Leading article
Smartphones make smarter surgeons T. L. Lewis1 and R. S. Vohra2 1 Medical Teaching Centre, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL and 2 Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (e-mail: [email protected])
Published online 25 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9328
The time when a mobile phone was used simply to make and receive telephone calls is long gone. The explosion in mobile technology has meant that only one-quarter of the time spent on a ‘smartphone’ is used to make calls. The rest is spent browsing the internet and on social networking sites. For clinicians, there are already recognized time savings and improvements in efficiency through the use of mobile devices: to review patient records, access radiology and laboratory results, and request investigations1 . These are only the beginning; mobile technology and smartphones offer further uses in a clinical setting with potential applications for improvements in communication, telemetry, research and education. Surveys have shown that over 80 per cent of clinicians own and use smartphones regularly, and they have become the main form of in-hospital communication2 . Smartphones can connect e-mail, short message services (SMS) texts and voice calls, which in turn allows interaction with other telephones, tablets or computers from one device3 . This means that important messages and documents are seen regardless of location, and can be acted on more quickly than ever before. There is already evidence that this helps in acute medical wards4 . For the surgeon, consultations held using smartphones may offer cost-effective postoperative follow-up with patients in remote locations. Furthermore, SMS text messages have been shown to facilitate improved medical interventions such as smoking 2013 BJS Society Ltd Published by John Wiley & Sons Ltd
cessation5 , which in turn may improve fitness before surgery. The potential of smartphones has been revolutionized by the development of mobile applications or ‘apps’. Apps provide a website’s functionality in a mobile-friendly format that can run independently of web-based browsers while storing information on a device6 . There are over 720 000 applications available, with nearly 20 000 medical and surgical applications offering access to clinical reference, medical education and decision-making tools. Formative sites, such as iMedicalApps and MedicalAppJournal, can help identify apps through peer reviews by other healthcare professionals. Many medical organizations including Journals and Associations have, or are developing, their own individual apps. Although inherently useful, it is becoming clear that they need to offer specific features that engage and retain users given that many apps lie dormant on smartphones. Development costs can be high as screen sizes vary from device to device and because of differences in the various operating systems. There are, however, some clinical apps with novel features that seem to appeal to trainee surgeons in particular. ‘Touch Surgery’ offers surgeons the opportunity to practise key stages of common operations such as laparoscopic cholecystectomy using cognitive task-based analysis. Another exciting idea has been the integration of ‘game play’ into apps like the Resuscitation Council’s ‘Lifesaver’ app that
can act as an adjunct to more conventional educational techniques. Apps can interact with other features within the smartphone, for example Bluetooth. This allows patients to be monitored remotely using physiological sensors. This could have a dramatic impact on ward care and follow-up in the early postoperative period, and seems a fertile area for research to assess feasibility, safety and potentially to alter practice. Surveys suggest that 59 per cent of the general population own or use smartphones and 20 per cent regularly use health applications7 . Physiological data may be collected and uploaded directly from a patient’s own device. This could have significant economic impact, for instance in avoiding unnecessary hospital attendances. Automated reminders to patients and trial participants may improve compliance with treatments, achieve better response rates and reduce missing data8 . An exciting challenge exists to capture, store, search, share, transfer and analyse these ‘big data’, which may lead to breakthroughs in treatments and patient outcomes. There are some important caveats and limitations to smartphone technology. The biggest issue is battery life. Regularly accessing messages, emails and apps rapidly drains the battery such that many devices will not last an average clinical working day, limiting their practical use9 . In addition, most hospitals have poor mobile coverage, currently making it impossible to rely solely on these BJS 2014; 101: 296–297
