What do you do when your campus server goes down and you want to find what the heck happened? Twitter. DSU disappeared from my Web sometime around 1 p.m. and hasn’t come back yet. (I’m playing Web karma and assuming that the moment I blog about it, the problem will be fixed.)

Two in-the-know Twitter pals spread the word that someone cut an SDN cable near Lake Madison. The DSU website, webmail, and cloud apps are thus inaccessible. (If my advisor is listening, I’m not ignoring your e-mails, really!)

This outage does highlight the importance of a backup channel for communications. DSU has an emergency communications system for the folks who really need to know and coordinate outage response. Our curriculum management system, Desire2Learn, is hosted elsewhere, so profs can use that to alert students that they can’t get at the library and other other campus resources and perhaps share materials through the D2L Content pages in the interim. And we can always text each other.

As for cloud computing, we’ll have some inevitable hiccups like this using remote apps. But are they any more frequent or inconvenient than the work stoppages caused by spilling Pepsi on your laptop or having your home system go ape from that one nefarious virus that sneaks through in that e-mail from Grandma?

A cut cable is just the new blizzard, the new snow day, the new canceled flight that keeps us from getting our work done when we thought we would.

Crawford Kilian, Writing for the Web, 4th ed., Self-Counsel Press: Bellingham, WA, 2009.

I just finished reading Kilian’s Webwriting guide. I would enjoy teaching English from this text. Kilian does a good job of putting communication into our clickety-quick context.

Kilian maintains a good Webwriting blog with lots of useful resources. Here’s my summary of key points and resources from the text:

  1. The Interactive/Constructivist Communication Model: When you write online, you need to think beyond the standard instrumentalist model of communication. That model says your sender transmits a message to a receiver, with the intent of making the receiver do something. Kilian says nuts to that: online, you’re having a conversation. Sender and receiver constantly change roles, interacting to jointly construct message and meaning. Corporate writers often have a hard time getting this (see Chapter 6).
  2. 25% Slower: that’s the oft-quoted stat from Jakob Nielsen on how much more slowly we read online. Paper has better resolution than computer screens. Our screens are getting sharper, but even on the iPad and Kindle, Nielsen found reading speeds 6% to 10% slower than in printed books. Write acordingly online: keep it short (Kilian says 100 words max!).
  3. Orientation, Information, Action: These three principles should guide all writing. Online, first orient your readers: make it clear to them where they are and how to get around your site. Inform them: be clear and correct (spell things right!). Then direct them toward action, whether it’s leaving a comment, contacting Congress, donating money….
  4. Advocacy and Marketing: Chapter 8 concisely summarizes tips for persuasive writing. The section on propaganda types, myths, and devices could make nice bite-size handouts and classroom activities.

Some online style guides cited:

Your boss has a say over you while you’re on the clock or using the boss’s equipment. But can the boss control what you say off-duty, on the Web? Officials in Kent County, Delaware, think so:

The county’s Levy Court — the equivalent of a county council — has an existing rule that bars employees from using government equipment for personal social media activity at work. But a recent proposal would extend that ban to include activity during non-work times, specifically as it relates to commentary that disparages co-workers or reflects unfavorably toward the county government [Brian Heaton, "Social Media Usage Becoming a Free Speech Question for Governments," Government Technology, 2011.05.17 ].

As law professor Phillip Sparkes points out in this article, Kent County is going well beyond the boundaries on public employee speech set by Garcetti v Ceballos (2006). That case recognized that public employers can place some limits on what city officials, teachers, and other public employees say while acting in an official capacity. However, that case does not allow government to impose rules on off-duty speech like those proposed by Kent County.

Arvada, Colorado, CIO Michele Hovet offers a more realistic approach to public employees’ First Amendment rights:

“I think folks that draw lines as far as what you can and can’t do on your free time are avoiding the inevitable,” she said. “Social media has been here and it’s not going away. Locking it down is just going to create more management headaches in the long run” [Heaton, 2011.05.17].

People are going to talk… and Tweet. They’re going to use their smartphones and iPads to do so. Trying to control employees’ every utterance is unconstitutional and impractical. Instead of trying to keep employees from talking, local governments will make better use of their time working to treat employees and the public right so they all have good things to talk about.

INFS 892: Health Informatics Research
Literature Review #3: Mobile Computing in Health Care Settings
Cory Allen Heidelberger
April 25, 2011

Introduction

Only a few years ago, discussion of meaningful use of electronic health records on mobile devices would likely have conjured images of rolling workstations and conventional laptop computers. In the last few years, the form factor for common mobile computing devices has folded down significantly, as touchscreen-enabled smartphones and tablets have experienced faster adoption that most previous technological innovations. Making meaningful use of EHR systems still requires systemwide investment in technology and training, but it can now take advantage of personal mobile computing devices widely adopted by health care professionals for their personal use. “Besides the obvious benefits of always-on, ubiquitous connectivity, it leverages something most doctors and patients already own — a mobile phone or, increasingly, a tablet. This is why we have seen so many healthcare solutions coming out that incorporate wireless” (Lewis, 2011b). This multiply advantageous form factor may not “crush” laptops in the healthcare space, as one champion proclaimed one month after the iPad hit the market (Merrill, 2010a), but new mobile computing tools are enjoying remarkably fast adoption in the healthcare field.

With the meaningful use verification period for the CMS EHR Incentive Program opened Monday (“‘Meaningful Use’ Reporting Period Starts for Electronic Health Records Program,” 2011), it is thus important and timely to see if adoption of mobile computing devices by health care professionals may help health care incorporate health IT in their regular service provision. This paper reviews current rates of adoption, uses, and motivating factors of mobile computing technology by health care practitioners.

