Healthcare Software

Key Themes in Health Software for 2011

Our healthcare team just returned from HIMSS 11. In the conference talks, and in walking the floor and talking to vendors, I came across a number of common topics and themes that I think will be driving factors in 2011.

Healthcare Technology Roundup: Cloud Computing

There is a lot of confusion in the industry around what “cloud computing” really means. Often, marketing communications that refer to a “cloud solution” actually mean an ASP offering with a SaaS business model.

True cloud computing is the use of virtualized servers that can be scaled on demand based on varying levels of resource requirements at run-time. For example, an application running on a cloud can programmatically turn on five servers in response to a spike in demand for computing resources. Several mature solutions include Microsoft Azure, Citrix, VMWare, Amazon Elastic Compute Cloud and Google App Engine.

What are the opportunities for healthcare innovation?

By making use of cloud computing, vendors can in theory enhance traditional ASP solutions by offering:

• Scalable hardware. Additional hardware can be turned on based on need.
• Efficiency and performance. Since servers are virtualized, different instances can reside on the same hardware. The instances can be moved around depending on need to make the best use of the hardware without compromising performance.
• Increased availability. Cloud hardware is distributed and fault tolerant. Cloud providers promise 99.95% availability. From a technical perspective, a cloud would be the best option for delivering a solution on scalable and fault tolerant hardware while still delivering on performance requirements.

What constraints does the technology face?

With ASPs, there is definite knowledge as to the location and ownership of the housed data thus satisfying privacy and data security laws. True cloud computing, on the other hand, is not in widespread use with EMRs since it is an issue of controversy due to privacy and security risks.

Some platforms such as Microsoft Azure offer private clouds to organizations facing trouble with compliance. At this time, however, this solution is intended for very large organizations who are working with at least 1000 servers, likely outside the scope of any major hospital. Microsoft has recently begun a push into the Healthcare IT space, so the time may be right to look to Microsoft for future innovations in cloud computing as it applies to EMR systems.

Until then, there are other ways for organizations to pump up their ASP offering – for example offering a client application with a richer user interface, more logic and even an “offline mode.” Technologies such as WPF and Adobe AIR represent a first step towards the creation of such rich clients.

Healthcare Technology Roundup: Mobile Home Care Devices

Mobile home care devices are pieces of hardware that allow patients to communicate the current state of their illness to a healthcare provider from home. Although still in the development stage, the potential for managing chronic illness is clear, and development of home care devices is moving quickly to meet the demand of our aging population.

Examples of existing mobile home care devices include blood pressure monitors, weight scales, glucose meters, pulse oximeters, and peak flow meters. One such device is Intel’s HealthGuide, which offers a variety of solutions to the patient in his own home.

What are the opportunities for healthcare innovation?

• Usability. Patients using these devices are often ill and/or elderly. The devices must be intuitive and robust, putting home care ethnographic study and other usability techniques at the forefront of innovation.
• Continuous data stream. Physicians can monitor patient activity and catch problems before they become severe. The EMR will become a meeting place for patient data.
• Access to CDS systems. A clinical decision support system can monitor patient readings and alert physicians to cases that need special attention. This can help physicians to be more efficient.
• Empowering patients. Inventive features could maximize the activities that can be taken on by the patient remotely, such as picking up prescriptions and scheduling interventional procedures.

How is this technology applied in healthcare today?

At the time of writing, Intel and GE Healthcare recently formed a new company in a joint effort to meet the future needs of telemedicine. In their vision, mobile home care devices will interact with EMRs to deliver the data to those in charge of the patient’s health. While this is the hot topic of the moment, most major Healthcare IT vendors (as well as many smaller organizations) have a telemedicine and home care product portfolio.

Many existing home care devices are standalone solutions that are used by the patient at home and then brought to the hospital or clinic during a scheduled visit. The data is then transferred into the EMR so that the physician can refer to the data in his interpretation and clinical notes. This process is often cumbersome, which has lead companies like Cardiac Science to offer a solution to bridge the gap between device and EMR so that integration is more automatic.

What constraints does the technology face?

Probably the biggest limitation to widespread mobile homecare device adoption is cost. Unless these devices can be cost effective, the average patient will not purchase one. In most cases, the devices are loaned out to patients who need special monitoring and reused by other patients down the road.