Smartphones make smarter surgeons
devices for communication. There are concerns that devices may host pathogenic bacteria, although this can be minimized by following guidelines on device cleaning10 . Factual inaccuracies have been found in certain medical apps and more quality assurance mechanisms are required11 . Security and encryption is another reason for some of the reluctance to integrate smartphones fully into clinical settings, although it is worth pointing out that major corporations and government departments use them as essential components of their communications strategy suggesting that the issues around data protection are not insurmountable. There are significant cost implications associated with smartphones. The telephone, maintenance and network infrastructure including WiFi are not cheap when many of these features are in regular use. Smartphones can be a distraction in the working environment, especially in an operating room12 . The size of the actual problem and its effects are difficult to quantify. However, the American College of Surgeons has published a statement13 to warn against the likely detrimental effects of mobile devices in this clinical area. Perhaps in the same way that music in the operating room has its enemies, the same attitudes may exist for the smartphone. Despite this, there is an inevitability about the widespread adoption of smartphone technology within hospitals. This could lead to improvements in patient care from several different areas. The technology underpinning the smartphone evolution is constantly improving, with wrist devices similar to a watch already commercially available. It is only imagination and battery
2013 BJS Society Ltd Published by John Wiley & Sons Ltd
297
life that currently limits the possibilities within clinical use. Disclosure
T.L.L. is a writer and editor for iMedicalApps.com, a website dedicated to providing news on the integration of mobile technology into medical care and the reviewing of medical apps for mobile devices. He is paid for his contributions as a writer and editor. He neither consults nor receives reimbursement from app developers or creators. R.S.V. is the founder of the Schoolofsurgery.org, a non-profit surgical news channel that provides continued surgical education around the globe. He is also a member of the member of Association of Surgeons of Great Britain and Ireland Informatics group, and a social media advisor to several companies and charities. References 1 Patel BK, Chapman CG, Luo N, Woodruff JN, Arora VM. Impact of mobile tablet computers on internal medicine resident efficiency. Arch Intern Med 2012; 172: 436–438. 2 Modahl M. Tablets Set to Change Medical Practice; 2011. http://www. quantiamd.com/q-qcp/QuantiaMD_ Research_TabletsSetToChangeMedi calPractice.pdf [accessed 4 September 2012]. 3 Wu R, Rossos P, Quan S, Reeves S, Lo V, Wong B et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. J Med Internet Res 2011; 13: e59. 4 Wu RC, Morra D, Quan S, Lai S, Zanjani S, Abrams H et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med 2010; 5: 553–559.
www.bjs.co.uk
5 Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012; (11)CD006611. 6 Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: a review of current and potential use among physicians and students. J Med Internet Res 2012; 14: e128. 7 Fox S, Duggan M. Health Online 2013. http://pewinternet.org/Reports/2013/ Health-online.aspx [accessed 31 May 2013]. ˜ 8 Dufau S, Dunabeitia JA, Moret-Tatay C, McGonigal A, Peeters D, Alario FX et al. Smart phone, smart science: how the use of smartphones can revolutionize research in cognitive science. PloS One 2011; 6: e24974. 9 Perrucci GP, Fitzek FHP, Sasso G, Kellerer W, Widmer J. On the impact of 2G and 3G network usage for mobile phones’ battery life. 2009 European Wireless Conference, Aalborg, 2009; 255–259. 10 Brady RR, Verran J, Damani NN, Gibb AP. Review of mobile communication devices as potential reservoirs of nosocomial pathogens. J Hosp Infect 2009; 71: 295–300. 11 Misra S, Lewis TL, Aungst TD. Medical application use and the need for further research and assessment for clinical practice: creation and integration of standards for best practice to alleviate poor application design. JAMA Dermatol 2013; 149: 661–662. 12 Jorm CM, O’Sullivan G. Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction? Anaesth Intensive Care 2012; 40: 71–78. 13 College’s Committee on Perioperative Care. Statement on use of cell phones in the operating room. Bull Am Coll Surg 2008; 93: 33–34.
