Wireless technology is transforming the way people communicate, and the medical community is not immune. In June 2011, there were more wireless devices in the United States than people, and more than 73% of physicians owned a smartphone — a 22% increase from 2008. This proportion is expected to reach 81% in 2012, according to estimates from the Manhattan Research Group.
“Pre-2005 there were very few smartphones. Now we see practically ubiquitous adoption of what is essentially a mobile computer that is unbelievably versatile in terms of memory, wireless Internet access, high-resolution color screens and camera capabilities,” Orrin Franko, MD, the lead application (app) editor for the newly launched peer-reviewed Journal of Mobile Technology in Medicine, said in an interview. “It basically has every tool you can imagine and fits in your pocket.”
Since Apple launched the iPhone in 2007 and the iPad in 2010, smartphone and tablet prices have steadily decreased, with alternative manufacturers emerging and more mobile carriers offering cheaper data plans to support the devices. This is making digital technology more accessible for everyone. Once considered specialist items, smartphones and tablets are now becoming essential tools for many health care providers.
Orrin Franko, MD, said that in the future health care providers will be using mobile technologies in their interactions with patients in ways we cannot yet imagine.
Photo courtesy of Franko O
Physicians using mobile health
Richard S. Schofield, MD, chief of medical service at North Florida/South Georgia Veterans Health System, has been using mobile health (mHealth) for more than a decade. The Veterans Health Administration has an ambitious goal of reaching 50% of their patients across the country with some aspect of virtual medicine by 2014 and his institution has been using a variety of technologies to do so, he said.
“In the future, I can see health care changing so that almost everything we do can be done in the palm of our hand, with fully electronic medical records, electrocardiograms that can be transmitted electronically, and patients and providers interacting more from a distance than they might face to face,” Schofield, who is also professor of medicine in the division of cardiovascular medicine at University of Florida College of Medicine, Gainesville, told Cardiology Today. “On the whole, it will probably be a good thing, but there will be a learning curve involved.”
Schofield sees enormous potential for mHealth telemedicine opportunities. During the past decade, telemonitoring has become a major component at his institution, including for cardiac patients. Telemonitoring has proven useful to help track patients’ trends in BP, heart rate and glucose levels, for example, and to make medication changes with ease.
“We have found telemonitoring to be a very useful adjunct to treating patients with CVD, especially those with HF,” he noted.
Video telehealth clinics for cardiac patients are also growing in popularity. Similar to Skype, videoconferencing enables physicians to have face-to-face medical consultations with patients who live at great distances from the medical center. Schofield’s group has organized video telehealth group educational clinics on HF including topics ranging from diet and exercise to basic pharmacology of HF medications. Initial use of the video telehealth clinics has helped save travel time and inconvenience for both patients and providers.
Secure messaging has also become more commonplace at institutions across the country, making full use of the electronic medical record systems which are now being widely adopted. At Schofield’s institution, their experience with secure messaging has helped save time during correspondence between patients and the medical team about simple issues and problems, like refills or cancelled/rescheduled appointments.
“Many things, like simple follow-up evaluations, may be able to be eliminated in the future if we expand our ability to virtually connect with our patients. I think we’ll be seeing more of that over the next decade,” Schofield said.
Carl J. Pepine
Cardiology Today Chief Medical Editor, Carl J. Pepine, MD, said he stays up to date with the latest research in his areas of interest by accessing journal articles on his iPad each evening.
“I see enormous potential for the use of handheld tablets in our clinical trials. We have designed new applications for certain trials that will permit subjects to directly input the information that we need to collect about them at each visit. That is a great way to capture data directly from the patients, reducing error, and saving our study coordinators’ valuable time.”
This ease of access, along with the tablet computer’s unprecedented versatility, assures that smartphones and tablets are not likely to be left behind on the kitchen table like many of their print counterparts.
“The biggest aspect of mHealth will be getting to the point where physicians will have tablet computers that will seamlessly connect to electronic medical records. If we can get to the point where physicians everywhere can walk around their clinic or hospital with an iPad, that would be a big advance,” Schofield said.
Public health outreach for chronic conditions
Although the technological capabilities of mHealth are impressive, the human component remains essential to the success of any mHealth program or intervention.