To counter this challenge, there is a growing push for home care software on consumer devices. The LifeScan Diabetes Monitor and Zume Life self-care service are both currently available on iPhone.

Vince Kuraitis, a thought leader in the growing home care industry, sums it up nicely:

“Think about your user experience when you get into your car into the morning. You are greeted by a dashboard of information about the vital processes in your car -- fuel availability, fluid levels, driving speed, etc. You know that if something goes wrong with a major system, you'll get a "check engine" notice.

Now think about your user experience with your body. What do you know about the vital processes going on in your body right now?

Remote patient technologies are beginning to provide the analogous dashboard to help people monitor vital processes and to take appropriate actions if something goes wrong.”

Healthcare Technology Roundup: Clinical Decision Support

As patient volumes increase, it can become difficult for providers to remember medical background material specific to each and every case. A Clinical Decision Support (CDS) system combines both background knowledge and case-specific information to help the provider make better decisions. A CDS can point a provider to reference material and information, perform certain actions, or supply alerts.

What are the opportunities for innovation?

EMRs are benefiting from CDS system integration by keeping medical knowledge at the fingertips of healthcare providers. Opportunities to push the envelope include:

• Learning patterns of care. Some CDS systems do not require a pre-developed knowledge base, but rather apply machine learning algorithms on medical examples fed into the system. Others can apply machine learning to build knowledge about user behavior. This concept exists in academic publications but the challenge remains to make this a widespread commercial reality.
• Reducing alert fatigue. When users receive too many alerts, they may begin to ignore serious alerts.
• Improving usability. Organizations can innovate by increasing the intuitiveness and speed of access in CDS systems. To date, whenever a CDS has been integrated into an EMR, the combined system has tended to behave as two distinct systems with different flows. Companies that can address this problem and improve usability stand a good chance of becoming leaders in the space.
• Sharing CDS. Multiple healthcare facilities can share anonymous data about clinical decisions so that they can benefit from each other’s behavior and improve the quality of patient care.
• Improved matching algorithms. Strong algorithms that match case instances to a knowledge base will deliver more pertinent information to users.

How are CDS systems used in healthcare today?

Most of today’s CDS systems provide clinical reminders for patients, identify possible risks for adverse events and errors, analyze clinical performance, and encourage adherence to standards of care.

The most common use of CDS/EMR integration is to identify drug-to-drug interactions. Popular solutions for e-prescription and drug interaction detection include DrFirst, RxNT, Medi-Span and a host of others.

A CDS can also be deployed as a stand-alone package that provides a lookup of medical knowledge. The Isabel and Elsevier CDS tools currently offer this functionality.

What constraints does CDS technology face?

• Patient data model accuracy. Patient data must be entered consistently for a CDS to contain accurate information.
• CDS system accuracy. The CDS system needs to be intelligent enough to be able to correctly identify similar cases and present them to the user when requested.
• Alert fatigue. A CDS system must take care to only alert the user in critical situations. Otherwise, the user will suffer from alert fatigue and ignore all alerts.
• Usability. CDS systems are often developed independently from EMRs and then integrated. This process limits the usability of the CDS. Users may choose not to use the CDS or become frustrated when it takes them too long to get to the information they need.

When a CDS becomes a nuisance as opposed to an aid – either because of inaccuracies, poor usability or alert fatigue – the system loses value and users simply abandon it. Organizations that can closely integrate their CDS with an EMR and overcome the obstacles mentioned above will have the best chance to stand out from the crowd.

Healthcare Technology Roundup: Unified Communications

Hospital team members are spread across departments and have different working hours. Patients at home using self-monitoring devices can encounter a problem at any time. As institutions continue to adopt software solutions, there is a growing opportunity to enhance their work and communication through Unified Communications (UC), which merges real-time methods of communication such as voice, video and chat with others such as email, SMS and voicemail.

UC solutions such as Microsoft OCS, Cisco HealthPresence, Avaya and Telus - Community Health Care can help organizations fully integrate EMRs into their clinical workflows. An open source UC solution, Asterisk, is also quite popular.

What are the opportunities for innovation?

