April 12, 2010

Tiny Tool, Huge Potential
By Alice Shepherd
For The Record
Vol. 22 No. 7 P. 10

The ubiquitous iPhone is dazzling healthcare observers with its versatility, adaptability, and ease of use.

Just a few years ago, cell phone use was prohibited in hospitals for fear that electromagnetic interference could affect pacemakers, medical devices, and computer systems. Since then, hospitals have learned to manage the slight interference emitted by newer phones while physicians have embraced the Apple iPhone for some of the services it can provide. In fact, some are even encouraging patients to communicate with them via smartphone.

Patients Love “Mouse Calls”
Caduceus Medical Group in southern California has developed an application that lets patients use their iPhones to access an online concierge. The new app allows them to e-mail physicians, schedule visits, request prescription refills, and obtain directions to their place of care, all from their iPhones. It also provides direct links to Twitter and shortcuts to Caduceus’ Web-based services, including blogs, daily health news features, and health-related quizzes.

“When we launched our first Web site in early 2009, we saw that patients really liked it,” says Melissa Christian, the group’s vice president of business development. “In the last six months of 2009, we had over 800 uses of the online concierge. Most of those were ‘mouse calls’—e-mails that are answered directly by the physicians, not nurses.”

The success of the online concierge led to the development of an iPhone application in late 2009 that made it even easier for patients to communicate with their doctors. While the online concierge is accessible from any computer or smartphone with a browser, the iPhone application directly connects that page. “Dr. Gregg DeNicola, our medical director, is not hesitant to open up channels of communication with patients,” says Christian. “Some physicians fear e-mail communications with patients. In contrast, he has embraced the communication vehicles patients use today. As an iPhone user himself, he’s very comfortable with the technology.”

In fact, rather than being inundated with e-mails requesting free medical advice, Caduceus has found that iPhone access, and online access in general, has increased efficiency. “We don’t consider patients to be an annoyance when they ask questions, and we have found no abuse,” says Christian. “Our patients ask appropriate questions, the same questions for which they would call the office. Even our few ‘frequent flyers’ use it as little as once a month.”

To request an appointment or a prescription refill or to ask a medical question, patients complete and send an easy-to-use form. Their encrypted message is transmitted to a cloud-computing server that is separate from the practice’s own in-house server. The physician (or liaison for refill requests) logs into the secure concierge system and replies to the e-mail. Patients can request a preferred method of contact (e-mail or phone) but most opt for e-mail. In urgent matters, the patient receives an immediate phone call in addition to an e-mail reply.

All e-mails and requests are handled the same day, often in as little as 20 minutes. “Being digital has made it a lot easier to meet our commitment of being responsive to patients,” says Christian. “Without digital access, patients would call and leave a message, which could create a longer response time because it would go through many different touches. Now we have one employee who oversees the concierge program and does so part time. She receives an SMS notification to her phone (also an iPhone) when a request has landed in the concierge inbox.”

Christian cocreated the application with a developer who designed templates and platforms that have evolved over time. The first major update in March added submenus so patients can learn about a specific physician at the touch of an iPhone button. Future enhancements include a direct-dial feature to each of the six clinical departments and video streaming.

“We’d like to stream how-to videos, instructional videos, and short messages (eg, on a flu outbreak),” says Christian. “Patients will also be able to get live directions to our offices from their current location rather than just viewing a map. We’re getting ready to complete our EMR implementation later in 2010 and are working with our vendor to make sure the iPhone application connects to the EMR portal.”

For other practices planning to develop a similar application, Christian recommends they understand how their patients use the iPhone and establish expectations that can be achieved if the application is interactive. If the application is not interactive, its purpose should be to provide valuable, actionable advice in a fun, entertaining way rather than just promote services.

Saving Lives From Bed
Physicians love remote access to EMR information, but they don’t want to carry multiple devices. They want to use one device, preferably one they already own. For many, that tool is the iPhone. That’s one reason Allscripts developed Allscripts Remote, an iPhone application that provides physicians access to its EHR platform virtually anytime, anywhere.

“A physician who gets a call in the middle of the night on an iPhone no longer has to get out of bed, power up a computer, and log into the EHR,” says Allscripts CEO Glen Tullman. “He or she can call up the records on the iPhone that just rang and view the patient’s summary information, medical history, lab results, and medications while counseling the patient at the same time. The physician can then use the iPhone to write a prescription and send it electronically to a 24-hour pharmacy closest to the patient’s home. Or the patient can be sent to the emergency room while the doctor is transferring relevant records and dictated notes to the ER. It’s not only more convenient for physicians but could save someone’s life.”

The application automatically checks whether the emergency department or pharmacy is accessible electronically. If not, it sends the patient data or prescription via fax. The physician can point and click to create notes on the iPhone or dictate comments that are translated into written notes by Nuance’s Dragon speech recognition software. To e-prescribe, the application accesses common diagnoses and pulls up the two or three most common prescriptions from which the doctor can select by touching the screen.

The application can be downloaded from the iTunes App Store, a service created by Apple for the iPhone, iPod touch, and iPad. No training is required for physicians familiar with iPhone capabilities. Those who prefer a larger screen can use the application on an iPod touch as long as they are within range of a Wi-Fi network. Within a hospital’s Wi-Fi network, the iPod touch can also access the EMR less expensively than the iPhone.

