EXECUTIVE SUMMARY
With new technologies erupting across the IT landscape, physician mobility is expected to leap forward in the coming years. But healthcare IT leaders and industry experts say thoughtful strategies and clear vision will be needed to make the mobile future a successful one for all those involved.
Mark Musco, M.D., remembers clearly what life was like in the pre-mobile-computing days for physicians. “It must have been in 2005 or 2006,” he recalls. “I was at a party with a bunch of friends from college, and two friends had Palm PDAs, and they were checking their e-mails, and I looked at them doing that with longing. And I realized in that moment how owning a mobile device would allow me to be connected to my practice, but also be with my family, or be at the park, or anywhere else-in other words, how it could untether me from a fixed workstation.” Not long after that, Musco began using his BlackBerry for some functions, and then switched to an iPhone just under two years ago.
And if Musco glimpsed the future of physician mobility several years ago, he's also someone who, in his role as CMIO of the Walnut Creek, Calif.-based Muir Medical Group IPA, has been charged with helping his 700-plus physician colleagues create the environment they want in order to facilitate the anytime-anywhere computing capabilities they need these days. So Musco, a family physician who practices two days a week in a three-doctor practice in nearby San Ramon, also spends two days a week at the Muir corporate headquarters, working with Tina Buop, the organization's CIO of clinical integration, and others, to help move everyone towards the new world of mobile computing. (The fifth day every week Musco devotes to managing a mix of administrative and personal activities.)
Musco himself currently performs many tasks in a mobile fashion-“coordinating care, taking calls, updating a patient's status with another provider-a lot of that I'm doing is via text-messaging now,” he notes. He also texts fellow physicians briefly regarding patients before receiving documents within the IPA's electronic health record (EHR) or a fax. Meanwhile, within his own three-doctor, one-physician assistant office practice, “All the people with direct patient care responsibilities are mobile,” using tablets for core clinical documentation and other functions, he notes.
As CMIO, what is he seeing? “The physicians have a few major concerns,” Musco says. “Number one, they're often driven by total cost. Number two, the physicians are very excited about instantaneous provider connectivity to ancillary services and other providers in the community; so basically, they want to be connected to a community of doctors collaborating and coordinating care on an e-community kind of platform.” The third and fourth levels of priority, he says, are “ease of use” of any platforms and devices “relative to their particular clinical needs”; and making sure that “the instrument that they're going to deploy in their office is going to help them meet evolving mandates or requirements, such as related to meaningful use, healthcare reform, or managed care needs.”
THERE'S GOING TO BE AN ENTIRE GENERATION OF ADOPTERS WHO NEVER KNOW WHAT IT'S LIKE TO HOST THEIR OWN SERVERS, BUT WHO INSTEAD WILL BE LOGGING INTO WEB-BASED, HOSTED SERVICES. - MARK MUSCO, M.D.
What's patently clear, Musco says, is that in a collaborative environment such as exists in IPA-based organizations like Muir, “The idea of maintaining something yourself in clunky servers in your office is going by the boards.” Instead, he says, “There's going to be an entire generation of adopters who never know what it's like to host their own servers, but who instead will be logging into Web-based, hosted services.”
MANAGING A SWIRLING MIX
Nationwide, CIOs, CMIOs, other healthcare leaders, and physicians in practice are all struggling over questions around physician mobility, as policy, regulatory, industry, technological, and societal developments continue to swirl forward in a heady mix of change. Far more than even a few years ago, there now exists the technical capability to provide physicians with unprecedented capabilities in mobile computing. But just because something is technically capable of being done, does that mean it should be facilitated? CIOs, CMIOs, and other healthcare IT leaders are faced with an almost bewildering array of choices to make, knowing that choosing correctly could boost physician productivity and potentially optimize reimbursement, while also enhancing patient safety and care quality and boosting patient and family satisfaction.
But no one can have everything; and the same industry and policy factors that could potentially support increased physician computing mobility are also weighed down by issues of cost, implementation scheduling, prioritization, and return-on-investment value. How to decide?
Tina Buop, Muir's CIO, is clear in her mind about all of this. “As a CIO, I'm constantly prioritizing in four key categories,” she says. “Number one, are we up, are we available, are we secure?” In other words, core maintenance, operations, and availability. The other categories are new projects and product development; implementation, training and adoption activity; and work that supports the vision and mission of the IPA's board. What is key about all the developments taking place around physician computing facilitation at Muir, she says, is that “We're constantly evaluating whether what's being requested is aligned with what the board is envisioning. So if you want an iPad, that's great, but would you like an iPad, or a new bidirectional interface for the lab?”