The component technologies of unified communications are of benefit to EMRs by facilitating professional-to-professional, professional-to-patient and patient-to-professional contact in order to create a much more fluid environment. With such technologies deployed, the EMR would become a meeting place where there would be:

• Recording of physician and patient consultations. These can be added to EMRs for patient playback in case something was missed.
• Virtual waiting rooms. Patients can queue remotely and wait in the comfort of their home, coming to the clinic only when the office is ready for them. The patients would be able to perform this action through the patient portal component of the EMR.
• Virtual consultations. Video conferencing would allow patients to visit physicians without having to actually come into the office.
• Supervised tests. Currently, with EMRs like GE Centricity, physicians can supervise tests via remote monitoring diagnostic systems. With integrated UC, they would be able to monitor both the computer terminal as well as the video from the examination room.
• Telehealth with video conferencing. At present, Telehealth solutions require users to call an expert by telephone. With the functionality of UC, video conferencing would be possible – giving the expert on call the ability to see symptoms and give more accurate advice.

By incorporating UC into your offerings, your organization could add a great deal of value to a hospital’s EMR since it would bind all communication services into one package.

How is UC applied in healthcare today?

Cisco and Allscripts have formed a partnership to integrate UC with their EMR solution, offering solutions like patient reminders, messaging, and intelligent call routing. GE Healthcare piloted Microsoft’s UC solution with fanfare, but these two software solutions currently operate independently.

What constraints does the technology face?

In addition to the general high cost of teleconferencing and videoconferencing hardware, integrating UC into the EMR poses the following limitations:

• Larger installation. An EMR is already a daunting task for a healthcare facility. Grouping a UC solution with that of an EMR would require an even larger overhaul of existing infrastructure. It may be better to install them separately with adapters in the EMR to allow for integration.
• Loss of personal contact. There is a strong value to face-to-face meetings in healthcare. It may be some time before the quality of low-cost virtual meetings is sufficient to inspire trust in workers and patients.

Despite these constraints, vendors are starting to explore how to best leverage current technology and innovate. EMR/UC integration is still at an early stage, however, which offers your organization the opportunity to be one of the first to truly utilize and promote unified communications in the healthcare industry.

Healthcare Technology Roundup: UI Design and Rich Internet Applications

One of the most challenging aspects of developing an EMR is designing the user interface. With an EMR, there is so much information and so many data elements, forms, tasks and actions to organize due to the large variety of user behavior patterns. As a result, most EMR applications tend to look the same, leaving UI design as a major opportunity for differentiation.

When an interface design needs to be created for the web (be it an ASP web-based EMR or a patient portal) it can become even more difficult to make it visually impressive and highly usable. The emerging rich internet application (RIA) technology provides the opportunity to design rich and consistent web-based user interfaces.

RIA technologies include Adobe Flex, Google Web Toolkit, Silverlight, and, to some extent, the upcoming HTML5/CSS3.

What are the opportunities for innovation?

The opportunities to create innovative UIs are limited only by the creativity of the designers and developers. Today’s designers should certainly take advantage of:

• A rich look and feel for user interface widgets. Menu animation, drag and drop components, and more advanced controls such as stack panels are available out of the box with today’s RIA technologies.
• Multimedia content. With RIAs, it is easier than ever to include rich content such as graphs, audio and video using built-in controls.
• Faster responsiveness. Since these applications run in the client browser, program responsiveness is quick. Technologies like Silverlight can take advantage of hardware acceleration to speed up video rendering. An important thing to remember with RIA technologies is that they don’t have to be used throughout the entire application. The richness they provide can be applied in choice areas in order to augment the experience offered by the application as a whole.

How is RIA technology used in healthcare today?

Due to the advantages a rich web interface provides, many EMR vendors already use such technologies. Examples of EMR vendors using RIAs to deliver their solutions on the web include:

What constraints does RIA technology face?

Despite the advantages of a rich web interface, the use of RIAs has some limitations.

• Upgrade runtime environments. RIA containers for Flash and Silverlight need to be upgraded in order to function properly. Functionality changes from one version to the next and it requires support from the developers.
• Risk of data loss. With client-side browser applications, data is entered on the client and periodically sent to the server. Users can accidentally close the browser or navigate away from the page and data can be lost. Well implemented auto-save functionality will avoid this.
• Slower initial page load. Since the client is heavy, the initial load of the page is often slower. Once loaded, however, the application is more responsive.

When designing an innovative UI, be sure to consider more than just the look and feel. A good UI is both visually attractive and easy to use. Working with a development partner that has both usability and RIA experience can help you create a user interface that is both appealing and intuitive.