Earlier Mobile Computing Devices

Mobile computing preceded smartphones and tablets in the form of personal digital assistants. 26% of U.S. physicians used PDAs in 2001 (Lu et al., 2003). However, at that time, PDA users in health care settings faced more barriers. Many more institutions lacked integrated information systems that could provide PDA users access to patient databases. Screen size and resolution, poor interfaces, short battery life, and hardware fragility hindered usability (Lu et al., 2003). Studies expected PDA use to rise rapidly (Lu, Xiao, Sears, & Jacko, 2005), but the above barriers prevented the devices from gaining dominance in the health care industry.

Laptop computers with tablet capability brought some expanded interface capacity. However, these devices posed challenges the same problem as PDAs with poor battery life, with the greater weight and bulk compounding usability problems. Older tablets also generally ran operating systems designed for use with keyboard and mouse, making operation in tablet mode unwieldy (Robertson, Miles, & Bloor, 2010).

Current Mobile Adoption

Now mobile computing tools appear to be rising to meet the hopes expressed for mobile computing years ago. Current literature echoes past promises of halcyon days for mobile computing—smartphone technology, for instance, is called a transformative, paradigm-changing technology (Bottles, 2011). However, current adoption and use rates appear to give ground for such statements. Smartphones are leading the way in modern penetration of mobile computing technology in the health care field. Knowledge Networks survey finds 64% of doctors have a smartphone. 27% of primary care providers and specialists have a tablet, an adoption rate five times the rate for the general population. That statistic is all the more remarkable given that health care practitioners generally lag other industries and the general population in information technology adoption. Manhattan Research mid-2010 found 72% of U.S. physicians have a smartphone or PDA; Chilmark Research finds 22% of physicians with iPad by end of 2010 (Dolan, 2011). A 2010 PricewaterhouseCooper survey found 63% of physicians are already using personal devices for mobile health solutions (Lewis, 2010b).

At the institutional level, in fall 2010, one IT enterprise supplier found that healthcare institutions constituted 10% of iPad-deploying customers, the third-largest segment among its clients, just behind the technology sector at 11% and well behind the leading financial services sector at 43% (Merrill, 2010b). An October 2010 HIMSS survey found 70% of responding members planning to deploy iPad and other Apple mobile devices in their health care facilities by the end of 2011 (Lewis, 2010a). Interestingly, 30% of physicians in a survey last year reported that, benefits notwithstanding, their hospital or practice leaders would not support the use of mobile devices (Lewis, 2010b).

Operating systems adopted show some significant differences between health care practitioners and the general consumer population. Nielsen numbers on the broader consumer market show devices running the Android operating system take up 48% of the market. iOS holds 31%, while Blackberry OS claims 18% (Zeman, 2011). A Bulletin Healthcare analysis (Hirsch, 2011) of its health professional subscribers found a much different breakdown of OS choice. It found 93% of its subscribers who use mobile devices use Apple-based machines. iPhone users decreased from an 86% share of the mobile audience in this group in June 2010 to 79% in February 2011. iPad users rose over the same period from 8% to 14%. Android doubled its share of users to 6%. This study found the three in ten subscribers used mobile devices to read Bulletin healthcare’s daily email briefings, showing that physicians use mobile devices for basic information seeking and ongoing professional learning.

The Bulletin Healthcare survey also found notable differences in mobile device adoption rates among different specialties:

Specialty

Mobile Adoption

Physician Assistants

41%

Emergency Room Physicians

40%

Cardiologists

33%

Urologists

31%

Nephrologists

31%

Dermatologists

30%

Gastroenterologists

30%

Psychiatrists

28%

Optometrists

28%

Radiologists

24%

Rheumatologists

22%

Endocrinologists

21%

Oncologists

20%

Clinical Pathologists

16%

Table: Mobile device adoption rates among different health specializations (Hirsch, 2011)

These different rates appear to be higher among more mobile practitioners like P.A.’s and ER physicians and lower among more lab-based analysts like radiologists and pathologists who may travel less in their facility in the course of their normal workflow.

Tools Available

Mobile computing funtionality ranges from access to integrated EHR solutions to standalone applications for communication, reference, and administration. DrChrono introduced its iPad EMR the same month the iPad launched; by September, ClearPractice followed with the Nimble EMR application (Merrill, 2010a). The MyChart Apple application lets patients access medical history, appointment times, and lab results. The University of Iowa Hospitals and Clinics are testing Canto (for iPad) and Haiku (for iPhone) for likely implementation in October with an upgrade of the Epic EHR system (Bennett, 2011).

The Emergency Medical Spanish Guide was developed by an EMT whose experience with Spanish-speaking patients led him to create an application that could provide and even pronounce simple yes/no questions in Spanish to bridge language barriers in the ER (Usatine, 2010). That application is now paying for the former EMT’s medical school tuition. A similar application exists to serve French-speaking patients (Castro, 2010). InVivoLink this month released OrthoPod, an iPad app to help orthopedic surgeons access their personal implant registry and see patterns in their procedures and patient data (press release, 2011).

Reference apps like Epocrates and WebMD are most popular mobile apps; apps from pharma manufacturers get little use (Dolan, 2011). As of April, 2010, over 125,000 doctors were using Epocrates on iPhone and iPod touch devices; one study claimed that “60 percent of Epocrates users avoided three or more medical errors a month” (Bottles, 2011). The American Medical Association released its first mobile application this month, a free application through iTunes to allow doctors to look up, track, and organize Current Procedural Terminology billing codes (Gillette, 2011). This release for Apple devices acknowledges the dominance of Apple products in this sector.

Articles on mobile applications provide multiple examples of physicians educating patients with mobile images from Netter’s Atlas of Human Anatomy (Davis, 2011; Porter, 2011). The FDA this February approved Mobile MIM, a mobile radiology application that allows clinicians to share and make diagnoses based on CT, MRI, and PET scans (Lewis, 2011b).