The key, in other words, is IT prioritization and governance. At Muir, that translates into an EHR physician advisory committee of 13 doctors, which meets at least three times a year, with Musco as chairman and Buop facilitating.
Among the questions she, Musco, and their colleagues at Muir are continuously trying to answer are the same ones their colleagues nationwide are looking at these days.
Among those are:
What strategies make sense from the organizational standpoint of a medical group, hospital, or integrated health system leadership level?
How can strategizing around mobility be successfully harmonized with overall clinical IT strategy development?
What kinds of analysis and trend-watching can be brought to bear, both in terms of the mobile, web, and infrastructure technologies themselves, and in terms of the policy, regulatory and reimbursement developments taking place that will in effect mandate certain clinical computing requirements?
How can the vendor development elements be managed, and can vendors move forward to more optimally partner with patient care organizations going forward?
While there are no simple answers to any of these questions, all those interviewed for this article agree that one of the numerous pressing challenges of the next few years for CIOs and CMIOs at all types of patient care organizations will be to figure out how best to facilitate mobile computing for physicians in ways that make sense for all the stakeholder groups involved, without breaking one's organization's bank or vaulting off a tech-fad cliff.
EXAMINING USABILITY
One thing is patently clear: physicians are becoming mobile very quickly-perhaps more quickly than many in the industry might have anticipated even a few years ago. This fact is documented in a recent survey conducted by QuantiaMD, a Waltham, Mass.-based mobile and online physician community. In the survey of 3,798 physicians, conducted online in May, more than 80 percent of doctors surveyed said they own a mobile device capable of downloading applications-a percentage far higher than that among the general public. For more details on the QuantiaMD survey, including results made available exclusively to Healthcare Informatics, see “Mobile Device Adoption Speeding Forward” (sidebar, p. 14).
The data on accelerating mobile-device adoption is obviously very clear. But one researcher who has done recent work in this area cautions that there is a flip side to the current wave of interest in mobile computing among physicians, and that has to do with the mobile applications currently being developed. Fran Turisco, a researcher in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices, a division of the Falls Church, Va.-based CSC, has been examining usage of mobile apps in healthcare. “What's interesting,” says Turisco, “is that while there are something like 17,000 mobile health, or ‘mHealth,’ apps out there, and they range from free-of-charge to some expensive, very sophisticated solutions, what we're seeing is that in many cases, physicians and other clinicians are trying out mobile apps, but not sticking with them very long.” She cites a recent industry survey that found that only 26 percent of mHealth apps retain end-user loyalty beyond about 10 uses.
“What I think that shows is that there are a lot of apps out there addressing certain needs; the question is what the value proposition is for them,” Turisco continues. “Our view is that something has to become the preferred way of doing something, or has to provide a unique way of accomplishing a task, for it to be adopted beyond the very short term,” she says. “These solutions are being built by physicians with a specific need, or by organizations with specific needs,” she adds, “and they're infiltrating care organizations, and that really puts the onus on organizations to get ready, to catch up-they're already behind, as doctors and patients are already using these technologies. So the broader question,” she says, “is really, how do you catch what I call the mHealth train speeding through your organization?”
Mobile Device Adoption: Speeding Forward
Just how quickly are physicians adopting mobile devices for clinical use? Pretty quickly, in fact, as the results of a survey conducted by QuantiaMD, a Waltham, Mass.-based mobile and online physician community, confirm. In QuantiaMD's survey of 3,798 physicians, conducted online in May, more than 80 percent of respondents reported that they already own a mobile device capable of downloading applications. And among those who already possess such a device, 59 percent had an iPhone; 29 percent had an iPad; 20 percent had an Android smartphone; 14 percent had a BlackBerry; 3 percent had an Android tablet; and 7 percent had some other device (and of course, many had more than one mobile device). And a full 44 percent intended to buy a mobile device this year.
Figure 1. About one in five group practices and institutions give their physicians a smartphone or tablet device. Source: Quantia Communications Inc.