Healthcare Technology Roundup: Patient Health Records (PHRs)

The future of healthcare is one in which the patient is more actively in charge of his health data. As proclaimed in a widely publicized CNN report early this year, patients are demanding control of their data. The California Health Foundation reported that although only about 7% of adults use a Personal Health Records (PHR) system today, 40% express interest in using one.

As patient-centric platforms such as Microsoft HealthVault and Google Health gain in popularity, EMR vendors have an opportunity to stand out by offering novel connections to these types of platforms.

What are the opportunities for innovation?

By creating innovative applications for patient health records, companies have the opportunity to help healthcare organizations:

• Improve patient tracking. Clinicians can closely track patients who regularly enter data into a PHR and can perform disease management, oversee progress and track medication dosage.
• Encourage patient participation. When patients become interested in their health, they often take better care of themselves. Having the EMR push data to their PHR will help them to learn more about their health.
• Save administration costs. A major advantage of a well-designed PHR system is to allow patients to book their own appointments or upload diagnostic results from a specialist themselves.
• Provide Clinical Decision Support (CDS) to the patient. As discussed in the next section, alerts and other elements of CDS could be provided to the patient.
• Offer social network integration. The growing Health 2.0 movement is exploring the integration possibilities between social networks and healthcare systems. Through PHRs, patients could interact with one another. Physicians can also participate and provide support on forums or in online group discussions.

Providing a patient with easy access to their records also satisfies the regulatory requirement that patients be given copies of the record should they ask for it.

How are PHRs used in healthcare today?

Most EMRs are currently implementing their own quasi-PHRs via patient portals. The eClinicalWorks patient portal website is a good reference for the types of features offered. These are not PHRs in the classic sense because the patient is not able to transfer his data to another application, unless he does it manually. The current lack of truly accessible PHRs means that there is an excellent market opportunity for an organization that can develop a PHR that is robust and easy-to-implement.

What constraints does PHR technology face?

While PHR systems are theoretically only constrained by the state of web software technology, there are some concerns around their use by patients:

• Security and privacy. Patients may be apprehensive about putting their health data online. There is ongoing debate around the level of security and access control that is required for a secure PHR.
• Standardization. PHRs should use a standard coding system such as ICD-9 for diagnoses. They must also define a standard format for data exchange such as CCR or CCD. Many patient portals today used proprietary standards that cannot be easily exchanged with other systems.
• Connectivity. Having to re-enter data into different individual EMRs will only frustrate users and encourage them to find alternative points of care. The more interoperable the data, and the more built-in interconnections it has, the more value the solution has for all levels of users.
• Usability. Systems must be designed with a high degree of usability or patients will quickly abandon them.

In short, there is a definite market opportunity for PHR differentiation. Organizations that can develop a PHR with a highly intuitive user interface built around the patient’s expectations will stand out from competitors and offer a truly valuable service.

Healthcare Technology Roundup: Voice Recognition

Physicians are trained in dictation. Classic physician consultations are dictated and transcribed for the patient record. Typing out these clinical notes has a cost associated with it, namely the transcriptionist’s time. Voice recognition (VR) promises to one day eliminate this step by automatically performing this translation from speech to text and eliminate the cost of transcription.

Voice recognition in an EMR is in high demand as both a convenience and cost saving tool. The accuracy of the technology, and especially the usability of the solution, will be key differentiators for EMR vendors.

What are the opportunities for innovation?

Innovation for VR in EMRs can come from enhanced integration of the technology into existing EMR solutions with an emphasis on usability. Voice recognition can offer:

• Broader access to dictation. Any device that supports a microphone, a network connection and a speaker (for system feedback) could conceivably support VR. This means that a doctor could dictate notes into his phone and enter a text note into the EMR from anywhere.
• Direct entry of rich content to the EMR. Patients and other healthcare providers can have access to the raw data entry. Having this access would allow them to get a sense of subtle diagnostic nuances that may not be captured in text or as a way of dealing with any errors with the recognition process.
• More natural voice commands. Having to learn VR system commands can sometimes be a daunting task for clinical workers who are already squeezed for time. One improvement that can be made to VR is to improve how the user interfaces with the system itself so that it can be more natural.
• Voice-print identification. This would allow physicians to perform more tasks over the phone by authenticating them using their voice.