The AirStrip Cardiology app (iPhone, iPad; planned for Android) gets data from GE Healthcare’s Muse Cardiology Information System’s cloud database of current electrocardiograms. Through the AirStrip system, doctors can access ECGs immediately anywhere instead of relying on potentially distorted faxes or PDFs. On mobile screens, physicians can zoom in on small differences, as small as a half-millimeter, that make make a big diagnostic difference but that might be lost in the resolution of a typical fax (Horowitz, 2011). This application complements other apps planned by GE Healthcare to expand mobile EHR access (Lewis, 2011b). AT&T last month announced similar expansion of its cloud-based Healthcare Community Online to include a mobility interface for smartphones (Lewis, 2011b).

Cloud computing and virtualization broaden mobile health IT from the realm of specific mobile apps to full mobile access to an institution’s integrated EHR system. Dell this month released a mobile clinical computing program that allows hospitals using the Meditech health Care Information System to virtualize their system and provide secure access to desktop applications via any number of devies, including tablets (Lewis, 2011c). Virtualized clients also mitigate concerns about information security on personal devices (Lewis, 2010a).

Mobile hardware is improving the capabilities available to doctors. This year’s iPad 2 processes images nine times faster than the original device in 2010, allowing faster processing of more detailed medical images. The dual cameras of the tablet also make it easier for rural doctors to share photos of wounds and conference with remote colleagues (Lewis, 2011b). These capabilities can facilitate communication among radiologists and clincians and expedite diagnosis and treatment (Choudhri & Radvany, 2010). Radiologists who are accustomed to more sednetary workflow in a dedicated imaging lab with specialized equipment may find value in accommodating mobile platforms to support better interaction with referring physicians in patient management teams (Shih, Lakhani, & Nagy, 2010).

Motivations for Mobile Adoption

The largest motivators for this apparent rush to mobile deployment include point-of-care applications, clinical decision support, medical image viewing applications, and general administration. Another survey finds that physicians agree the greatest benefit of mobile health will be the ability to make decisions faster by accessing more accurate data in real time (Lewis, 2010b). The perception overlaps with the perception among more than 60% of physicians that the best benefit of EHR systems is real-time patient information access (staff, 2011).

A Knowledge Networks marketing survey finds physicians relying on mobile units for checking email, researching medications and conditions, and taking surveys. Physicians still prefer in-person visits with drug company representatives over e-marketing—markedly more so among physicans over 55, but still with a strong majority among those under 40 (Dolan, 2011). Nonetheless, Epocrates has just launched a mobile drug-sampling service, offering their 315,000 physician members the ability to order custom samples via mobile devices (Millard, 2011).

Christ Community Health Services in Memphis chose iPads as its main hardware platform for its coming switch to electronic health recorsd. The hospital chose from among numerous technological options based on tests in clinical settings and criteria including battery life, ease of use, and portability. As a result, CCHS Memphis is now preparing to implement 38 iPads in five health care centers for use in all charting. CCHS physician John David Williamson said “that intimate, non-disruptive doctor-patient interaction is the ‘definite advantage of the iPad. Rather than having my back turned to a patient while on a computer, I can actually continue to have a normal interaction with the patient…’” (Maki, 2011). Similar advantages have driven an Ottawa hospital to order 1800 iPads to be in the hands of its physicians, residents, and pharmacists by July (CBC, 2011).

Methodist Le Bonheur Hospital in Memphis started with in-house iPad pilot project and is now testing use of a virtual private network to give authorized iPad users outside the hospital access to medical records (Maki, 2011). Such a move is a logical extension of the mobility allowed by such devices, not just from room to room within the facility, but beyond the walls of the facility. MLBH user cites portability, ease of use, and quick access (no long boot-up, no long log-in and log-out from room to room) as reasons for adoption. Hospitals that have already implemented EHR may also have invested in desktop computers in each room, lessening the need for mobile solutions (Bennett, 2011; Maki, 2011). One official at Stern Cardiovascular Center in Memphis suggests putting desktop on cart to wheel from room to room (Maki, 2011), although physicians who have tried newer handheld mobile solutions might balk at the idea that the traditional computer on wheels (the COW, as it is abbreviated with just a touch of mockery) can provide comparable utility.

Dr. John Halamka, chief information officer of Beth Israel Deaconess Hospital in Boston, puts mobile medical device criteria in concrete terms that argue strongly in favor of iPads as a perfect fit for doctors: “The secret for the ideal clinical device is it has to weigh a pound, it has to last 10 hours, because that’s [a doctor’s] shift, you have to be able to disinfect it so there’s no risk of contamination, and you have to be able to drop it 5 feet onto carpet without damage” (Davis, 2011). Size, weight, and battery life are cited by other users and observers as reasons newer mobile computing devices are gaining acceptance among health care practitioners (Merrill, 2010b). Doctors at Beth Israel Deaconess also say ability to share information with patients is key. Consider the difference between visiting with a doctor who is ensconced a few feet away at a computer terminal, data upon which the patient cannot see, and a doctor bedside, entering data on a screen the patient can see and even touch and manipulate.  Mobile devices create the possibility for more natual bedside communication and interaction (Bennett, 2011) between health care providers and their patients.

Mobile applications provide another opportunity to reduce the separation between health care provider and patient. When tools are downloadable to common platforms like mobile phones and tablets, doctors and patients may be able to use these devices together on their own devices with minimal expense. A psychiatriast may be able to provide information to a visiting patient from an application like the new PTSD Coach, just released this month by the Department of Veterans Affairs and Department of Defense to help veterans with post-traumatic stress disorder (Montalbano, 2011). If the patient has a compatible smartphone or tablet, the psychiatrist can just as easily “prescribe” that the patient install the application on his or her own mobile device and use the application outside the office to manage his or her own symptoms. Unlike a large integrated EHR system accessible only to physicians at hospital or clinic workstations, mobile applications open more possibilities for patient use and interaction with their health care providers and data. Common mobile devices also offer physicians channels by which to provide remote healthcare, an option a majority of consumers and physicians find acceptable (Lewis, 2010b). Such remote monitoring could mark an electronic return to the practice of “house calls” (Lewis, 2010b).