Lygeia Ricciardi, EdM, senior adviser of Consumer e-Health at the US Department of Health and Human Services Office of the National Coordinator (ONC) for Health Information Technology (HIT), said facilitating communication between patients and doctors and encouraging improved self-care are top priorities for her program.
“It’s important not only to think about how technology can improve the delivery of health care services, but also how it can help engage patients in their own health,” Ricciardi said in an interview. Mobile phones and smartphones offer several distinct advantages to other forms of digital technology for public health efforts, one of which is reaching populations in underserved areas.
Whereas much of the Western world is enamored with the high-tech aspects of mHealth, Jesse Coleman, MSc, an independent consultant and mHealth expert who has held positions as the mHealth project manager for the British Columbia (BC) CDC and performed considerable field research on mHealth programs throughout Africa, said the utilization of simple text-messaging programs is important to improve access to health care.
Ricciardi said the HHS hopes to achieve improved health care delivery with mHealth interventions for US patients with chronic diseases, such as diabetes and CVD. “We want to use mHealth to shift the health care model from the more traditional model, in which patients see their health care providers only when they’re sick, to one in which patients are encouraged to be a partner working toward the shared goal of staying healthy or managing a chronic condition.”
Ricciardi said specific patient within the United States are more likely to benefit from mHealth campaigns than others. These groups include racial and ethnic minorities, who are more likely to use mobile devices to look up health information than other populations, and those living in urban areas, which have some of the highest uninsured populations. For members of underserved populations who may or may not have personal computers, mobile phones often serve as the primary source of information as well as communication.
“MHealth technology is really unique because it has the ability to be much more personal than traditional Internet-based forms of communication,” Ricciardi said. “We’ve found that people are more likely to use their mobile phone or smartphone to look up information about potentially sensitive topics, such as services related to STD management, mental health or substance abuse.”
Integrating apps and EHRs
As more US medical practices move toward meeting federal goals for universal adoption of electronic health records (EHRs) by 2014, many expect the role of mHealth in ensuring continuity of care to grow even further as the ability for apps to integrate with EHRs improves.
Elizabeth S. Dodds Ashley
“We don’t have an app yet at our institution, but I’m still able to access the EHR system from my mobile device, and that’s hugely helpful in getting the patient information I need with appropriate secure networking,” said Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS, an infectious disease pharmacist and associate director for Clinical Pharmacy Services at Rochester Medical Center in New York.
This is especially useful when out of the office, when she wants to provide answers to real-time questions or if she gets a call to approve an antibiotic.
“I can immediately get the patient information I need at my fingertips, see the cultures and make appropriate recommendations. Or if I’m on a pharmokinetics consult, I can see the exact time of the patient’s last dose from wherever I am. That’s very helpful in providing up-to-the-minute care from inside or outside of the hospital,” Dodds-Ashley said.
The Epic EHR system in use at Franko’s institution has two apps available to review patient information: Haiku for the iPhone and Kanto for the iPad. However, he said that a major limiting factor is that these are read-only systems. “The apps are beautiful aesthetically. They are really well done, but you can’t place orders on them or write notes.”
Other limiting factors include the relatively small screen size on smartphones, the limited amount of space available to store data, short battery lives and no standard keyboard for those who wish to type; but, technology is evolving at a rapid pace to meet these needs. Voice recognition software is becoming increasingly accurate and popular, virtually eliminating the need to type.
Cloud computing, whereby users on a network access data stored on a remote secure server via a Web browser or app housed on a smartphone or tablet, makes the amount of space available to store data limitless, and also offers solutions to security concerns about remaining HIPAA compliant in a mHealth world.
Health care data breaches involving patient information increased 32% from 2009 to 2010 in a network of 65 health care organizations, according to data from the Ponemon Institute’s Second Annual Benchmark Study on Patient Privacy and Data Security.
During the 2 years before the study’s publication in 2010, 60% of participants reported that they experienced more than two data breaches, with each participant experiencing an average of 2.4 data breaches during the study period. A lost or stolen computing device was among the top three causes given for these security breaches, along with unintentional employee action and third-party error.
Many said cloud computing will make situations like this less likely. “As we move into a cloud-based mobile computing world, very little patient information will actually be stored on phones and, therefore, very little information will be at risk for theft,” Franko said.