Significantly, 19 percent of survey respondents are already using a tablet device clinically, while another 65 percent say they will likely or very likely do so in the next few years (only 15 percent said it is unlikely they will do so, and only 2 percent said they absolutely won't).
At this publication's request, QuantiaMD researchers have shared additional statistics exclusively with Healthcare Informatics. Among those findings: 12 percent of group practices, 10 percent of inpatient hospitals, and 11 percent of outpatient, hospital-based organizations have provided physicians responding to the survey, with mobile devices (see figure 1). In the vast majority of cases, however, doctors are buying those devices themselves. In addition (see figure 2), it is interesting to note that there appears to be no correlation between whether organizations have purchased mobile devices for physicians or they bought them themselves, and their level of interest in using those devices. Also, significantly, a minority of “super-mobile physicians” identified in the study-doctors who use both smartphones and tablet computers in their practice-are performing such tasks as “accessing patient information and records,” “learning about new treatments and clinical research,” and using their devices to aid in patient diagnosis, at significantly higher rates than other doctors.
Figure 2. Physicians who have purchased their own mobile devices are just as interested in connectivity to EMR data as those with institution-provided devices. Source: Quantia Communications Inc.
What does all this mean? “I think the most surprising finding was around these super-user physicians,” says Mary Modahl, QuantiaMD's chief communications officer, and the author of the survey report. “We found that once a doctor had acquired both a tablet and a smartphone, they started using their devices overall at a higher rate than those physicians with only one of those types of devices,” she says. “And certainly the speed with which the tablets are coming on” is another noteworthy finding of the survey. “Of course, physicians have incomes that allow them to buy tablets easily; but the level of interest also reflects a growing level of interest in mobile applications that serve the healthcare field,” she says.
A COMPLEX INPATIENT ENVIRONMENT
While the mHealth express may be speeding through the physician office and outpatient environments, within the inpatient hospital setting, physician mobility remains a distinctly local train for now. The fact is that there are a number of complex inhibiting factors that are keeping many physicians from becoming fully mobile, at least at the tablet and smartphone levels, says Christopher Longhurst, M.D., CMIO at Lucile Packard Children's Hospital (LPCH) at Stanford University, Palo Alto, Calif.
“Whether or not doctors are going fully mobile” at the level of tablet use, Longhurst says, “has to do with the use case: are they doing data review or data entry? The fact is that doing rounds involves a lot of data entry-you're writing a lot of notes, doing e-signing, you're doing electronic billing, and doing electronic order entry. And so the reality is that a device that doesn't allow for facilitation of those tasks falls short.” In other words, without a dedicated keyboard, physicians are finding iPads and their brethren inhibiting when it comes to any significant data entry tasks.
LPCH has provided iPads to some of its physicians, including in its neonatal ICU. “But our early experience shows that if you want to provide those devices, you need to provide software that optimizes such use,” Longhurst says. “You can load [Cerner's] PowerChart or the Epic EMR right up there, but what you get is not the simple, intuitive interface you've come to expect from an iPad app, right? Most of the EMR products are really still meant to be used in a Windows 32 environment, even if you're working on a tablet,” he notes.
“So the question is, how rapidly can the Windows-based EMR vendors rewrite their platforms to accommodate tablets? And the newer vendors, like PracticeFusion, are on modern technology where the data layer and the presentation layer are separate, and they can rewrite the presentation layer pretty easily. But the core big-box software vendors have a lot of legacy software code that makes it much harder to extend these applications.” Meanwhile, Longhurst says he is highly critical of the “basic iPad apps” from some of the core-clinical vendors. “They give you very basic access to a small subset of data in the EMR,” which makes such apps highly limiting at this point in time. But, he adds, “I think that because of the ubiquity of mobile devices, there will be increasing pressure on the software vendors to support them and you're already seeing some of that pressure having an effect now. Still, for more intensive and comprehensive data entry purposes, he says he sees physicians in inpatient hospitals continuing to rely on COWs (computers on wheels) in a majority of situations.
If the inpatient environment is somewhat clouded by complexities around documentation tasks, adequately supporting the infrastructure for mobility remains a key ongoing challenge for medical groups, says Les Clemmer, CIO of Quincy Medical Group (QMG), a 95-doctor group in the Mississippi River town of Quincy, on the far western frontier of Illinois. With himself and six other IT staff (out of a total medical group staff of about 600) supporting their EHR full-time, Clemmer reports that “We are a Citrix shop, as well as a full VMware environment, with about 90 servers, mostly virtual,” and with full Citrix Access Gateway availability for Quincy Medical Group physicians from anywhere.