Integrating mobile devices into regular care may also promote patient confidence in the quality of their care. A Sage Healthcare Insights study released this month finds 81% of patients “have a positive perception of documenting patient care electronically” (staff, 2011), a level of positive perception greater than that found among physicans (62%). Patients report greater confidence in physicians who use EHRs and icnreasingly expect physicians to give them access to electronic records and tools (staff, 2011). These findings stand in contrast to concerns expressed that patients may object to their physician answering questions by seeking answers from a machine instead of consulting their own professional knowledge; besides, the push for evidence-based medicine will demand increased use of technology in health care (Shaw, 2011). Also driving expectations of greater health care technology use may be the againg and retirement of baby boomers. This demographic has egnerally lead other groups in technology spending and adoption (Bottles, 2011); as they become senior citizens and increasingly need health care services, they will bring their preferences for technology to that industry. Physicians can respond to such perceptions and expectations by working with EHR data via mobile devices in sight of patients and even showing them the information they are accessing and entering on those devices.

Personal choices and innovativeness appear to be playing an important role in mobile device adoption. At one Memphis hospital, for example, almost all iPads in use are owned by individual physicians (Davis, 2011). Even if their institutions lag in promotion and integration of health information technology, individual practitioners are finding the new generation of smartphones and tablets sufficiently useful to incorporate into their own workflow, even if just for reference and communication. The new mobile technologies are also sufficiently accessible that health care practitioners have designed many of the simple apps available for varios devices.

Conclusion

Past health information research contains various predictions of great technological advances in mobile computing that did not catch on. However, the swift penetration of smartphones and tablets in the heallth care industry, coming on the heels of increased institutional and government investment in EHR, suggest that mobile computing has reached a new level of integrative utility for health care providers.

Works Cited

  1. Bennett, M. (2011, April 13). Doctors use iPads, iPhones for medical records. The Daily Iowan. Retrieved April 19, 2011, from http://www.dailyiowan.com/2011/04/13/Metro/22798.html
  2. Bottles, K. (2011). Physician Executives Should Not Ignore How Smartphones Will Transform Healthcare. The Health Care Blog. Retrieved April 22, 2011, from http://thehealthcareblog.com/blog/2011/01/31/physician-executives-should-not-ignore-how-smartphones-will-transform-healthcare/
  3. Castro, H. (2010). Doc APProvED: A Day in the Life of an iPad. Emergency Medicine News, 32(6).
  4. CBC. (2011, April 20). 1,800 iPads ordered by Ottawa Hospital. CBC News. Retrieved April 22, 2011, from http://www.cbc.ca/news/canada/ottawa/story/2011/04/20/ottawa-ipads-hospital374.html
  5. Choudhri, A. F., & Radvany, M. G. (2010). Initial Experience with a Handheld Device Digital Imaging and Communications in Medicine Viewer: OsiriX Mobile on the iPhone. Journal of Digital Imaging, 24(2), 184-189. doi:10.1007/s10278-010-9312-7
  6. Davis, M. (2011, April 4). For some doctors, the iPad is claiming a key spot next to the stethoscope. Boston Globe. Retrieved from http://articles.boston.com/2011-04-04/business/29380774_1_ipad-tablet-computers-ulcer
  7. Dolan, B. (2011, March 31). Survey: 27 percent of US doctors have tablets. mobihealthnews. Retrieved April 21, 2011, from http://mobihealthnews.com/10627/survey-27-percent-of-us-doctors-have-tablets/
  8. Gillette, B. (2011, April 7). AMA introduces CPT coding app. Modern Medicine. ArticleStandard, . Retrieved April 21, 2011, from http://www.modernmedicine.com/modernmedicine/Cosmetic+Surgery/AMA-introduces-CPT-coding-app/ArticleStandard/Article/detail/715114?contextCategoryId=40174
  9. Hirsch, R. (2011, April 14). Physician Mobile Use Grows 45%; Apple® Dominates Android™ and Blackberry® | Business Wire. Business Wire. Retrieved April 19, 2011, from http://www.businesswire.com/news/home/20110414005326/en/Physician-Mobile-Grows-45-Apple%C2%AE-Dominates-Android%E2%84%A2
  10. Horowitz, B. T. (2011, April 7). AirStrip, GE Launch Cardiology App for iPhone, iPad. eWeek: Health Care IT. Retrieved April 21, 2011, from http://www.eweek.com/c/a/Health-Care-IT/AirStrip-GE-Launch-Cardiology-App-for-iPhone-iPad-590966/
  11. Lewis, N. (2010b, September 10). Mobile Devices To Transform Healthcare. InformationWeek: Healthcare. Retrieved April 21, 2011, from http://www.informationweek.com/news/healthcare/mobile-wireless/227400122
  12. Lewis, N. (2010a, December 10). Healthcare iPad Deployment To Approach 70% In 2011. InformationWeek: Healthcare. Retrieved April 21, 2011, from http://www.informationweek.com/news/healthcare/EMR/showArticle.jhtml?articleID=228800929
  13. Lewis, N. (2011b, March 7). iPad 2 Highlights Mobile Healthcare Advancements. InformationWeek: Healthcare. Retrieved April 21, 2011, from http://www.informationweek.com/news/healthcare/mobile-wireless/229300499
  14. Lewis, N. (2011c, April 12). Dell Launches Meditech Desktop Virtualization. InformationWeek: Healthcare. Retrieved April 21, 2011, from http://www.informationweek.com/news/healthcare/mobile-wireless/229401432
  15. Lu, Y. C., Lee, J. J. K., Xiao, Y., Sears, A., Jacko, J. A., & Charters, K. (2003). Why Don’t Physicians Use Their Personal Digital Assistants? AMIA Annual Symposium Proceedings (Vol. 2003, p. 405).
  16. Lu, Y. C., Xiao, Y., Sears, A., & Jacko, J. A. (2005). A review and a framework of handheld computer adoption in healthcare. International Journal of Medical Informatics, 74(5), 409–422.
  17. Maki, A. (2011, April 14). Medical Breakthrough: Health Care Providers Hope iPad Can Enhance Their Services. Memphis Daily News. Retrieved from http://www.memphisdailynews.com/editorial/Article.aspx?id=57807
  18. “Meaningful Use” Reporting Period Starts for Electronic Health Records Program. (2011, April 18). Government Technology. Retrieved April 21, 2011, from http://www.govtech.com/health/Meaningful-Use-Electronic-Health-Records-Program.html?elq=94f4d7ef7d0f4fbca95f1f700fb73c98
  19. Merrill, M. (2010a, December 1). iPad helps docs go paperless. Healthcare IT News. Retrieved April 21, 2011, from http://www.healthcareitnews.com/news/ipad-helps-docs-go-paperless
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  21. Millard, M. (2011, April 15). Vendor Notebook: M*Modal and WebChartMD partner on speech IT. Health. Retrieved April 21, 2011, from http://www.healthcareitnews.com/news/vendor-notebook-mmodal-and-webchartmd-partner-speech-it-0
  22. Montalbano, E. (2011, April 19). PTSD iPhone App Launches For Veterans. InformationWeek: Government. Retrieved April 21, 2011, from http://www.informationweek.com/news/government/mobile/229401873
  23. Porter, S. (2011, April 1). Health IT Can Make Good Family Medicine Practices Even Better. AAFP News Now | American Academy of Family Physicians. Retrieved April 21, 2011, from http://www.aafp.org/online/en/home/publications/news/news-now/ehr/20110401fpehrstories.html
  24. press release. (2011, April 5). InVivoLink Releases iPad App for Analyzing Orthopedic Practice Patterns. EMR Daily News. Retrieved April 21, 2011, from http://emrdailynews.com/2011/04/05/invivolink-releases-ipad-app-for-analyzing-orthopedic-practice-patterns/
  25. Robertson, I., Miles, E., & Bloor, J. (2010). The iPad and medicine.
  26. Shaw, G. (2011, April 19). Do Decision Support Tools Make Docs Look Dumb? HealthLeaders Media. Retrieved April 22, 2011, from http://www.healthleadersmedia.com/print/TEC-265124/Do-Decision-Support-Tools-Make-Docs-Look-Dumb
  27. Shih, G., Lakhani, P., & Nagy, P. (2010). Is Android or iPhone the Platform for Innovation in Imaging Informatics, 23(1), 2-7. doi:10.1007/s10278-009-9242-4
  28. staff. (2011, April 21). Study: Patients believe EMRs bring accuracy to their records. Healthcare IT News. Retrieved April 21, 2011, from http://www.healthcareitnews.com/news/study-patients-believe-emrs-bring-accuracy-their-records
  29. Usatine, R. (2010). Smartphones in Medicine 2010. The Teaching Physician, 9(4), 3-4. Retrieved from http://www.oucom.ohiou.edu/FD/Teaching%20Physician/1010TeachPhy.PDF
  30. Zeman, E. (2011, April 14). Doctors Favor iPhone, iPad Over Android. InformationWeek: Healthcare. Retrieved April 19, 2011, from http://www.informationweek.com/news/healthcare/mobile-wireless/229401603

