper slot for a phlebotomist to collect. In spite of this archaic backdrop, the iPad in particular has blazed a trail to the bedside of the patient. A number of medical schools and residency programs are actually buying iPads for their students and residents, sometimes with and at other times without a clear idea as to how the tablets would be used. One thing is certain: that tablet computing has made its inroads into the medical community, and it is here to stay.

While tablet computers have a variety of uses for consumption by medical trainees such as reading textbooks (whether through the Kindle or iBook stores, individual apps developed by big publishers, or through interactive textbooks that are being developed) and watching instructional videos (e.g. how to perform an arterial blood gas), production of new content has major barriers. In particular, most people do not find the glass keyboard of the iPad comfortable enough to type anything longer than a short e-mail. Even for me, someone who has used computers since an early age with good manual dexterity, I find that even the iPad 2 with its faster processing speeds and reduced typing-key-to-screen delay is too cumbersome and can be a hindrance to efficiency, an achievement so rarely acquired in health care delivery settings. I have tried using text expansion and templates to speed up the process, but writing an admission or consultation note remains a chore.


[ Hypothesis ]
Accordingly, I was very excited to discover the ClamCase, a keyboard case for the iPad and iPad 2. Unlike other keyboard cases, it has a hard shell and seamless method of connecting the Bluetooth device to the iPad. I suspected that this device might succeed where others might not: in facilitating a rapid means of text input in the medical setting into a device that is built for speed and convenience.


[ Results ]
The ClamCase, as one might expect from the name, has two halves like the shell of a clam. The iPad snaps into place in the top half: two lips hold the iPad tightly into place. The top half has indentations to allow for head phones and the charger to be plugged in; recesses for the power, orientation, and volume buttons to be accessed; and a cutout for the rear camera to take pictures and video. Unlike with some other cases, the alignment is perfect. The bottom half houses the recessed keyboard, two indicator lights, and rubber bumpers on the top and on the bottom to protect the iPad screen and provide friction on the bottom to prevent sliding. The bottom half has a small USB port for charging with the cable provided (which can be plugged into the same AC adaptor as that used by the iPad). The two halves are connected by a tight hinge which feels very sturdy.

The case itself has a spectrum of orientations. When completely closed, it provides full back, front, and edge protection for the iPad as though it were a laptop. It can then be pulled opened and angled in the same way (90 to 120 degrees) as a laptop. However, it doesn’t stop there: the hinge rotates a full 180 degrees, allowing you to use the keyboard face of the bottom half as the support/stand for the device, allowing for easy access to the screen when reading at a table or watching a video. Finally, the case can be fully folded back and used as a tablet held in one hand and directed with the other.

The case does have some weight and nearly doubles the weight of the iPad. Of note, much of the weight is in the top half of the case, meaning that tilting the screen too far back while it rests on a slanted surface that the rubber grips can’t hold as well (like a lap) can cause it to topple over if one isn’t careful.

The case comes in three colors: white, black, and a limited edition aluminum/brushed metal finish.

Typing on the keyboard is surprisingly pleasing. The keyboard is notably smaller than a full-sized keyboard, but this is the same trade off one would find with a netbook of a similar size. After a few minutes, I found that I could easily touch-type the way I would with a full-sized keyboard.

The Bluetooth connection between the keyboard and iPad is one of the best features. After the initial setup, the keyboard connects to the iPad 2 automatically. Like other magnet cases, the iPad 2 activates the lock screen or turns on when the case is opened. After clicking any key on the keyboard, the keyboard emerges from its “sleep” or “suspend” mode and immediately connects to the iPad as indicated by the flashing Bluetooth symbol at the top right of the iPad screen. After a couple of seconds, the synchronization is complete, and one can start typing. As expected, the keyboard returns to a sleep mode when it has not been used for some period of time. It is possible to turn on and off the keyboard as well when one does not want to accidentally press the keys (for example, when using the case in tablet mode wherein the keys would be resting against a surface such as one’s forearm).

Lastly, the keyboard offers a number of features that would be missing from a non-keyboard case: keyboard commands (such as copying, pasting, cutting), arrow keys, easy access to numbers and letters and punctuation on the same spread, and finally special characters (such as accents).

[ Discussion and Conclusions ]
While all keyboard cases would add much needed ease of use and additional functionality to the iPad, the ClamCase appears to stand ahead of the crowd. After inserting the iPad into the case, the device and case truly feel unified. One does not need to keep plugging and unplugging the iPad from the keyboard. Many other cases have a “pasted-on” feel to the keyboard which might add extra bulk but very little form factor or protection, but the ClamCase makes one forget that this isn’t actually a traditional laptop. The landscape orientation feels much more natural for word processing than does the portrait orientation used by some other keyboards, an orientation that is better suited for stylus writing on the screen.

The convenience, utility, and form factor do come at a price, though: $150 for the iPad and iPad 2 versions. Most keyboard cases come at a price ranging in the $50 to $150 range. Nonetheless, while some balk at the idea of spending more money on an already expensive device, the money could be very well spent if the added functionality is worth it. For me, my impression thus far is that the added value of a solid keyboard for generating medical notes (in the setting of a medical record system that lacks text expansion, a medical team structure that suffers from long rounding times and frequent activities that removes one from the ward computers, and a service that has a high admission and consultation rate) is well worth this price.



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