QMG doctors have total anytime/anywhere access to all the key EMR and other clinical IT capabilities the group offers (including full PACS-picture archiving and communications system capabilities), Clemmer reports. The key to success across the many medical specialties involved, he says, has been forging consensus on supporting core clinical solutions that work broadly across the entire spectrum. Or, as he puts it, “The challenge to a multispecialty group is, you don't get to buy best-of-breed for every ‘ology.’ I've got 28 different specialties here. So I have to let everyone know I understand that this system is not perfect for everyone, but we need to share, and provide that common platform to everybody.” Given ongoing consensus on that level of uniformity, supporting mobility is highly sustainable over the long run, he says.
DOING ROUNDS INVOLVES A LOT OF DATA ENTRY; YOU'RE WRITING A LOT OF NOTES, DOING E-SIGNING, YOU'RE DOING ELECTRONIC BILLING, AND DOING ELECTRONIC ORDER ENTRY. THE REALITY IS THAT A DEVICE THAT DOESN'T ALLOW FOR FACILITATION OF THOSE TASKS FALLS SHORT. -CHRISTOPHER LONGHURST, M.D.
FOCUS ON FUNCTION, DOCTORS SAY
Regardless of the specific decisions that are made around infrastructure for mobility and support for mobile clinical apps, physicians in practice want CMIOs and CIOs to understand their mindset as they contemplate how to strategize around mobility. “My mantra is that workflow trumps everything,” says Dan Imler, M.D., a second-year pediatric emergency medicine fellow at Boston Medical Center. “I don't care what device I use or where it comes from or anything; all I care about is managing my workflow in the most efficient and effective manner possible.”
I DON'T CARE WHAT DEVICE I USE OR WHERE IT COMES FROM OR ANYTHING; ALL I CARE ABOUT IS MANAGING MY WORKFLOW IN THE MOST EFFICIENT AND EFFECTIVE MANNER POSSIBLE. -DAN IMLER, M.D.
In fact, Imler says, “There are times when a mobile device is not nearly as good as a PC in certain settings. For instance, if I'm in an office setting, there's no need for me to have a mobile device. Now, in the ER, that's somewhat true, but surprisingly, mobility does matter there-for example, to show a patient something on an iPad, or to check on something when I'm just a few feet away from a workstation.” The bottom line for him? CMIOs and CIOs need to think in terms of physician needs in order to get clear on what their mobility strategies should be.
Steven Davis, D.O., a family physician in Southern California, agrees with Imler. And, like Muir's Musco, Davis is both a physician in practice and a medical informaticist. As medical director of clinical information services for the Torrance, Calif.-based HealthCare Partners organization, which encompasses physicians practicing in both group-model settings in Southern California, and doctors in IPA organizations in California, Nevada, and Florida, Davis has been working closely with the organization's CIO, Zan Coulson, to create and maintain the infrastructure to support mobile computing for doctors in very diverse settings across a far-flung multi-state organization. As at Muir in Northern California, the leaders of HealthCare Partners are using an IT governance structure, including in their case an interoperability workgroup, in order to develop strategies that are sustainable and optimal.
“How do you make data accessible to the physician at the point of care? The art of the future is going to be getting all this information together, but making it relevant to the time and place needed,” Davis says.
In this view, he is supported by James L. “Larry” Holly, M.D., CEO of Southeast Texas Medical Associates (SETMA), a 26-physician, 12-nurse-practitioner medical group in Beaumont, Texas. SETMA has received numerous awards and recognitions for its pioneering work in developing the patient-centered medical home and focusing on care management for patients with chronic diseases. “What mobility does for us that is key is that it allows numerous clinicians and staff to be contributing and sharing data and information about patients simultaneously,” Holly says. That, he contends, will be the basis for ongoing breakthroughs going into the future, as physicians and other clinicians in patient care organizations will increasingly become truly interconnected in real time, with obvious benefits to patients and families.
Will support for physician mobility continue to pose challenges going forward? Obviously. But, all those interviewed for this story agree, with the right strategies, mindsets, and collaboration, the mobility express is set to turbocharge forward in ways that will significantly improve patient care for everyone.
Healthcare Informatics 2011 September;28(9):10-16