 

I’m speaking today on my effort to create an instrument for coding narrative content in online discussions. Following are sources cited in the presentation.

ReCal2: Reliability for Coders: a handy online calculator for intercoder/interrater reliability for nominal data. Calculates Percent Agreement, Scott’s Pi, Cohen’s Kappa, and Krippendorff’s Alpha (nominal). Site also offers tools for more than two raters coding ordinal, interval, and ratio data.

Altman, D. G. (1991). Practical Statistics for Medical Research. Chapman & Hall/CRC.

Greene, K., & Brinn, L. S. (2003). Messages Influencing College Women’s Tanning Bed Use: Statistical versus Narrative Evidence Format and a Self-Assessment to Increase Perceived Susceptibility. Journal of Health Communication, 8(5), 443–461.

Greenhalgh, T., & Hurwitz, B. (1999). Narrative based medicine: Why study narrative? BMJ, 318(7175), 48-50. Retrieved from http://www.bmj.com

Jones, D., Turner, M., Singleton, C., & Ramsay, J. (2009). A study analysing inconsistent responses from people with multiple sclerosis in a recent national audit. Disability and Rehabilitation, 31(25), 2064-2072.

Klenke, K. (2008). Qualitative Research in the Study of Leadership. Emerald Group.

Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33(1), 159.

Lombard, M., Snyder-Duch, J., & Campanella Bracken, C. (2010, June 1). Intercoder Reliability. Matthew Lombard. Retrieved 02:40:32, from http://astro.temple.edu/~lombard/reliability/

Osborne, J. W. (2008). Best Practices in Quantitative Methods. SAGE.

Papacharissi, Z. (2007). Audiences as Media Producers: Content Analysis of 260 Blogs. In M. Tremayne (Ed.), Blogging, Citizenship, and the Future of Media. New York: Routledge.

Polkinghorne, D. (1988). Narrative Knowing and the Human Sciences. Albany, NY: State University of New York.

Sarbin, T. R. (1986). Narrative Psychology: The Storied Nature of Human Conduct. Praeger.

Winterbottom, A., Bekker, H., Conner, M., & Mooney, A. (2008). Does narrative information bias individual’s decision making? A systematic review. Social Science & Medicine, 67(12), 2079.

Roddenberry had the wisdom to realize that ‘advanced’ didn’t mean ‘more complicated.’ He actually wanted things to be much simpler. So we took that to mean that it was cleaner, better user interfaces, fewer buttons, fewer things to learn how to operate.

