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.

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