The Menlo Park, Calif.-based Spyglass Consulting Group recently released a study showing significant growth in physician adoption of smartphones—94 percent of physicians reported using smartphones, compared to a 59 percent usage rate in November 2006. The study also reported that clinicians were often overwhelmed with the volume of incoming communications and found it difficult to connect with colleagues during office hours. Spyglass’ managing director Gregg Malkary spoke with HCI associate editor Jennifer Prestigiacomo about why physicians are loving their smartphones, and why those devices won’t be fully integrated into clinical workflow anytime soon.
Healthcare Informatics: What were some of the major findings that came out of this study?
Malkary: I think one was the predominance of the use of the smartphone by docs as a communication device for managing their personal workflow—it’s really becoming an all-encompassing device. And that they see as a requirement for managing daily personal and business activities. They’re also utilizing all the capabilities of the device, primarily as a standalone system. So in other words, it’s not integrated into any other systems. Healthcare IT is shunning that and the reason is that [it’s hard to] deal with the complexity and the cost to support those devices; healthcare IT doesn’t want to network up to those devices.
HCI: The percentage of physicians using smartphones seems awfully high; were you surprised by this figure?
Malkary: For reference-based tools it’s probably about 85 percent. As soon as you go to any clinical applications, like lab results viewing, chart capture, viewing of EKGs, and electronic prescribing, it’s less than four percent. And there is a reason for that. Terminals are so widely available that if you’re working at a hospital or clinic, you’re never more than 10 minutes away from accessing a terminal. Why would you want to look up clinical information on a really small [screen] that is hard to see? And that’s actually the most common response we heard.
Now, when we started doing this study back in 2002, we started hearing that in some of the more wired hospitals, like Partners Health [Partners HealthCare, based in Boston] and Mass General [the Boston-based Massachusetts General Hospital, a Partners organization], that clinical information systems were really starting to gain traction. Now that they’re starting to gain traction across the country, doctors are now particular on where they want to spend their time. If I continue to have to scroll in order to see information, it’s really a waste of time. That’s really the most common response. With that said, we really need the vendors to step up to the plate, because what they’re trying to do is force clinical applications designed for a 19-inch monitor onto a small form factor. What we really need to do is look at the user interfaces and see what information is really needed. And there is a small genre of applications that is suited for a smartphone. This includes chart capture, electronic prescribing, census management, and reviewing lab results. But clearly not looking at a patient’s complete medical record, which is ludicrous on a device this small.
HCI: Did anyone talk about security issues surrounding using their smartphones at their practices?
Malkary: There’s a huge security issue, especially around the iPhone [made by the Cupertino, Calif.-based Apple]. There’s a huge perception that the iPhone is less secure than the RIM [Waterloo, Canada-based Research in Motion] Blackberry. I think the iPhone has a lot of built-in security mechanisms to make it as secure. But there is a perception that it is a toy, so therefore, healthcare IT is highly resistant to integrate it within the infrastructure including e-mail—even the Microsoft Exchange implementation option is very robust. So if you put these other devices on the network, what are the cost issues involved, how many devices can you support? There’s a lot of resistance, because as soon as you open the kimono up to every RIM Blackberry, you have all this infrastructure that needs to be in place, and you open the network up to vulnerability.
HCI: Why do you think there is a preference for the iPhone over the Blackberry?
Malkary: It’s a cool device. I know that doesn’t sound like much, but there is a status factor to this. You also see nurses starting to adopt the iPhone as well, especially as the price point is coming under $99 if you buy last generation. Docs have a very positive image of using Apple in the past from desktop computing. The interface is easy to use, and there are really cool applications. There is the emergence of location based services. RIM doesn’t have that. It’s the equivalent of a DOS-based device. It doesn’t have the ecosystem, the usability quotient as Apple has. And these docs are the same docs we’ve interviewed in years past who were using the Palm Treo [Palm was recently acquired by the Palo Alto, Calif., -based HP.] and the RIM Blackberry; so they are dropping the RIM Blackberry in favor of the iPhone.
HCI: What have you heard from physicians about their usage of the iPad?
