November 8, 2010

Healthcare Jumps on the Mobile Bandwagon
By Robert N. Mitchell
For The Record
Vol. 22 No. 20 P. 20

From accessing patient information to dictating encounters, physicians are using smart devices to help make the care process run more smoothly.

In a recent Wired magazine article, “The Web Is Dead. Long Live the Internet,” authors Chris Anderson and Michael Wolff argue that the Web is in decline as services (or apps) increase, with the pair pointing out that apps are everywhere.

“You wake up, check e-mail on your bedside iPad—that’s one app. During breakfast you check Facebook, Twitter, and The New York Times—three more apps. On the way to the office, you listen to a podcast on your smartphone,” the authors note.

Additionally, at work, we scroll RSS feeds and converse on Skype and via instant messaging, the authors continue. At the end of the day, we return home, listen to music on Pandora, play some games on Xbox LIVE, and watch a movie on Netflix’s streaming service—all of them apps.

The argument is that the digital world is moving away from the Web to semiclosed platforms, using the Internet for transport rather than display. And it’s being driven by the iPhone mobile computing model.

If everything is running on an app, how is healthcare, including mobile dictation tools, evolving in today’s app-filled world?

Dictation Apps
Good Shepherd Medical Center in Longview, Tex., recently developed an iPhone app for physicians to view patients’ clinical and demographic information. Applications Manager Chris Reed says the tool is not a native iPhone app (Web application), so some doctors are using it on their Palm devices.

“You have a lot of patient information in disparate systems; every area within the healthcare setting uses different systems,” says Ron Short, Good Shepherd’s vice president of operations. “And because most places choose a best-of-breed approach, there’s not a lot of integration. We wanted to bring a common integration and have data displayed as close to real time as possible.”

Good Shepherd’s app gives physicians the ability to see which patients need attention and to view lab values, medication lists, and radiology reports. “They can also listen to voice clips in a PACS. That’s been one of the biggest successes with the physicians,” Short says.

In addition to those features, physicians can search for and add patients and view outpatient histories. “It gives physicians one place for the clinical information they need for a patient,” Short says. “The physicians like that they have access to the information and don’t have to look for an available computer or the patient’s chart.”

For other healthcare organizations considering the development of their own mobile app, Short recommends first obtaining buy-in from the targeted user group. “That’s true whether you’re implementing an EMR, a new change in processes, or implementing CPOE [computerized physician order entry]—you need that buy-in,” he says. “We knew if we put out sufficient functionality, we would have a core group of docs who would embrace this. We asked what else would be helpful (eg, lab values, radiology reports, visit history). By using these individuals as resources, we prioritized what was most feasible to do and what would provide the biggest bang.”

Whether it’s on a desktop or in a mobile setting, the app is for viewing only. Nevertheless, its introduction has been a success thanks in large part to its ability to get useful information into physicians’ hands. “For other hospitals considering developing their own app, especially for smaller hospitals, you have to engage physicians early and often or it won’t work. While our system is slick looking, it doesn’t mean anything if they don’t use it. You have to involve them in the process. If the physicians are engaged, you can build on that,” Short says.

Reed says several physicians were eager to use the mobile app, “but we first wanted to understand their workflow. Once the beta version was released, it was surprising what happened: The early adopters would be using the app and their peers would see it and ask how they could get the app.”

Nuts and Bolts
With the federal government pushing hard for HIT adoption, there’s been a gradual change in physician documentation habits. “The physician is being asked more and more to stop dictating using narrative dictation and instead use the EHR to enter information,” says Steve Retz, document creation business manager at 3M Health Information Systems.

In the inpatient environment, a physician will interact with a patient and typically update the EHR documentation or create a document in the EHR based on that encounter.

“This process often means the physician has to leave the exam room, find a computer, log in to it, load an application, search for the patient, find a template, fill out the template—all the while hoping that the template covers all the information that has to be documented,” Retz says. “The process for creating documentation in the EHR sometimes takes nine or more minutes, where an average dictation takes three or four minutes.”

Physicians working at a clinic or in a physician practice also see an impact in workflow even when using portable laptops. As a result, the time required to enter information into an electronic system can distract from patient care.

Physicians are overcoming this hurdle by updating all records at one time using notes kept throughout the day. When a physician documents from memory, it increases the risk of incomplete or inaccurate documentation. “We’re offering mobile apps that can solve some of this for the physician by capturing narrative dictation at the point of care and then integrating the dictation with the EHR,” Retz says. “Physicians spend less time creating documents and more time providing patient care.”