—Michael Okuda, Star Trek production designer, in Chris Foreman, “How Star Trek Artists Imagined the iPad… 23 Years Ago,” 2010.08.09

James Bond, backseat driver:

Apple iPhone Apps Store: Remote Control

Conducer culture: CafePressEtsyImageKind

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INFS 892: Health Informatics Research

Literature Review #2: Health Care Professionals’ Use of Online Social Networks

Cory Allen Heidelberger

March 25, 2011

 

In less than a decade, online social networks have become a prominent and powerful extension of social interactions throughout our culture. Through tools like blogs, Facebook, and Twitter, we keep in touch with friends, make new friends, do business, and gain new knowledge.

Health care professionals do not exist in isolation from online social networks. These new online tools offer the same social, informational, and professional benefits to doctors, nurses, and pharmacists as they do to executives, students, merchants, and retirees. Since so much of health care relies on effective and professional communication among health care professionals and between them and their patients, a communication tool like online social networks has significant potential to affect the effective delivery of health care. Preliminary to studying how the use of online social networks may affect the practice and outcomes of health care, it is important to understand how and how much health care professionals are adopting and using online social networks to support their professional practice. Given the sensitive, high-stakes nature of health care, it is also important to understand the ethical dimensions of online social network use among health care professionals.

 

Online Social Networks: Defining the Field

The “backbone” of online social networks is the connected collection of user profiles (Boyd & Ellison, 2008). Such profiles usually include user names, photos, and basic demographic information. Online social networks generally include information about connections between members. That information may reside in explicitly declared links, like unidirectional “Like” or “Follower” links or bidirectional “Friend” links (Boyd & Ellison, 2008). Health care providers may interact with patients and with each other on any established online social networking site. Health care providers may turn to health social networks specializing in health issues. They may focus their online activity even more narrowly in online social networks like Sermo.com, membership to which is open exclusively to physicians.

Inquiry into health care provider use of online social networks need not be confined to platforms like Facebook or Sermo. While such platforms dedicated to social networking create an easy point of entry, standardized format, and accessible audience for most casual Internet users, some health care professionals may create their own online social networks through their own blogs, wikis, and other social media. For example, several nurses may create independent blogs but over time find each other’s websites. They may include each other on their blogrolls, comment on each other’s blogs, and write blog posts responding to items they read on each other’s blogs. This nurse “blogosphere” may exist on several different platforms (Blogger, Tumblr, WordPress, etc.), have no formal leadership or organization, follow no business model, and offer no standardized format or features, but it would still constitute an online social network. Its “backbone” of user profiles may be much less well defined than the profile/friend structure of platforms like Facebook, but a blogosphere still offers a clearly definable network of social interactions supported by online technology.

 

Professional–Patient Use

Patients are turning increasingly toward the Internet for health information (Fox & Jones, 2009). No longer the “sole custodian[s] of medical data” (Eysenbach, 2008), health care professionals are increasingly “one of many input sources” (Swan, 2009). Some health care providers are responding to this shift in patient demand: as of January 2011, 906 U.S. hospitals (less than 20% of all U.S. hospitals) had established 3,087 social networking sites (Bennett, 2011). 170 Canadian hospitals (12% of total) have been found to be using social media (Fuller, 2011). Social media adoption rates among European hospitals vary, with around 45% of Norwegian and Swedish hospitals using LinkedIn, but 22% hospital adoption of Facebook in Norway compared to 0% in Sweden. The percentage of German hospitals using online social networks is in the single digits, while adoption in the United Kingdom ranges from 16% for Facebook, 21% for Twitter, and 41% for LinkedIn (Engelen, 2011). Australia’s hospitals are lagging 12 to 18 months behind the U.S. in social media adoption (Cadogan, 2011).

Medical schools are also catching up with adoption of the Web and social networking sites. As of March 31, 2010, 100% of U.S. medical schools had websites. 95% of U.S. medical schools had some sort of Facebook presence: a quarter had official school pages, over 70% had student groups, and more than half had alumni groups on the social networking site. Just over 10% had Twitter accounts (Kind, Genrich, Sodhi, & K. C. Chretien, 2010).

Creating a social media presence does not mean hospitals and other institutions are using them effectively to promote interaction with patients. A marketing study of 120 American hospitals selected at random found all had Facebook pages, but less than 40% posted content to those pages daily, 25% posted twice a week, 25% posted once a month, and 5% had posted nothing (Dolan, 2011). Any discussion of health care providers’ use of online social networks requires remaining mindful that effective use of online social networks requires being social—i.e., being present, producing content, and interacting, not just creating a static electronic brochure.

Patients are seeking information to supplement, not replace, the advice of health care professionals. Overwhelming majorities say professional sources are more helpful in providing accurate medical diagnoses and information about prescription drugs; strong majorities also favor professional sources for information about alternative treatments and recommendations for doctors, specialists, or medical facilities (Fox, 2011). Smaller majorities prefer non-professional sources for emotional support and quick remedies to everyday health issues (Fox, 2011). This split suggests that patients may be receptive to informational support from health care professionals in online social networks but that professionals may want to extend their professional emotional reserve to the online realm and leave laypeople the room they value to provide each other emotional support.

Health care professionals have been able to enter patient health social networks to recruit participants for medical trials. As part of its multi-platform social media strategy during the 2009 H1N1 outbreak the CDC monitored and responded to social network conversations to provide the public with accurate disease and treatment information (Keckley & Hoffman, 2010).

While engaging patients in the online forums they are adopting has the capacity to build effective provider-patient relationships, the health care industry lags in adoption of social media in part due to lack of a clear business model. Online social network activities require time and effort; compensating the physician and the facility for such engagement, from information systems development and maintenance to the actual medical information shared by practitioners, is complicated. Charging patients by the Tweet is problematic in a realm where users are accustomed to free-flowing, unmetered exchanges. Advertising is restricted by professional guidelines and regulations (Keckley & Hoffman, 2010), thus hindering another possible revenue source to make social media efforts pay for themselves.

