The Landscape: Physician use of handhelds is by no means a new concept. But as the devices - particularly the RIM BlackBerry, Apple iPhone and Google Android - become more sophisticated and more applications become available, the game is changing, quickly. And with so many hospitals upgrading their infrastructures to offer ubiquitous wireless coverage, clinicians are using smartphones in the hospital setting to access online tools such as drug references, and communicate with colleagues. For CIOs, it's a no-brainer - physicians and nurses are already carrying these devices, so why not capitalize on the trend by enabling users to access clinical information and link to patient records. A number of organizations have adopted this thinking and are on the road to enabling EMR access via mobile devices. And while there are certainly sticking points, it's an area that many say is poised for significant growth in the next few years.
The Future: Many innovative organizations are looking to provide access to electronic records and other clinical data through smartphones. Plans are already being formulated to leverage the devices to facilitate patient handoff and sign-out, as well as to link charge capture with quality measures. Cutting-edge organizations are looking to create actionable information for clinicians through software that can analyze data, track patients' progress, and send out alerts when conditions worsen.
When it comes to cutting-edge technology, sometimes the implementations that fail are the ones that end up having the greatest impact.
A few years ago, Children's Hospital Boston launched an initiative to plug clinical data into smartphones - the result was disappointing. According to Daniel Nigrin, M.D., CIO and senior vice president of information services, the IT team at the 396-bed hospital linked smartphones to the Cerner (Kansas City, Mo.) EMR system, enabling physicians to view patient information online. But the project never quite took off, says Nigrin, who believes it was primarily because the technology “wasn't quite up to the degree that it is now. In order to secure the devices to the degree that we thought was required, clinicians had to enter a clunky password each time they logged on,” he says. “It was enough of an obstacle that it led to providers just not bothering to log in. That was one of the places we stumbled.”
Making it too difficult for users to access electronic records was a critical mistake, he says, but it was one that Children's certainly learned from. And with the organization now looking to get back into the smartphone space, Nigrin says he feels he and his team are at a distinct advantage. “As we consider redeploying similar types of things, we know what we really have to focus on,” he says. “Things like, how are we going to secure the information to the degree that we need to, while also making it streamlined and easy enough for the clinicians that they'll log in and use the tool.”
Presently, clinicians at CHB are using smartphones for tasks like searching for drug information through applications like Epocrates, and are accessing Web-based tools through the hospital's Intranet. But in the next few years, Nigrin's team is looking to leverage the technology to facilitate patient handoff and sign-out by creating an application that extracts data from the Cerner EMR system and feeds it into the handheld device.
Children's is also working to link charge capture with quality measures. “We've got a significant effort underway to try to collect clinical quality outcomes from the providers at the time of care,” says Nigrin. The function will be available both through the EMR system and via the handheld, he adds, letting clinicians choose the method most convenient for them.
For many, that option is the handheld. “I think there is more and more of an interest” in accessing patient data via smartphones, he says. “Clinicians aren't banging down my doors asking for it, but there are enough comments being made that I think as we start to roll these things out, the uptick will be better than the last time around.”
Craig Brandis, a principal at mHealth Consulting based in Portland, Ore., says this reflects what he is noticing across the industry. “I've seen an enormous surge of interest in smartphones,” he adds, estimating that 70 percent of physicians carry the devices. “The amount of reference information available is constantly going up, and people are looking for more integrated, more actionable information.”
Perhaps the biggest appeal of smartphones, he says, is the fact that clinicians are already using them as personal communication devices. “That's the number one thing - it's a ubiquitous platform. And I think the expectation is that if your regular data is available on your smartphone, then why isn't the clinical data there?”
According to Brandis, the two areas CIOs are looking to improve by rolling out smartphones are patient safety and communications.
At Sarasota Memorial Hospital, easing communication between staff members was the key objective when Apple (Cupertino, Calif.) iPod Touch devices were piloted at one of the Med/Surg departments in 2009. And while Vice President and CIO Denis Baker was confident that the deployment would be successful, he admits he was surprised by one of the outcomes. During the trial run, the staff quickly discovered that corresponding via text messaging meant that the overhead paging system was used much less frequently, which made for much quieter hallways. “In any hospital environment, noise is always an issue. So while it wasn't an initial goal, it was certainly one of the more positive benefits that came out,” says Baker. “You'd think voice-to-voice over a phone would be optimum, but it turns out that people don't always necessarily want to answer the phone while they're doing something. With texting, they still get that communication.”
