Since the introduction of the Apple iPhone in 2007, mobile devices have transformed the way consumers access information, communicate and work. Ubiquitous Internet access from handheld devices has made it possible to get reference material from virtually anywhere. SMS texts and push notification e-mail have spawned new styles of communication. Apps have changed how software is developed, with an emphasis on products optimized for specific tasks that are pleasurable to use. Perhaps as important, the advent of “App Stores” has fundamentally transformed how mobile products are marketed and sold. While consolidating control over software distribution, they have also decreased the barriers for small developers to enter the market with innovative products. While App Stores make a profit on every unit sold, they also make it possible for savvy individuals to compete in a mass market alongside industry giants.
In the same time period, a different revolution has been transforming the role of computers in medicine. While computers have been used to support clinical care for decades, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided billions of dollars in federal stimulus funds to expand the adoption of health information technology (HIT). To ensure a beneficial impact, a key provision of the legislation requires “meaningful use” (MU) of electronic health records (EHRs). Unfortunately, the rush to qualify for HITECH dollars focused on promoting adoption and the usability of EHR systems did not initially receive significant attention.1 As a result, problems with integration into existing workflows have emerged, and have left many clinicians frustrated that this new technology creates more work, disrupts workflow and decreases time with patients,2 all of which compromise delivery of quality care.
These parallel developments couldn’t be more divergent – the simple, low-cost mass appeal of mobile apps that has lowered barriers to entry for both developers and consumers alike, contrasted against the complex, expensive, highly customized health care market where costs and barriers to entry continue to mount. Despite this divide, demand for apps in clinical environments is strong, forcing the convergence of mobile technology and health care. Both medical and informatics literatures are already full of reports detailing successful mobile technology initiatives in clinical settings for communication, reference, research, patient engagement and medical education.3-5 However, an evidence-based role for mobile technology in the delivery of health care in the United States has not yet been well established.6 Obviously, not all tasks in medicine are well suited to a 3.5-inch screen, but the limits of what can be done effectively on mobile devices also has not yet been defined. The broader adoption of HIT has been fraught with “unintended consequences,” with surprising increases in error rates in some cases and the emergence of new types of error in other situations.2 It is likely that expanded use of mobile technology initiatives will also spawn unintended consequences, but with awareness of the unique aspects of this technology, some issues can be anticipated.
Distraction, Disruption and Interruption
Continuous access to relevant information is a key aspect of effective mobile technology use. While such availability might ensure that important information is provided at the right time and place, it also introduces the potential for distraction and disruption.7 With the ability to constantly refer to reference material, there is a risk that inattention could lead to complications. Similarly, access to personal cellular phone service, SMS texting and push-notification e-mail has the opportunity to improve communication, but it also creates the potential for significant interruption of work flow. The temptation to engage in personal business, while not unique to the technology, is perhaps greater given the power and sophistication that mobile devices offer.
As a core mobile technology, widespread adoption of texting has already transformed consumer communications, and the appeal of clear, concise, bidirectional communication has obvious importance in clinical settings. However, the ease and speed with which text messages can be generated may lead to interruptions and “information overload.” It is also important to consider the risk of potential error and inaccuracy from “thumb typing” on a device that also uses auto-completion and auto-correction functions. Issues with security and privacy pose yet another challenge, and texts can only contain personally identifiable patient data if sent using a HIPPA-compliant platform.
Security and Privacy
One reason for the success of mobile devices is their personal appeal. While devices could easily be passed between individuals covering a particular role (i.e., a “code pager”), it seems likely that most clinicians would prefer the simplicity of carrying a single device. Eliminating redundant and unnecessary portable phones and pagers also has the potential for reducing administrative costs and shifting the burden of purchasing, operating and maintaining a new technology onto the individuals who are actually using it. For this reason, BYOD (“bring your own device”) may emerge as a standard practice.
This also shifts responsibility for information stewardship from organizations to individuals, and creates new potential risks for security and privacy. While accidental loss of paper notes containing identifiable patient information has always been a problem, the sheer volume of data potentially stored on a mobile device combined with constant access to the Internet across different data networks exponentially increase the risk of a security violation. Further compounding the problem is potentially blurred responsibility between health care organizations and individuals should a breach occur involving a personal device.
App Stores Today
A search for “anesthesia apps” yields more than 100 products, some targeted specifically for anesthesia providers and others with appeal to a broader medical market. Most are quick reference guides and are available for free or for a few dollars. However, a quick perusal of reviews suggests you get what you pay for, with many reviewers of low-cost products expressing disappointment that the amount of content included could have been written on an index card. Other apps are essentially mobile versions of textbooks and are priced equivalently. While providing quick access to accurate reference and educational material at the bedside has value, these types of apps serve the same niche as existing pocket reference guides or complete textbooks. Apps that can integrate existing information sources specific to individual patients, providers and clinical environments to drive more effective information delivery would seem more valuable to a practicing clinician, and yet apps capable of providing targeted information are noticeably absent. For example, a medication app that “knows” a patient’s weight could potentially be a more effective means of providing dosing information than a reference chart. An anti-coagulation app that “knows” both when the last dose of low molecular weight heparin was administered and when the next dose is scheduled could be effective in planning regional anesthetics and reducing the risk of thromboembolic complications. This type of clinical decision support should be available within a well designed and implemented commercial EHR – the problem is shifting content delivery from workstation to bedside.
The Future: How Can Mobile Help Us Use Technology Meaningfully?
The rapid adoption of mobile technology by consumers has already impacted the HIT market. Strong demand for “anytime, anywhere” access has driven both established vendors and health care organizations to develop mobile applications. One potentially desirable “unintended consequence” of this shift is that it forces a complete interface re-design – without a mouse and keyboard, reusing existing design templates simply doesn’t work. “Starting over” on the design of the user experience may yield products that are useful and pleasurable to use, a description not often used to describe the current EHR products, and a potential solution for clinicians frustrated with the usability of current systems.
The “app store” model depends on both a consumer market hungry for products and independent developers who can quickly respond to market demands. The “there’s an app for that” mentality demonstrates how open development and distribution can lead to a vibrant market that benefits developers, distributors and consumers alike. While the design requirements for a fully functional EHR are likely too complex for an entirely mobile platform, an open, modular approach optimized for specific tasks and workflows has already been suggested as an alternative design.8 Such an approach could enable more choices in the HIT marketplace and yield technology that could adapt to the needs of clinical workflow rather than forcing workflow to adapt to the needs of technology.
Sadly, without a standardized way to securely share clinical data, development of a complementary app market driven by health care providers seems unlikely in the near term. Until a standard mechanism for exchanging patient information becomes available, solutions can only be provided by the EHR vendors themselves or within highly motivated health care organizations with adequate resources to support custom development. Hopefully, with demand from clinicians and evidence of benefit, the future will include mobile technology that brings patient-specific information to the bedside, improves outcomes and is truly meaningful to patients, families and clinicians.
Peter Vincent Killoran, M.D., M.S. is Assistant Professor, Department of Anesthesiology and School of Biomedical Informatics, UTHealth, Houston, Texas.
Jaideep Mehta, M.D., M.B.A. is Assistant Professor, Department of Anesthesiology, and Chief of Acute Pain Medicine, UTHealth, Houston, Texas.
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