Health care professionals may find support for an online social-networking business case in the marketing potential of such online tools. Online social networks offer health care professionals the ability to disseminate information quickly, broadly, and at almost no cost. They allow providers to cheaply advertise health-related seminars and community activities. From a pure marketing standpoint, using online social networks to interact with patients sends a message to return and potential “customers” that the providers and their hospital or clinic are cutting edge businesses (Tariman, 2010). Engaging in social media may also be “essential” for institutions and practitioners to combat misinformation that patients and others will spread via those same channels (Pho, 2011a). High-quality physician blogs like KevinMD humanize the healthcare industry as a whole, giving physicians’ perspectives and offering popularly accessible explanations of medical decisions (Bhargava, 2009).

 

Professional–Professional Use

Health care professionals can also use online social networking to obtain information and other support for themselves. Professionals are using these online resources, especially younger professionals (Guseh, R. W. Brendel, & D. H. Brendel, 2009). Roughly one in six U.S. physicians have created accounts on Sermo.com (Bureau of Labor Statistics, 2009; “Introduction | Sermo.com,” 2011). Ozmosis and SocialMD offer similar “walled (and safe) communities for physicians to share opinions and interact in a guarded environment” (Bhargava, 2009). 65% of nurses say they plan to use online social networks for professional purposes (Keckley & Hoffman, 2010).

Health care professionals, like professionals in other fields, have found blogs useful as public document repositories, discussion space, and opportunities to expand professional networks and knowledge base (Thielst, 2007). Such blogs become part of the literature and public face of the profession, informing and reflecting on the medical community as a whole (Lagu, Kaufman, Asch, & Armstrong, 2008). Less public, members-only social networks for physicians may support more valuable sharing of specific medical knowledge and support. Professional online social networks Sermo, Ozmosis, and radRounds allow members to share cases for community discussion and collaboration (Keckley & Hoffman, 2010).

 

Ethical Issues

Doctor-patient interaction online remains relatively rare. Only 5% of adults report receiving information, care, or support from health professionals online (Fox, 2011), a number no higher than the number of adults who reported exchanging e-mails with their doctors in 2008 (Cohen, 2009). Such interaction is stymied not by an absence of health care professionals in online social networks but by ethical concerns. In 2009, 60% of U.S. physicians said they were already using online social networks or were interested in doing so (Darves, 2010). A survey of medical residents and fellows at one French facility in fall 2009 found 73% of respondents had Facebook profiles, with 99% of those including the user’s real name, 97% including birthdates, and 91% including a personal photo. 85% of responding medical professionals said they would automatically decline “friend” requests from patients, and 76% expressed concern that a patient discovering a physician’s Facebook account and gaining access to the content would affect the doctor-patient relationship (Moubarak, Guiot, Y. Benhamou, A. Benhamou, & Hariri, 2011). Another study found more than 80% of University of Florida medical students and residents included personally identifiable information in their Facebook accounts, and only 33% of those users imposed privacy protections on that information (Thompson et al., 2008).

A fundamental tension exists between establishing appropriate boundaries (Luo, 2009) and promoting education and empowerment, a problem addressed by developing “a more sophisticated awareness of privacy and engagement within online communities” (Lewis, Goldman, Bennett, Shine Dyer, & Kolmes, 2011). That understanding of engagement may require simply applying the common sense of face-to-face workplace communication: treat the online social network as a public space at the hospital, and make the publicity explicit to patients who may share that space to give them a sense of what personal matters they should address offline (Giurleo, 2011a; Sydney, 2007). Such public prudence may not differ significantly from the professional ethics doctors have wrestled with in social situations for generations; however, the stakes of maintaining that professionalism are arguably higher in the online realm, where indiscretions can cause damage much more quickly across a much larger social network (Jain, 2009). Ethical professional use of social media also requires constant compassion, with a concerted awareness that the avatars and text with which professionals interact are still real people (Giurleo, 2011b), an awareness that may too easily be lost in online realms that convey less social presence.

Ethical demands may differ among different health care fields. For example, psychotherapists use transference, in which patients experience the psychotherapist in ways similar to their connections with people from their past, to help patients work through their problems. Psychotherapists avoid self-disclosure and maintain professional boundaries to avoid hindering that process. Self-disclosure via social networks may directly impact treatment (Luo, 2009). Because of the nature of their work, psychiatrists who engage in public activities on blogs or Facebook may draw unwelcome attention from emotionally unstable or dependent individuals (Perez-Garcia, 1998). Direct communication and the face-to-face process of narrating their own stories are part of treatment; accessing information about therapists online may short-circuit those processes (Yan, 2009).

On the other hand, psychiatrists may find uniquely valuable information about their patients’ thoughts, emotions, and relationships by using Web searches and social networking sites to incorporate Internet habits into their history-taking (Perez-Garcia, 2010). Health care providers may be able to use online information to verify patient information, especially in mental health situations where patients may be prone to falsehood (Luo, 2009). Acting on false information supplied by patients may lead health care providers to deliver incorrect or harmful treatments; however, online information may be just as prone to inaccuracy and requires active efforts at verification (Hughes, 2009). The APA Ethics Committee has ruled that using the Internet to gather information about a patient is ethical “only in the interests of promoting the patient’s care and well-being and never to satisfy the curiosity or other needs of the psychiatrist,” but another expert contends that Googling patients without their knowledge, even in the interest of providing care, violates patient autonomy and dignity (Yan, 2009).

The problem of unintended disclosure on online social networks may affect patients as well as providers. For example, a physician discovered via Facebook photos that a patient who had denied smoking was indeed a smoker (Guseh et al., 2009). Such unintended disclosure may provide the physician information that may affect recommended treatment; however, if included on medical records, that unintended disclosure could also cause the patient to face higher medical insurance premiums (Chin, 2010).

