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Top Ten Tech Trends: Making Doctors Mobile: Zeroing in on Clinical Workflow

January 26, 2015
by David Raths
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Health systems seek ‘purposeful embrace of mobility’
Donald Plumley, M.D., a pediatric surgeon at Arnold Palmer Hospital for Children in Central Florida, recently wrote a moving firsthand blog account of how access to medical images on his mobile device helped save a life. A regional medical center needed immediate expertise with a newborn patient with an abnormal X-ray. Plumley was taking a personal day off, but because his Level 1 pediatric trauma center had joined a cloud-based image-sharing network, from his car he was able to pull over to the side of the road and use his iPad to look at a scan and diagnose a condition that needed emergency surgery, which ended up saving the child’s life. “Cloud-based image-sharing is not only revolutionary, it’s life-saving,” he wrote.
Although that type of story is becoming more common, for several years the hype about mobile tools has been running a little ahead of their actual utility in clinical practice. Too often, doctors have gotten excited about the idea of viewing results on their iPads, only to have to seek out a PC with a keyboard in order to enter orders. But in 2015, with the increasing maturity of devices and software, some organizations are starting to refine what mobile means to their clinicians by closely studying the impact on workflow. Also, advances in mobile solutions targeting healthcare are starting to eliminate communications inefficiencies. A recent PwC Health Research Institute survey found that 79 percent of physicians believe using mobile devices can help clinicians better coordinate care.
“Many healthcare organizations have embraced mobility for the sake of leveraging mobility,” says Rasu Shrestha, M.D., chief innovation officer for the University of Pittsburgh Medical Center (UPMC) health system in Pittsburgh. “But we don’t believe in just doing mobility to put a checkmark on a requirement list. Yes, we have done mobility. But it has to be a very purposeful embrace of mobility.”
A 2014 survey of nearly 600 clinicians by EHR evaluation site Software Advice found that 35 percent use tablets and 20 percent use smartphones (respondents could choose more than one option.) And a surprisingly high 17 percent reported using mobile and portable devices exclusively to use their systems. 
For John Salmon, senior director of the EMR Group at the University of Pennsylvania Health System in Philadelphia, mobile vs. desktop is not really an either/or situation. “We seek to understand which environment and which context a mobile app may be most helpful in vs. when you need a keyboard and full screen,” he says. Penn Medicine is seeing increasing uptake of mobile apps. For the Epic users in the ambulatory environment, they are registering 3,500 mobile log-ins a month and 300 distinct users out of 1,800 physicians. “Epic has done a good job of understanding where mobile is most helpful to clinicians,” Salmon said, adding that Penn Medicine has not yet implemented order entry on mobile devices.
Elsewhere, Penn Medicine’s thinking about mobile tools has evolved, says Glenn Fala, senior director of software development. Of the 75 applications developed in-house, about 10 percent are mobile apps. “As more users shift to mobile, we try to present a subset of the data in a mobile app. And anything we start new these days, we are thinking immediately of the mobile part of it.” The app can be built once and run on desktop or mobile. “We realize certain user stories that are mobile ones,” Fala says. “They only need to do certain things on the phone. We focus on the use and that tells us what to build.”
Penn Medicine is working on several mobile solutions. In an internal study, researchers found clinicians spending too much time on administrative tasks and communicating. “They were having the same conversation with 10 people, but not at the same time,” says Neha Patel, M.D., director of quality in the section of hospital medicine at the Hospital of the University of Pennsylvania. “That led us to pilot secure messaging for group exchange throughout the day in real time that allows for closed-loop communication.” In May 2013, the hospital started using an application called Cureatr. Anecdotally, residents are saying that its use saves them one to three hours a day, and nurses about an hour, Patel says.
“It not only saves a lot of time, it improves the quality of care,” says Subha Airan-Javia, M.D., assistant professor of clinical medicine and director of internal medicine residency EMR and health IT training. “Everyone involved in the patient’s care gets the same text. As soon as anybody gets information, everyone is on the same page working toward the same thing. It has made better or earlier discharge possible.”
Dr. Airan-Javia also has helped Penn Medicine software developers create an app called Connexus that aggregates data from five siloed applications for a comprehensive view of the patient. “It was designed to match how the clinicians want to see the data and to integrate data doctors and nurses get separately,” she says. Getting all that data to fit a phone format was a design challenge, she adds. “We put aside assumptions about the display and focused on the user stories we are trying to address. We threw out a lot of assumptions about how it should look, and all of us have been pleasantly surprised.” 
UPMC has done something similar with a homegrown application called Convergence, a tablet-based platform that extracts patient data from a variety of clinical information systems and presents it in a visually compelling way. UPMC is rolling out 2,000 Surface tablets across a wide range of clinical scenarios.  “The challenge is that you have these legacy solutions that don’t talk to each other,” Shrestha says. “But if you create a mobile app on iOS, you are almost distancing yourself from the investments you’ve made in these legacy solutions.” He said UPMC initially created Convergence on an iPad. “The visual layer was fantastic. But when you needed to take action, such as placing an order it essentially became useless,” he says. You had to put it down and find a Windows desktop to log in to Cerner or Epic, a process that was very labor-intensive and disconnected. “But when Windows came out with Windows 8, we saw a great opportunity to connect past, present and future.” The past is the legacy solutions with valuable data, he explained. The present is the touch form factor, with intelligent visualization; the future will be moving Convergence into the clinical care pathways where health care reform is going, such as utilization appropriateness and evidence-based guidelines. 
Mobile technology also has a physician engagement component. A few years ago Rockdale Medical Center, a 138-bed acute care hospital near Atlanta, held a physician engagement group around IT. “We found that many of them wanted to have greater access to mobile technology,” says Lisa Gillespie, M.D., chief medical officer. “Also, as you seek to attract new providers, they want to know what you are doing with technology. We wanted to make it easier for them to use their own devices, so they don’t have to learn anything new.”
Rockdale has been rolling out a mobile patient monitoring technology called AirStrip One that allows obstetricians to monitor labor and delivery patients and gives cardiologists access to electrocardiograph data on their smartphone or tablet. Gillespie says the plan is to expand usage of AirStrip technology to critical care teams and hospitalists. Also, EMS technicians will soon send cardiologists EKG results on the way to the hospital. “The EMS truck can do an EKG and be talking to the cardiologist on the phone at the same time,” she says. “The cardiologist can decide if the patient needs an intervention and activate a team before the patient gets to the hospital.”

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