BJS 2014; 101: 296–297
Smartphones make smarter surgeons T. L. Lewis1 and R. S. Vohra2 1 Medical Teaching Centre, Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry CV4 7AL and 2 Academic Department of Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (e-mail: [email protected])
Published online 25 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9328
The time when a mobile phone was used simply to make and receive telephone calls is long gone. The explosion in mobile technology has meant that only one-quarter of the time spent on a ‘smartphone’ is used to make calls. The rest is spent browsing the internet and on social networking sites. For clinicians, there are already recognized time savings and improvements in efficiency through the use of mobile devices: to review patient records, access radiology and laboratory results, and request investigations1 . These are only the beginning; mobile technology and smartphones offer further uses in a clinical setting with potential applications for improvements in communication, telemetry, research and education. Surveys have shown that over 80 per cent of clinicians own and use smartphones regularly, and they have become the main form of in-hospital communication2 . Smartphones can connect e-mail, short message services (SMS) texts and voice calls, which in turn allows interaction with other telephones, tablets or computers from one device3 . This means that important messages and documents are seen regardless of location, and can be acted on more quickly than ever before. There is already evidence that this helps in acute medical wards4 . For the surgeon, consultations held using smartphones may offer cost-effective postoperative follow-up with patients in remote locations. Furthermore, SMS text messages have been shown to facilitate improved medical interventions such as smoking 2013 BJS Society Ltd Published by John Wiley & Sons Ltd
cessation5 , which in turn may improve fitness before surgery. The potential of smartphones has been revolutionized by the development of mobile applications or ‘apps’. Apps provide a website’s functionality in a mobile-friendly format that can run independently of web-based browsers while storing information on a device6 . There are over 720 000 applications available, with nearly 20 000 medical and surgical applications offering access to clinical reference, medical education and decision-making tools. Formative sites, such as iMedicalApps and MedicalAppJournal, can help identify apps through peer reviews by other healthcare professionals. Many medical organizations including Journals and Associations have, or are developing, their own individual apps. Although inherently useful, it is becoming clear that they need to offer specific features that engage and retain users given that many apps lie dormant on smartphones. Development costs can be high as screen sizes vary from device to device and because of differences in the various operating systems. There are, however, some clinical apps with novel features that seem to appeal to trainee surgeons in particular. ‘Touch Surgery’ offers surgeons the opportunity to practise key stages of common operations such as laparoscopic cholecystectomy using cognitive task-based analysis. Another exciting idea has been the integration of ‘game play’ into apps like the Resuscitation Council’s ‘Lifesaver’ app that
can act as an adjunct to more conventional educational techniques. Apps can interact with other features within the smartphone, for example Bluetooth. This allows patients to be monitored remotely using physiological sensors. This could have a dramatic impact on ward care and follow-up in the early postoperative period, and seems a fertile area for research to assess feasibility, safety and potentially to alter practice. Surveys suggest that 59 per cent of the general population own or use smartphones and 20 per cent regularly use health applications7 . Physiological data may be collected and uploaded directly from a patient’s own device. This could have significant economic impact, for instance in avoiding unnecessary hospital attendances. Automated reminders to patients and trial participants may improve compliance with treatments, achieve better response rates and reduce missing data8 . An exciting challenge exists to capture, store, search, share, transfer and analyse these ‘big data’, which may lead to breakthroughs in treatments and patient outcomes. There are some important caveats and limitations to smartphone technology. The biggest issue is battery life. Regularly accessing messages, emails and apps rapidly drains the battery such that many devices will not last an average clinical working day, limiting their practical use9 . In addition, most hospitals have poor mobile coverage, currently making it impossible to rely solely on these BJS 2014; 101: 296–297
