Physicians & Smartphones: The Story Behind the Numbers
Physicians are all about smartphones, embracing them en masse. Adoption rates hover anywhere from 72 percent (Manhattan Research, Taking the Pulse, May 2010) to 94 percent (Spyglass Consulting Group, Point of Care Communications for Physicians, July 2010). The numbers, however, don't tell the full story, because adoption does not necessarily equate to robust clinical use. At this stage, there are a few killer apps, but true integration into the clinical practice of medicine and the meat of clinical workflow, a.k.a. the EHR, remains a work in progress.

Bottoms up

One of the key differences between smartphones and other clinical IT systems is the bottom-up nature of dissemination. With EMRs, the C-suite and health information management administrators pushed technology onto clinicians, but not always with great cooperation, observes Claudia Tessier, CEO of mHealth Initiative in Boston.

"The utilization of smartphones and related apps is reversed. It's spontaneous among clinicians," says Tessier.

"Physicians are becoming accustomed to gaining access to various apps and services via the smartphone," adds Steve Flammini, CTO of Partners HealthCare in Boston. "My sense is that physicians view the smartphone as a computer, which gives rise to the expectation that they would be able to connect to clinical systems on it."

Smartphone technology is just about primed to meet that expectation. Battery life, display quality and size, operating system power and the maturity of wireless technology have progressed to the point where the systems may be capable of meeting physicians' expectations.

Flammini and his team were charged with testing the hypothesis late in 2009, when health system leadership challenged them to develop version 1 of a mobile EHR viewer.  

One of the primary early flaws in EMR development, says Tessier, was focusing onmaking paper records electronic instead of thinking about what technology could do to improve documentation and care. Flammini et al apparently learned the lesson.

"We did not create any new infrastructure for the project. We optimized presentation for mobile devices, which represents a 90 percent re-leveraging of existing assets and 10 percent net new development," says Flammini. The end result is an effective, intuitive application without a lot of bells and whistles.

Physicians use the mobile EHR to inform clinical decision-making without interrupting rounds, update patient charts without leaving their rooms and check results, notes and clinic schedules from home. "It's a useful adjunct to the systems they currently use. They aren't ready to abandon conventional apps in favor of it, but they see its value when they are on the go," continues Flammini.

A large part of the success of the project is due to its simplicity. Flammini and his development team gathered input from a group of physicians and other stakeholders before devising an architectural approach that recognizes the potential and the limits of mobile technology. For example, physicians aren't likely to write a progress note on an iPhone, but template-driven documentation is feasible, and will be developed with ease of use top of mind.  

Although version 1 is a home run with many users, the project was not without opportunities for learning. Partners' mobile EHR viewer initially supported iPhone, iPad and Blackberry devices. However, Flammini found that demand was much higher for Apple devices and that the volume of demand didn't justify development costs for the Blackberry.

The technology team will continue to evaluate emerging platforms, such as the Android-based devices—with a caveat. "Security is not perfect on any of these devices, but it is adequate on the iPad and iPhone 3GS and above, with enterprise-strength Android-based devices on the horizon," says Flammini.

The Partners HealthCare mobile project worked around key players—EMR vendors. But that model may not suffice in most organizations.

However, Tessier is cautiously optimistic about EMR vendors' growing acceptance of mobile technology. "The EMR community is taking notice of mobile technology and making moves toward integrating mobile device data into EMR systems so that data can be accessed, used and even created and generated through a mobile app."

Beyond the EHR

Indeed, the message about clinical utility of smartphones is a bit mixed. Bleeding-edge adopters may be stretching toward EHR integration. However, the bulk of U.S. physicians may be content with other uses. At least for now.

Some physicians are slower to transition from paper notes to mobile devices, says Joseph Kvedar, MD, director of the Center for Connected Health at Partners HealthCare.

"No doubt there are plenty of physicians who are successfully integrating smartphones into their clinical practice. However, although there is value in bringing a tablet computer or smartphone from room to room, a lot of EMR use will be on fixed devices with an Ethernet connection," Kvedar explains.

While significant progress has been made, Kvedar cites two obstacles to more widespread adoption of mobile platforms for EMR access: the frustration of trying to access clinical data on a 3G network with one bar and the still-limited adoption of EMRs by physicians.

But Kvedar does see enormous potential for smartphone use by clinicians. "Epocrates [which provides drug reference, educational and clinical apps] is very handy, even though we have decision support in the EMR." Other current useful tools are education guides and social networking sites for providers. All are independent of local workflow and infrastructure, which means physicians can access these apps regardless of local IT support for smartphones or the EMR.

In fact, the mHealth Initiative has compiled a list of current primary clinical applications of smartphones, which includes patient and professional communication, point-of-care documentation and access to resources.

Form factor does come into play with smartphone applications. Although smartphone screen size is smaller than that of workstations or tablet computers, navigation and pull-down menus are very much like EMRs, explains Tessier. "The contrast is that smartphone functionality is so attractive that form factors that might hold back adoption of other systems don't have the same strength of impact with mobile devices."

Kvedar notes that the form factor of a smartphone vs. an iPad does represent a tradeoff. "Accessing the EHR on an iPhone screen is a bit of a challenge because of its size. The screen size is fine for lab results, but viewing an image or echo study is compromised on a smartphone." But while the iPad screen is "great" for looking at an image or echo study, a smartphone can be carried in the shirt pocket.

A connected future

As clinical adoption of smartphones continues to diffuse and include the EMR, Kvedar and colleagues envision a mobile-enabled transformation of healthcare. "Through the combination of sensors to gather clinical information about patients, communications vehicles and mobile devices, we can create a healthcare delivery model that has two value propositions: improved self-care and engagement and improved just-in-time care," which will replace the model that limits care delivery to the office visit.

For example, after being presented with individual patient data on a mobile device, a physician could tailor a patient message, sending the patient a reminder about healthy behaviors. In another example of mobile technology, Kvedar's team and Partners Community Benefits created a text messaging program for young, at-risk pregnant women. This program offered informational and supportive text messages throughout their pregnancies, helping to ensure that patients and their babies received the right amount of prenatal care. Text messages were offered in English or Spanish, and each message included a phone number to reach the OB clinical team.

Although the concept represents a work in progress, Kvedar notes similar models have succeeded in heart failure, diabetes and hypertension patients. Heart failure patients in the Partners HealthCare network are now automatically enrolled in Connected Cardiac Care, enabling patients to transmit weight, heart rate, pulse and blood pressure to a telemonitoring nurse each day. This program allows patients to be more engaged and educated about their condition, and providers are able to offer just-in-time interventions to improve care. Connected Cardiac Care has achieved a 48 percent reduction in re-hospitalizations for participating patients, Kvedar says.

In a similar Partners program, diabetes patients can monitor and upload their daily blood sugar levels and record medication changes online. Providers also can access this information, send secure messages to their patients and change treatment as needed. Participating patients had a mean HbA1c reduction of 1.4 percentage points.

As smartphone use cases define new roles such as EHR connectivity, interactive patient management and more, their power to improve patient care and enhance physician productivity becomes increasingly clear.