Mobile medicine: "are we there yet?"
Editorials / Commentaries
Karim Jessa, MD, FRCPC;
From the Emegency Department, York Central Hospital, Richmond Hill, ON and North York General Hospital, North York, ON.
This article has been peer reviewed.
© Canadian Association of Emergency Physicians
It is often said that “information is power.” In medicine, having immediate access to the right information can be immensely powerful for both the patient and the physician. Access to information about medications and to diagnostic and treatment information can have an impact throughout the patient stay. In the January/February issue of CJEM, Worster and Haynes described a six-page methodology for foreground questions once a diagnosis is made.1 Although this is very relevant, foreground and background questions are intermingled in arriving at a diagnosis and subsequent management plan.
However, only having access to information is not enough. The right information needs to be available at the right time to be of maximal value to the patient in front of you. In health care, due to the dynamic nature of our work, this information needs to be available anywhere, anytime. Increasingly, information needs to be accessible via a mobile format. The increased use of smartphones in the general population and specifically in health care provides a tremendous opportunity for increased patient safety and efficiency.
The authors are correct that detailed searching, investigating and exhaustive searches for patient information and background information is cumbersome at the point of care. However, mobile technology and ubiquitous Internet access have brought the library to the bedside. As Apple has demonstrated, “It's all about the apps, baby.” Never before has so much information been so readily available to providers and patients alike. Worster and Haynes are correct when they write that the source of this information needs to be verified,1 but even Wikipedia's self-governing philosophy ensures that questionable medical information is quickly discounted and often replaced by information provided by the experts. Before coming to the emergency department, patients will often refer to the same sources of information as physicians would. How often have emergency physicians (EP) (and physicians in general) been challenged by patients when presented with a diagnosis and therapeutic options?
The clinician is responsible for the synthesis of all the symptoms and signs and background information. True clinical decision support will incorporate existing information about the patient into future management. A simple example would be the adjustment of heparin or low-molecular-weight heparin dosing based on the patient's creatinine clearance. Another example would be automated warfarin dosing being guided by the international normalized ratio. More advanced clinical decision support could offer antibiotic choices based on already existing information regarding antimicrobial and pathogenic prevalence in certain areas. This could offer an antibiotic of choice for a female presenting with signs and symptoms of a urinary tract infection. Furthermore, with integration of medical records and disparate information sources such as drug prescription information obtained from the pharmacy and laboratory information from the Ontario Laboratories Information System (OLIS), one could conceivably be told that an individual being prescribed a macrolide for pneumonia should instead receive a fluoroquinolone as a macrolide had already been prescribed in the past 3 months. In the inpatient setting, evidence already exists as to the benefits of standardized order sets and electronic reminders in decreasing morbidity when prescribing deep vein thrombosis prophylaxis for hospitalized patients.2 This is the value of a true clinical decision support system (CDSS).
Worster and Haynes suggested that a simplified CDSS would provide a differential diagnosis generator that already exists with commercially available products such as PEPID (<http://www.pepid.com>). Products such as these provide a rich source of validated information. Importantly, this information is provided to the EP without the EP having to leave the bedside. This point of care access is particularly important for the EP as interruptions can prolong a patient encounter. Furthermore, the use of a reference in front of a patient and/or family further adds to the credibility of the information provided and results in increased patient and physician satisfaction and potentially fewer complaints.
The evidence suggesting that there is an increase in patient safety by having applications readily available is very compelling. As the Institute of Medicine's report, To Err Is Human, states, patient medication errors are a regular occurrence in medicine, adding to the morbidity and mortality of patients.3 Existing applications such as EPOCRATES (<http://www.epocrates.com>) and PEPID provide common dosing for medications, whereas enhanced versions provide a medication interaction checker that could lead to safer prescribing habits. Additionally, a review of the Medical Category at the Apple App Store reveals no fewer than 2,076 applications (at the time of this writing). Applications vary from simple medical calculators to a full electronic health record. Also, services such as Medscape (<http://www.medscape.com>) offer textbooks and other reference material on a smartphone or tablet.
Another benefit of mobile technology is improved communication among clinicians. The myth regarding the use of cell phones in hospitals has been debunked. Many clinicians have eliminated their use of pagers in favour of their cellular or smart phones. Furthermore, the advent of social media and applications such as Blackberry Messenger (<http://www.blackberry.com>) or even text messaging allows information to flow quickly, with questions answered in real time. The use of the camera on the smartphone opens a wide range of possibilities to improve patient care. Pictures of electrocardiograms can be sent to offsite specialists for further review. Photographs of PACS monitors containing x-ray, computed tomographic, or magnetic resonance images can be sent across the world for information sharing or patient transfer decisions. The privacy implications will need to be considered by policy makers, but given the choice between a delayed diagnosis or delayed transfer and the maintenance of privacy, most patients would choose the ability to share data.
The increased availability and adoption of tablets such as the Apple iPad (<http://www.apple.com>), Samsung Galaxy (<http://www.samsung.com>), and Blackberry Playbook will further accelerate the mobile health revolution. Increased gains in patient safety can be achieved by computerized provider order entry (CPOE), which should become easier at the point of care using these devices. Physician documentation should also become easier at the point of care.
Mobile health, or m-Health, has the potential to revolutionize the way that clinicians will interact with patients. m-Health offers increased safety and efficiency and the ability to access information that was once very difficult to find. The future for medicine and the patients we serve seems very bright!
Worster A, Haynes RB. How do I find a point-of-care answer to my clinical question? CJEM 2012;1:31-35.
O'Connor C. Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes. J Hosp Med 2009. 4:81-9, doi:10.1002/jhm.399.
Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer system. Washington (DC): National Academy Press; 1999.