Taking IT Home: Smartphones' Role in Telehealth
While hospitals are starting to see a significant surge in use of smartphones in the clinical setting, one area where adoption is already high is chronic disease management, according to Stan Schatt, vice president and practice director, Security and Healthcare, ABI Research (New York). Applications that assist with glucose and cardiac monitoring or checking for irregular rhythms are commonly used in the patient home, he says. “And what's really spurring it is the iPhone. There are a lot of health-related applications available now, and there is a definite trend toward giving patients equipment and having them use the smartphone to monitor themselves.”
Schatt says the appeal for hospitals is that clinicians can spend their time more productively. “Instead of having the patient come in for a periodic check-up to see how it's working, they can have the information sent over a network.” The problem, he says, is that it costs hospitals money upfront to buy the equipment in order to be able to receive this information. Schatt says whether manufacturers can convince hospitals to invest in the servers and software to interpret the metrics is a big debate. And, he says, whether insurance will pay for it is of concern. “But the idea itself makes a lot of sense.”
The devices, he says, will be rolled out incrementally to critical care units and other areas throughout the organization.
One factor that helped make the pilot successful, according to Baker, was the staff's willingness to provide feedback to Voalte (Sarasota, Fla.), the developer who worked with the hospital during the implementation. Nurses regularly offered input on issues like which orders they wanted on their task lists, and how they wanted to be notified when action needed to be taken, he says.
The next frontier for Sarasota is to enable clinicians to access its Atlanta-based Eclipsys EMR system using iPhones. The IT team, says Baker, has begun discussions with the vendor to develop a format that will enable optimal use by clinicians.
Scoping out the market
While several EMR vendors are beginning to offer smartphone applications, the issues that should be top of mind for CIOs are data integration and creating actionable information, according to Brandis. For example, software from companies like San Francisco-based Keane can analyze multiple data streams, signal a patient is deteriorating, and send out alerts - it's this type of smart trending that can really usher smartphones into the next frontier, he says. “Clinicians are drowning in data. They need actionable information. You want them to have all of the clinical alarms from the monitors, all of that history and all of the event information in their hand.”
Look Before You Leap
The decision to implement a new technology is one that can't be taken lightly, says Daniel Nigrin, M.D., CIO and senior VP at Children's Hospital Boston. “I love new technology and new devices, but I don't necessarily just jump and try to implement them unless I know exactly what problem it's solving. We've sort of had a cautious deployment approach.”
That philosophy, he says, applies to rolling out smartphones. So while applications that enable users to view imaging studies or real-time waveforms might seem attractive, Children's has its sights set on initiatives “that we think will solve a real need and not necessarily just ‘wow’ people,” he says.
“We're thinking about using smartphones for those instances when it's not convenient to log on to a full workstation,” says Nigrin. With the handheld device decision, or any other one, Nigrin says he asks two questions. “First, will this solve a need? And second, once we implement it, can we justify its use? As far as the support and ongoing maintenance requirements - can we justify it in terms of the benefit that it's going to bring, compared with all the other tools that we provide for completing that task now.”
According to Brandis, Welch Allyn (Skaneateles Falls, N.Y.) is also establishing itself in the smartphone space with a solution that “integrates lethal arrhythmias and all the parameter information and puts it, in real-time, in your hand.” The tool also has a feature that lets clinicians automatically escalate alarms when they are busy and review patient alarm histories, he says. Brandis says he believes that improving workflow and eliminating bottlenecks should be top priorities, particularly as technologies like smartphones become more prevalent in the hospital setting. “I think the CIOs are being driven bottom-up, increasingly, by the end users,” he notes. “And so I think this is a very good time for them to step back and understand their end-user needs better and look at central solutions.”
And while CIOs need to be conscious of which new technologies should get the green light, particularly in these economic times, Brandis believes that “when everyone is carrying a platform like a smartphone all the time, it's a golden opportunity to help clinicians get access to information they need when they need it.”
Healthcare Informatics 2010 February;27(2):24-27