3M’s mobile app interfaces with scheduling systems and patient admissions, discharge, and transfer systems. A physician can use a mobile device to dictate notes, view patient lists (which can be filtered by patient, location, or date), and access current patient information.

The tool allows a physician to dictate directly into a smartphone during a patient encounter. “It immediately puts them into recorder mode. Some physicians encourage patients to listen to them dictate, helping them understand what the physician is adding to their chart, which promotes patient satisfaction,” Retz says. “And once the dictation is complete, the job is sent for speech recognition and then into the transcription system.”

Emdat, a Web-based transcription software provider, has developed mobile apps for the iPhone and the Windows Mobile platform, each of which allow physicians to download their patient schedule and record their dictation directly into the mobile device. Once the physician is finished, the file is uploaded to the medical transcription organization, which transcribes the report and submits it to the doctor.

“In both cases, the … app can be used to view the transcription. And with the iPhone, it also can be used for electronic signatures,” says Kevin Saliga, Emdat’s cofounder and vice president of application development. “The electronic signature occurs after the physician has reviewed the transcribed report and approves it. The approved file is then sent to our server where it is electronically signed and recorded.”

The ability to back up or restate a dictation was originally written on the iPhone app, Saliga says. “We were working with version 3 of the operating system and when you shut down an app, you were given a limited amount of time to save your work. Being able to overwrite or insert dictation within the existing report was more time than would be allowed. However, on Apple’s new version 4 operating system, it allows the app to support this functionality because background processing continues once the app closes, so we have plans to include this in our functionality as well,” he explains.

Voice Files Stored
Another function allows a physician to confirm that the dictation has been completed, signifying that it can no longer be modified. “However, if the doctor is in the middle of a dictation and moves away to do other things, he can always go back and edit that dictation as long as the file has not been uploaded,” Saliga says. “The app also allows the physician to add dictation without there being an appointment or create multiple dictations against the same appointment, thereby creating a second dictation and noting that it needs to be added to the previous dictation.”

ExecuScribe, a Rochester, N.Y.-based medical transcription service provider, utilizes BayScribe’s mobile dictation app to allow providers to dictate into their smartphones. BayScribe develops mobile dictation apps for the iPhone (both in versions 3 and 4 operating systems), the iPad, Windows Mobile devices, and BlackBerry. A Google Android app will be coming later this fall.

“The technology we’re using is really the way the industry is headed, especially with mobile dictation apps, which are moving toward speech recognition and natural language processing,” says IT manager Dean Ganskop. “This takes an entire narrative from a doctor and the engine parses out discrete reportable transcription [DRT] information such as allergies or diagnosis list.”

The value of DRT was spotlighted in a recent white paper issued by Sten-Tel President George Catuogno, who illustrated how the data could help healthcare organizations meet meaningful use goals: “At the center is DRT, which allows clinicians to use EHRs for viewing clinical information without giving up narrative dictation, which can be routed through speech recognition technology or sent to a transcription service. Either way, the documentation created is structured (ie, encoded with XML tags) and can be imported to automatically populate an EHR with practice-specific discrete reportable data.”

According to Ganskop, one feature of mobile dictation apps that physicians enjoy the most is the ability to add anecdotal elements to a patient’s record. In general, a dictated narrative allows for richer detail than a point-and-click menu system. “I’ve been told that some providers using point-and-click systems will refrain from asking patients certain questions that they think might lead to answers that can’t be easily entered into the system,” Ganskop says.

Claudia Tessier, RHIA, MEd, president of the mHealth Initiative and former CEO of the American Association for Medical Transcription, says dictation apps are the latest example of clinicians using mobile devices to enter patient care information into a system.

“That’s the bridge: Physicians are using smartphones to dictate. Apps for mobile dictation offer the services that the physicians are seeking and need in order to have access to patient information,” she says. “What’s happening is that the device is used to capture the information and enter it directly into a patient’s medical record.” The degree to which it’s being used depends on an institution’s willingness and readiness to incorporate the technology and on clinician demand, she says.

Despite the advent of these new technologies, the review of a dictated report is never going to go away, according to Tessier. “The need to review what one dictates, whether on paper or an electronic document, on the computer or on a mobile device, persists. There has to be caution in using prompts (eg, automatic fill-ins) because it can be easy on a laptop, PC, or mobile device to select the wrong automatic insertion,” she says. “It’s also important to confirm that what one said—or what one thinks was said—is indeed what is documented. The transformation of dictation to documentation should be reviewed [or] authenticated whether it’s directly recorded into a mobile device [or] an EMR or transcribed remotely.”

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pa.