How is voice recognition used in healthcare today?

Voice recognition is used in several existing EMRs. EMR vendors such as Epic, Allscripts, Cerner, GE, McKesson, NextGen, eClinicalWorks have incorporated Dragon NaturallySpeaking into their products.

An example of VR use within a practice is with clinical note dictation. After a consultation with the patient, the physician can dictate his note into the patient chart using VR. The note can then be automatically entered into the patient chart. Traditionally, this process would be performed using a Dictaphone and then transcribed into the patient chart by a medical assistant.

Dragon certifies EMRs according to how well they integrate with their solution. The details of the certification test include emphasize dictation and correction capabilities in the EMR, as well as audio preservation and other support tools.

Today’s VR technology, when trained to the speaker’s voice, has reached relatively high levels of accuracy compared to just a few years past. Dragon NaturallySpeaking, for example, boasts 99% accuracy when properly trained to the speaker’s voice.

What constraints does voice recognition technology face?

Although it can be useful, VR poses limitations that have prevented widespread adoption in the healthcare industry to date. These include:

• Need for a quiet station. Most VR is done in a quiet corner or in the doctor’s office. The presence of noise can affect VR. This limits the mobility of computing since it cannot be done in any location.
• Training is required. Although speech is natural and doctors are used to dictation, all VR systems take time to train in order to reach a high level of accuracy.
• Usability. Typing is fast for those who are expert at it but VR systems are good when dictating large portions of text. If the VR system is remote and the user has to keep correcting it, navigating backwards, or replaying certain parts, as is often the case with a physician’s progress notes, it can take a lot of time to input data.
• Unseen errors. Often a word can be misheard by the system and a different (but correctly spelled) word can be used in its place. These “typos” are often hard to detect and pose a risk for patient safety. These errors happen more often than is acceptable. With a VR system that is 97% accurate, there are 1 to 2 errors on average every 50 words. This leads to about 37% of dictated notes containing at least one error.

For an in-depth review of physician impressions of VR systems, we recommend the publication “Acceptance of speech recognition by physicians: A survey of expectations, experiences, and social influence” by Alexandre Alapetite.

Despite these constraints, VR has the potential to reduce the cost of healthcare delivery by automatically transcribing clinical notes. Organizations that can resolve these constraints and integrate with or develop VR systems that are both accurate and easy to use will certainly stand out from the pack.

Healthcare Technology Roundup: Digital Ink

The ability to have touch-sensitive screens has made it possible for users to write on a screen just as they would on a piece of paper. This technology has long been integrated into the EMR, but there has been a recent resurgence with the ability to convert the ink strokes to structured text, via technologies like Microsoft Ink.

What are the opportunities for innovation?

Although ink-to-text solutions like those from Microsoft are gaining in popularity, there is still a significant issue around the accuracy of the conversion. A charting system that accepts stylus input and converts to text will not be acceptable if there is a chance of error converting the charting details to structured data.

The possibilities for innovation therefore fall into 2 categories: the use of digital ink in innovative ways that are not error-prone, and the creation of new solutions that reduce or eliminate conversion errors.

Some examples of the former are listed below (while the latter is discussed more in the next section):

• Drawing images. In fields such as plastic surgery, it is often useful to draw pictures to facilitate communication between doctor and patient.
• Annotating diagnostic images. The doctor can add ink to x-rays or MRI scans to indicate important properties and describe the judgment made for it.
• Inputting text naturally. In some cases, the patient is unable to communicate and digital ink can be used to write a note to the doctor to explain something or to direct the course of treatment.
• Authenticating reports. Physicians can use digital ink to authenticate reports quickly and easily.

How is digital ink used in healthcare today?

Just as some EMRs are marketed specifically around touch screen technology, others such as MedConnex, Aprima and Medscribbler tout the advanced use of digital ink for stylus-based charting.

Aprima highlights the utility of ink data entry since it allows physicians to maintain eye contact with patients during a consultation. MedConnex emphasizes a fast learning curve when going from the paper world to their stylus-based charting.

What constraints does digital ink technology face?