Malkary: We’ve talked with folks about the iPad, and there’s guarded optimism. As you know, we’ve already been through the tablet before, so that’s really what it is. So a lot of the same issues are still there—the size, weight, and form factor. You’re still going to carry it around. It’s lighter than the MCA [the Intel-designed mobile clinical assistant] or mobile clinical system was, but there are still some significant issues like session control issues. Can I clean the device? There are issues around the ecosystem. Are the applications for reading materials readily available at an affordable price? There’s also a lack of clinical applications. The iPad may be ideally suited for viewing clinical information. There are two things going on. One, are the vendors willing to spend the tens of millions of dollars to redesign their applications to leverage gesture based computing? Second, is Apple willing to set up the appropriate infrastructure to enable the distribution of an enterprise level application not in the app store. There’s also workflow integration issues, really including this into clinical decision workflow management, which is never an easy task. If nurses are going to use it, we have issues dealing with the lack of integration of a barcode or a RFID [radio-frequency identification] scanner. It’s not quite clear if Apple is willing to step up to the plate and provide the right developer to support the efforts of GE [Barrington, Ill.], McKesson [San Francisco], Cerner [Kansas City, Mo.], etc.
HCI: The study talks about coordination of patient care. Can you talk a little more about that?
Malkary: There are no processes in place for patient hand-off. The patient referral process is absolutely broken. So say I’m a primary care doc, and I want a specialist to see [this patient]. Frequently, there’s no documentation that goes with the patient. The specialist looks at the patient and has no idea why they’re there; the patient has no idea why they’re there. He has to start from ground zero, which includes redoing the medical tests, or hopefully, he gets in touch with the primary care doc and gets the medical records transferred over. but this delays the quality of care. And the other part is the documentation back to the primary care doc. It might be weeks before he gets that documentation back.
It’s better if you’re a part of a multispecialty clinic using an electronic medical record, and everything’s instantaneous, which makes the effort easier with the referring doc and the specialists involved. I know this seems really simple, but it’s not being done today.
HCI: As your study points out, physicians said they were overwhelmed with daily communication. What do you think the problem stems from?
Malkary: There are so many modalities. Before it was easy, they had a phone, a desktop, a pager, and an answering service that would screen calls. And now they have multiple cell phones and multiple pagers. So with those they’re using email and text messaging, Facebook, Twitter, etc. With the more modalities they have, the more things they need to check—which by the way are in separate silos, so it’s very time consuming to utilize. What some of the older docs are doing is using their cell phone only for outbound calls, having a pager, and telling patients to call the nurse. But for those who want to me more wired, they’re just overwhelmed. And the reason this is significant is that they have no financial incentive to be more available to colleagues or to patients unless its critical. Every minute they’re on the phone, is one less minute they could be making money when they see patients. The financial issue is huge; every doc I talked to brought it up.
You’re starting to see some of these communication issues addressed in many of the large physician group practices and some of the more advanced medical centers, because they’re all kind of tied in together, and it all affects the bottom line. They look at preventive care as a loss leader because they make up the money in specialty care, but they’re part of the same group. When one wins, they all win.
HCI: What do you think needs to happen in the industry for smartphones to be more integrated in patient care?
Malkary: What we’re definitely seeing right now is the emergence of email. Docs really like email and they’re using it more and more in communicating with their colleagues—primarily for administrative purposes. As time goes on, and as we have better tools within the EMR for communicating clinically significant information, I think that could be a big win, especially if that could be integrated into the smartphone. These clinical systems are incredibly user unfriendly; therefore there’s huge resistance to using them. So that is one email doctors get [from clinical information systems], and they get other personal emails on their smartphone, and there’s other emails at the office. None of this is consolidated. We need better integration for communication and support for the smartphone. And healthcare IT is probably not going to go there any time soon because of HIPAA.
HCI: What are some of the challenges for smartphone adoption as electronic medical records proliferate?
Malkary: We asked them about what were the challenges with physician adoption and they said, ‘We’re not technophobes.’ Especially all the guys I talked to who are technologically savvy. It’s that the technology doesn’t benefit them. Doctors will adopt technology for a purpose, and the smartphone clearly fits into that realm; electronic medical records don’t. It improves the quality of care, but it comes at a cost of time. And the beneficiary of the electronic medical record is more the large integrated delivery [system] and the insurance providers, but they’re not willing to help pay for the technology infrastructure costs for docs.