Smartphones make smarter surgeons
devices for communication. There are concerns that devices may host pathogenic bacteria, although this can be minimized by following guidelines on device cleaning10 . Factual inaccuracies have been found in certain medical apps and more quality assurance mechanisms are required11 . Security and encryption is another reason for some of the reluctance to integrate smartphones fully into clinical settings, although it is worth pointing out that major corporations and government departments use them as essential components of their communications strategy suggesting that the issues around data protection are not insurmountable. There are significant cost implications associated with smartphones. The telephone, maintenance and network infrastructure including WiFi are not cheap when many of these features are in regular use. Smartphones can be a distraction in the working environment, especially in an operating room12 . The size of the actual problem and its effects are difficult to quantify. However, the American College of Surgeons has published a statement13 to warn against the likely detrimental effects of mobile devices in this clinical area. Perhaps in the same way that music in the operating room has its enemies, the same attitudes may exist for the smartphone. Despite this, there is an inevitability about the widespread adoption of smartphone technology within hospitals. This could lead to improvements in patient care from several different areas. The technology underpinning the smartphone evolution is constantly improving, with wrist devices similar to a watch already commercially available. It is only imagination and battery
2013 BJS Society Ltd Published by John Wiley & Sons Ltd
297
life that currently limits the possibilities within clinical use. Disclosure
T.L.L. is a writer and editor for iMedicalApps.com, a website dedicated to providing news on the integration of mobile technology into medical care and the reviewing of medical apps for mobile devices. He is paid for his contributions as a writer and editor. He neither consults nor receives reimbursement from app developers or creators. R.S.V. is the founder of the Schoolofsurgery.org, a non-profit surgical news channel that provides continued surgical education around the globe. He is also a member of the member of Association of Surgeons of Great Britain and Ireland Informatics group, and a social media advisor to several companies and charities. References 1 Patel BK, Chapman CG, Luo N, Woodruff JN, Arora VM. Impact of mobile tablet computers on internal medicine resident efficiency. Arch Intern Med 2012; 172: 436–438. 2 Modahl M. Tablets Set to Change Medical Practice; 2011. http://www. quantiamd.com/q-qcp/QuantiaMD_ Research_TabletsSetToChangeMedi calPractice.pdf [accessed 4 September 2012]. 3 Wu R, Rossos P, Quan S, Reeves S, Lo V, Wong B et al. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study. J Med Internet Res 2011; 13: e59. 4 Wu RC, Morra D, Quan S, Lai S, Zanjani S, Abrams H et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med 2010; 5: 553–559.
www.bjs.co.uk
5 Whittaker R, McRobbie H, Bullen C, Borland R, Rodgers A, Gu Y. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst Rev 2012; (11)CD006611. 6 Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: a review of current and potential use among physicians and students. J Med Internet Res 2012; 14: e128. 7 Fox S, Duggan M. Health Online 2013. http://pewinternet.org/Reports/2013/ Health-online.aspx [accessed 31 May 2013]. ˜ 8 Dufau S, Dunabeitia JA, Moret-Tatay C, McGonigal A, Peeters D, Alario FX et al. Smart phone, smart science: how the use of smartphones can revolutionize research in cognitive science. PloS One 2011; 6: e24974. 9 Perrucci GP, Fitzek FHP, Sasso G, Kellerer W, Widmer J. On the impact of 2G and 3G network usage for mobile phones’ battery life. 2009 European Wireless Conference, Aalborg, 2009; 255–259. 10 Brady RR, Verran J, Damani NN, Gibb AP. Review of mobile communication devices as potential reservoirs of nosocomial pathogens. J Hosp Infect 2009; 71: 295–300. 11 Misra S, Lewis TL, Aungst TD. Medical application use and the need for further research and assessment for clinical practice: creation and integration of standards for best practice to alleviate poor application design. JAMA Dermatol 2013; 149: 661–662. 12 Jorm CM, O’Sullivan G. Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction? Anaesth Intensive Care 2012; 40: 71–78. 13 College’s Committee on Perioperative Care. Statement on use of cell phones in the operating room. Bull Am Coll Surg 2008; 93: 33–34.
BJS 2014; 101: 296–297