To avoid ethical pitfalls and harm to patient care, some professionals may also adopt the position that as social and recreational spaces, popular online social networks like Facebook are as inappropriate a space for professional–patient interaction as the local bar; such professionals may thus declare online social networks totally off limits (Darves, 2010; Tariman, 2010). Others recommend very cautious guidelines for online social network engagement, with a first principle of “friending” patients being don’t (Guseh et al., 2009). However, one may question whether health care providers restricting their online social network content to purely professional material will miss out on the social utility of such we tools and whether limiting disclosure on Facebook and personal blogs will make any meaningful contribution to professional privacy when vast amounts of information about health care professionals is already available on other sites outside of their control (Holm, 2009). While certain one-to-one interactions like “friending” on Facebook may complicate professional detachment, forthright engagement with the general public in health care provider blogs and other social networking tools may help put a human face on the industry and provide consumers with a better understanding of health care (Bhargava, 2009). Medicine and law are still catching up with technology, so to avoid running afoul of HIPAA and other rules, practitioners generally avoid blogging about patients, even though discussions of certain challenging cases could be greatly informative for the general public (Darves, 2010). Despite ethical complications—or perhaps because of them, practitioner blogs may be the most logical venue for discussion of ethical and practical guidelines for engaging patients and fellow professionals in social media settings to improve health care delivery. One might even argue that practitioners have a professional, ethical obligation to use the blogs and other social networking tools by which misinformation might spread to combat that misinformation by helping patients find reputable health data (Pho, 2011b).

Awareness of privacy issues online is not universal. A 2006 sampling of medical blog content found 33% providing first and last name of authors and 16% providing sufficient identifying information (Lagu et al., 2008). 16% included positive comments about patients; 18% included negative comments about patients. Blogging allows some popular health care professionals to disseminate good health information to the masses (Darves, 2010), but that same channel can carry incorrect and harmful information just as quickly. To avoid harm and personal liability, health care professionals engaging in blogging appear to be developing voluntary “self-regulation regarding patient privacy, transparency, anonymity, and patient respect” (Kruglyak, 2006; Lagu et al., 2008).

Such self-regulation appears to rise with experience and training: multiple investigations find younger medical students and recent medical school graduates frequently exhibiting unprofessional behavior in online social networks, although concerns in this area seem to arise as much from injudicious posting of their own personal information and evidence of behavior outside healthcare settings that might impinge on their and their schools’ or employers’ reputations as from actual improper healthcare practice or improper direct interaction with patients or other professionals (Cain, Scott, & Akers, 2009; K. C. Chretien, Greysen, J.-P. Chretien, & Kind, 2009; MacDonald, Sohn, & Ellis, 2010; Thompson et al., 2008). Institutions like Harvard Medical School and Drexel University College of Medicine already caution students about the potential unintended professional consequences of injudicious personal disclosures on social networking sites (Jain, 2009). However, as of March 31, 2010, while nearly 97% of U.S. medical schools had posted student guidelines on publicly available websites, only 10% had published conduct policies specific to social media (Kind et al., 2010). Given that prohibiting online social network use is unlikely to stop the widespread adoption and use of these tools by health care professionals, it seems more fruitful to follow to route recommended for using e-mail in health care: proactively defining boundaries, improving user knowledge, and developing practical guidelines centered around patient privacy and trust (Chin, 2010). A similar route in online social networking—developing training in privacy, identity protection, and e-professionalism (Mattingly, Cain, & Fink, 2010; Thompson et al., 2008)—seems a more mature route (van den Broek, 2010) that will trains medical students to develop the professionalism necessary to navigate difficult situations rather than simply avoiding them. Such an approach that addresses the challenges of professionalism online would then allow practitioners, professional organizations, and health care businesses to harness online social networks for advancement of the profession

 

Directions

Adoption of online social networks is unlikely to subside, especially as mobile tools accelerate the blurring of boundaries between online and offline social networks. That adoption process may be slower among health care professionals in their work than among other users in other professions, due to the sensitive and literally life-or-death nature of health care and the professional and ethical considerations that arise therefrom. The health care profession is moving more cautiously into this realm of electronic communication just as it has moved more cautiously from paper to electronic medical records. An inappropriate use of new tools in health care could cause enormous harm. But just as with electronic medical records, the appropriate use of online social networks to communicate with patients and fellow professionals could greatly improve the delivery of health care.

Understanding the current state of online social network use by health care professionals, we can proceed to investigating those potential improvements. Some evidence already exists that patients can find online interaction with doctors satisfactory (Cohen, 2009). Research should further investigate the capacity of online social networks to improve patient perceptions of health care and well-being. Similarly, it will be valuable to determine the satisfaction health care providers obtain in using such online tools, as well as potential professional and organizational benefits such as better workflow, cost savings, acquisition of expertise, and development of and engagement with professional organizations.

While more complicated to quantify, research should also investigate whether health care professionals’ engagement results in better health outcomes. Does advice given online affect the likelihood of patients adopting and sticking with prescribed health behaviors? Does online engagement increase patients’ likelihood to consult with physicians on subsequent health issues? Could online interaction lead to a reduction in face-to-face visits that might in turn lead to health care providers missing certain health indicators that would be obvious in a physical meeting? Answers to all of these question will be of keen interest to providers and patients alike.

Parallel to this course of health investigation should run a line of ethical investigation. As we investigate the impacts of online social networks on provider-patient relationships, we should engage providers and patients in conversations about their expectations of privacy and professionalism in the online realm. These conversations will help shape guidelines to maintain quality and propriety in the increasingly virtual doctor’s office. Such discussions and investigations of current use will also inform the necessary legal scholarship that will develop around online social networks so health care providers may better understand their liability for online communication. Answering these ethical questions alongside the practical questions of health outcomes and provider and patient satisfaction will support increasing appropriate use of online social networks in health care delivery.

 

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