As discussed, stylus entry and digital ink introduces an intuitive and natural way to enter data into a patient’s chart, but is not without its constraints:

• Loss of precision, illegible handwriting, and error-prone conversion to text. Pen and paper are as precise as they need to be. Touch screens are often not as precise as their real world analogs. Writing with digital ink tends to resemble writing with a marker on a piece of paper. One of the reasons for developing EMRs was to reduce the amount of ambiguity in handwritten notes. Digital ink may duplicate or increase this ambiguity. There is a definite opportunity for innovating new methods of auto-correcting or translating ink to text on the fly, in a way that is highly accurate but does not interfere with usability.
• Auditing is more complex. A very strict auditing mechanism should audit the digital ink for every logical set of strokes. Otherwise, users could leave the page open for several hours and write notes. In this case, it will be unknown which strokes were written at which time. The audit logs would have to record the time of the strokes, not just the time the “save” button was clicked.
• Handwritten data does not facilitate data exchange and analysis. Solutions offering ink-only input that cannot convert to structured data may be more suitable for small clinics where data entry and recall is all that is needed. Without structured data, a solution is very limited in what it can exchange with other systems and what meaningful analysis it can perform on the data.

Healthcare Technology Roundup: Touch Screens

While touch screen technology has existed in one form or another for years, the technology of resistive and capacitive touch detection has recently flourished, allowing for pressure sensitivity, multi-touch and gesturing. From a usability point of view, a touch screen can be more intuitive than a mouse since the user can select an item directly without having to first drag a pointer. Moreover, touch screen technology allows for more robust computer installations – particularly in public areas, where a traditional keyboard and mouse that require regular maintenance tend to be the first things to fail.

Touch-ready operating systems are now available such as Windows 7, Apple iOS and Linux. This software allows for the handling of touch actions such as touch begin, touch moved, touch end and can be used to recognize the mouse-like events (click, drag and double click), as well as complex actions such as flick, pan, zoom, pinch and rotate.

What are the opportunities for innovation?

EMRs can benefit immensely from touch screens. A touch screen can offer:

• Enhanced usability in specific settings. In a hospital setting, for example, where clinicians use gloves or other protective apparel (ER, surgery, infectious diseases), or a setting where a small number of repetitive tasks need to be done quickly (ER admittance, drug orders).
• Innovative user interfaces. A richer user experience exists with advanced touch features such as inertia in which objects continue to exhibit a behavior after they are released, e.g. a scroll panel that considers the velocity of the user’s finger swipe.
• Easy navigation. 3-D diagnostic models (such as those from a cardiac CT scan) can be manipulated with swipes and multi-touch rotation.
• Data to all levels of users. Inpatients can be provided with touch screen consoles in which they can have a direct connection to their data in the EMR and make decisions about their care.

On modern software platforms such as .NET, libraries exist to support complex touch screen actions. This is an opportunity in and of itself to innovate – leveraging this software framework will allow you to rapidly enable touch screen functionality in your healthcare solution.

How are touch screens used in healthcare today?

Some EMRs, such as 3Plus and Encounter Notes, are marketed specifically as “touch screen EMRs.” While these EMRs are not known as leaders in the market, their value proposition is certainly something all vendors could draw inspiration from.

Most leading EMR vendors are offering ad-hoc touch screen solutions as they begin their foray into tablet PCs, smart phones and digital ink. Other common uses of basic touch screens include:

• Patient kiosks. Offering patients the ability to enter their basic information without needing a clerk. This data is then entered directly into the EMR.
• Bedside devices. Touch screen technology frees up space by not requiring a keyboard and mouse. The information displayed is sourced from the EMR.
• Home care devices. Well-designed touch interfaces can be easier for patients to use at home as they offer a more simple and intuitive interface.

What constraints does touch screen technology face?

Touch screens introduce a new paradigm for user input. This step away from the traditional keyboard and mouse is not without its limitations and controversies, however. These constraints include:

• Repetitive stress disorders. Researchers from Arizona State University believe that touch screens could lead to new types of musculoskeletal problems.
• Device contamination. Diseases can be exchanged from person to person via the touch screen. It’s important to be able to clean the touch screen often if it is being used by patients.
• Text input. Although touch screens are meant to be more natural in terms of usability, text entry is a challenge that can result in typos and wrongly auto-corrected words.
  There is a definite opportunity for innovation in terms of text entry, spell check and auto-correction, particularly around medical and prescription nomenclature.
• Unwanted input. When using a conventional computer, the user has control over the input devices. With a touch screen it is easier for others to provide undesired input – another opportunity for innovation around security and access control.