MHealth may actually improve patient privacy in the long run. “If you walk into any hospital in the world, you will see paper charts all over every counter top,” Franko said. “People bank online. They have all of their finances online. I don’t see how a mobile phone connected to a cloud-based database is in anyway less secure than online banking.”
International Mobile Equipment Identity number
In April, the Federal Communications Commission (FCC) and the International Association for the Wireless Telecommunications Industry announced an initiative to help curb the theft of smartphones that should eliminate concerns about stolen patient information.
The initiative will enable smartphone owners to disable the device after reporting it lost or stolen using an International Mobile Equipment Identity (IMEI) number, the equivalent for smartphones to a vehicle identification number (VIN).
Tampering with a smartphone’s IMEI number will be designated as a federal crime, and smartphone service providers are creating databases of all IMEI numbers so that those reported lost or stolen cannot be reactivated.
Databases for smartphones that operate on the Global System for Mobile (GSM) communication are expected to be ready in October, and databases for phones operating on Long Term Evolution (LTE) should be active by Nov. 30, 2013, after which any lost or stolen smartphone will essentially be useless for accessing confidential information.
In the meantime, health care organizations must make sure that they are following appropriate security protocols.
“If I’m accessing any sort of patient data I always do it through a secure virtual private network (VPN) connection set up through the medical center,” Dodds-Ashley said. “Our organization’s policy is that we don’t store any patient data on the devices.”
Future of mHealth
As more health care providers begin using their smartphones in the clinical setting, ensuring that tools are reliable, accurate and consistent through pre-implementation testing and post-implementation monitoring are the goals for mHealth in 2012 and beyond.
According to Ricciardi, the three key requirements for mHealth to be successful are: that it provide specific, actionable information; that mHealth programs be regularly evaluated to determine what is working and what is not; and that text services for apps be evidence-based.
“It’s going to take a concerted effort on the part of health care providers to encourage patients to engage in improving health care using mHealth technology,” Ricciardi said.
While many are confident that mHealth will advance the management of patients with CV disorders during the next decade, Schofield noted several potential drawbacks, including the need for additional medical personnel to offer virtual appointments and technical glitches.
Coleman expects that the mHealth industry will see more funding and development from private corporations as they begin to realize the business potential of the mHealth market and less funding from government health organizations facing tight budgets due to global economic constraints.
“In the future, health care providers will be using mobile technologies in ways I can’t even imagine at this point,” Franko said. “No one is throwing away their smartphone anytime soon, so medical software developers will continue to find new ways to integrate with mobile technology.”
In the meantime, Franko encourages health care providers from a wide range of specialties to become more involved with designing apps to meet the unique needs of their respective professions. – by Nicole Blazek, with additional reporting by Katie Kalvaitis
For more information:
- Berg A. “Carriers, FCC crack down on smartphone theft.” Wireless Week. Published: April 10, 2012.
- Blumberg SJ, Luke JV. “Wireless substitution: Early release of estimates from the National Health Interview Survey, July-December 2010.” National Center for Health Statistics. June 2011.
- Fox S. The Pew Research Institute Report on Mobile Health 2010. Available at: www.pewinternet.org/Reports/2010/Mobile-Health-2010.aspx.
- Ghosh PR. “The Spectacular Mobile Phone Revolution in Africa.” International Business Times. Published: Nov. 17, 2011. Available at: www.ibtimes.com/articles/251484/20111117/africa-mobile-phone-sms-service-rural-south.htm
- Han L. The Kaiser Commission on Medicaid and the Uninsured. “Mobile Technology: Smart Tools to Increase Participation in Health Coverage.” e-Health Snapshot. 2011. Available: www.kff.org/medicaid/8153.cfm.
- Lester RT. Lancet. 2010;doi:10.106/S0140-6736(10)61997-6.
- Ponemon Institute Research Report. Second Annual Benchmark Study on Patient Privacy and Data Security. December 2011. Available at: www2.idexpertscorp.com/ponemon-study-2011/
- Mr. Coleman and Drs. Dodds Ashley, Franko, Pepine, Ricciardi and Schofield report no relevant financial disclosures.