Tullman says security is not an issue because no patient data resides on the iPhone. “Even if a physician were to use security to access the EMR and then leave the iPhone behind in a cab, access would be shut off two minutes later,” he explains.

Applications for interface devices such as the iPhone are inexpensive because their development is less complex than creating software for a full-scale computing network. Allscripts offers similar applications for the BlackBerry and Windows mobile devices. It is currently developing a so-called glucophone, which will double as a cell phone and a glucometer to measure and transmit glucose levels to a physician, a caregiver, or an endocrinologist. “A type 1 juvenile diabetic will only need to carry a cell phone, not two different devices,” says Tullman. “It will facilitate real-time monitoring of young children fighting diabetes.”

A Communications Hub
Smartphones are well on their way to increasing consumer access to care and improving the delivery of quality medical services outside the traditional medical setting. This is evident from the growing number of free and low-cost consumer-driven applications. Among these are trackers for diet, sleep, mood, fertility, and various symptoms; body imaging applications (PET, CT, MRI, internal organs, skeleton, etc); disease diagnosis tools; generic and brand-name drug interaction checkers; medical encyclopedias; and even applications that promise to reduce snoring.

Particularly popular are applications that process signals from external devices and transmit them to the iPhone, turning it into a communications hub. Weight scales, body mass index calculators, blood pressure cuffs, glucose monitors, pedometers, and the like are equipped with Bluetooth interfaces that send wireless signals to smartphones.

“The phone processes the information, and patients can view it or transmit it to a provider,” says Joseph Kvedar, MD, founder and director of the Center for Connected Health, which applies communications technology and online resources to increase access and improve care delivery in nontraditional settings. “In addition to a display device, the phone also serves as a data aggregator, plotting readings on graphs. Applications such as these are among the countless opportunities for technology-enabled care programs and new strategies in healthcare delivery. Today, only a very small percentage of home health patients use smartphones, but in the future, these devices will play a major role in delivering quality healthcare in the home.”

“Smartphone applications are the future of healthcare,” says C. Peter Waegemann, vice president of the mHealth Initiative, a not-for-profit organization promoting mobile health applications. “They will be the main point of contact between patient and doctor. Patients can regularly transmit health data electronically to the doctor’s office and reduce the number of office visits, or they can bring the iPhone and show the doctor the accumulated data.”

 The prospects for how mobile devices can reshape the care paradigm seem endless. “The iPhone could play an important role in improving patient adherence,” says Kvedar, who is researching how a combination of remote-monitoring technology, sensors, and online communications and intelligence can improve engagement and clinical outcomes. “Adherence is typically abysmally low. One of the reasons is that patients get their pills mixed up. I’d like to see an application that lets patients take pictures of their pills and match them up with the photos in the online medication database of The Physicians’ Desk Reference. It might help people become more adherent to their care plan.”

“Even now, if a patient cannot recall the name of his or her medication during an office visit, the physician can pull up pictures of drugs on the iPhone and show them to the patient so they don’t have to guess,” says Waegemann.

One reason such technology is not more widely deployed is that the smartphone user demographic does not overlap much with the population segment suffering from chronic illness. Until that changes, Kvedar suggests providers take full advantage of voice calls and text messaging to reach the millions of patients who have mobile phones. “Text messaging, for instance, is a valuable tool to remind people to engage in healthy behaviors that will improve their care,” he says. “For example, one of our research studies indicates that individuals who received a daily text message reminding them to use sunscreen were twice as likely to comply as people who received no such message.”

Waegemann says of the more than 2,000 smartphone healthcare applications, the most commonly used are database inquiries that give consumers the ability to perform tasks such as medication checks against a health plan’s formulary. “That amounts to less than 1% of available smartphone applications,” he says. “Health information professionals need to understand the paradigm shift and learn to manage information in a new way. This is not a short-lived fad.”

The radiology community has also developed an interest in the iPhone for the purpose of displaying digital images such as CT scans and MRIs. “Providers could access images in an online database and make decisions on the go rather than finding a workstation,” says Kvedar. “The iPhone’s small screen would not be a problem because the device allows you to zoom in and expand portions of the image very quickly with finger movements.” For providers who find the iPhone screen too small for viewing or keying in text, there is the Apple iPad, which has the same functionality as the iPhone on a 10-inch screen.

Security and privacy concerns with iPhone use are minimal, according to Waegemann. “The main risk derives from the built-in camera,” he says. “Hospitals need very strict policies to prevent staff and volunteers from using the camera to record private information.”

To help healthcare organizations guard against privacy incursions, the AHIMA plans to release Management and Security of Health Information on Mobile Devices, a guidebook written by mHealth Initiative President Claudia Tessier, RHIA.

A Potential Regulatory Barrier
Some industry thought leaders believe smartphones are becoming the communication and access device of choice and may in time become the computers of the future. “Whether healthcare reform passes in Washington or not, technology is changing healthcare from the inside out,” says Tullman. “The iPhone and other devices are empowering physicians with real-time information so they can make better and more cost-effective decisions.”

However, there is a new challenge on the horizon for iPhone applications. When consumers upload data from a Bluetooth-enabled device to be processed by the iPhone, the question is, does the iPhone become a medical device that should be FDA certified? “If the FDA decides to step in, who will bear that regulatory burden?” asks Kvedar. “It would be unfortunate if regulation were to stifle innovation in the use of smartphones as a connected health tool.”

For now, however, the iPhone is enjoying the spotlight as one of healthcare’s rising stars.

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.