Surgical smartphone applications across different platforms: their evolution, uses, and users.

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Surgical Smartphone Applications Across Different Platforms: Their Evolution, Uses, and Users Myutan Kulendran, Marcus Lim, Georgia Laws, Andre Chow, Jean Nehme, Ara Darzi and Sanjay Purkayastha SURG INNOV published online 7 April 2014 DOI: 10.1177/1553350614525670 The online version of this article can be found at: http://sri.sagepub.com/content/early/2014/04/06/1553350614525670

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SRIXXX10.1177/1553350614525670Surgical InnovationKulendran et al

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Surgical Smartphone Applications Across Different Platforms: Their Evolution, Uses, and Users

Surgical Innovation 1–14 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350614525670 sri.sagepub.com

Myutan Kulendran, MD1, Marcus Lim, MD2, Georgia Laws1, Andre Chow, MD1, Jean Nehme, MD1, Ara Darzi, FACS1, and Sanjay Purkayastha, FRCS1

Abstract Introduction. There are a vast array of smartphone applications that could benefit both surgeons and their patients. To review and identify all relevant surgical smartphone applications available for the Apple iPhone iOS and Google Android platform based on their user group and subspecialty for which they were designed. Method. Both the literature using PubMed and Google Scholar were searched using the following terms: application$, smartphone$, app$, app*, surgery, surgical, surg*, general surgery, general surg*, bariatric$, urology and plastic surgery, ortho*, orthop(a)edic, cardiac surgery, cardiothoracic, neurosurgery, and ophthalmology. Results. The search yielded 38 articles of which 23 were eligible. Each of the key specialties was searched in the Apple iTunes App Store for iPhone iOS and the Google Play Android application store. In total, there were 621 surgical applications for Apple iPhone iOS and 97 identified on Android’s Google Play. There has been a 9-fold increase in the number of surgical applications available for the Apple iPhone iOS from 2009 to 2012. Of these applications there were 126 dedicated to plastic surgery, 79 to orthopedics, 41 to neurosurgical, 180 to general surgery, 36 to cardiac surgery, 121 to ophthalmology, and 44 to urology. There was a wide range of applications ranging from simple flashcards to be used for revision to virtual surgery applications that provided surgical exposure and familiarization with common operative procedures. Conclusions. Despite the plethora of surgical applications available for smartphones, there is no taxonomy for medical applications. Only 12% were affiliated with an academic institution or association, which highlights the need for greater regulation of surgical applications. Keywords colorectal surgery, breast surgery, neurosurgery, orthopedic surgery, simulation, surgical education

Introduction Smartphones are handheld telecommunication devices that combine miniaturized hardware of a personal computer and a mobile phone with a relatively large touch screen. It is the hardware similarities to a personal computer that give smartphones a unique edge over a regular feature phone. They have the added functionality of a personal digital assistant (PDA), wireless Internet access, a compact digital camera, global positioning system, and a high-resolution touch screen. High-speed wireless data access is provided by various wireless data transmission technologies like 3G or Wi-Fi. There were 5.9 billion mobile phone subscribers globally with mobile penetration reaching 87% worldwide.1 Smartphones have been widely adopted by clinicians with recent UK figures showing that 75% of junior doctors and approximately 70% of all doctors owned an iPhone.2 Globally, this is likely to be greater with an American

market research firm estimating that 81% of US physicians being expected to use mobile phone by 20123 and 85% of medical providers working in Accreditation Council for Graduate Medical Education training programs reported use of smartphones.4 Smartphones are capable of running third-party software known as Apps (applications). The mobile operating systems (OS) used by modern smartphones include Google’s Android (Google Inc, Mountain View, CA), Apple’s iOS (Apple Inc, Cupertino, CA), Research In Motion’s Blackberry OS (Waterloo, Ontario, 1

Imperial College London, London, UK St Thomas’ Hospital, London, UK

2

Corresponding Author: Myutan Kulendran, Centre for Health Policy, Imperial College London, Praed Street, Paddington, London, W2 1NY, UK. Email: [email protected]


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Canada), and Microsoft’s Windows Phone (Albuquerque, NM). Applications are now ubiquitous with everyday clinical practice, whether it is to prescribe medications, to assist diagnosis or as a reference tool to aid patient management by clinicians and allied health care workers.5 With the increasing sophistication of applications, in addition to being reference tools, surgical applications are becoming more interactive, like allowing clinicians to learn operative procedures in a step-by-step fashion and viewing complex radiological images.6 Such innovative mobile software supports learning in times of limited training opportunities and provide provisions for medical care in remote settings.7 The review identifies applications in each of the major surgical specialties, to provide a comprehensive account of available applications and to highlight the emergence of novel surgical applications. Only the Apple iPhone iOS App Store and Google Play (application store for Android phones) were searched for surgical applications, as these are the most widely used App stores currently.

Method Two clinicians using the terms application$, smartphone$, app$, app*, surgery, surgical, surg*, general surgery, general surg*, bariatric$, urology and plastic surgery, ortho*, orthop(a)edic, cardiac surgery, cardiothoracic, neurosurgery, and ophthalmology searched PubMed and Google Scholar on March 11, 2013. The search criteria did not include any limitations on publication date. Only abstracts in the English language were selected for further review. The reference list of included articles was also searched systematically. Citation indexes were also searched on the Apple’s iPhone iOS App store and Google Play. The developer, category, rating type of surgery and costs were recorded. Surgical applications were divided into either being clinician or patient focused. Furthermore applications were classified into their content which was either educational, virtual surgery based, focused on morphology, research orientated (academic journals and academic conferences) or involved professional networking. Applications that were primarily intended as a game (Table 1), intended for general medical practice or were cancer care applications aimed at patients, were excluded from the search results. All articles identified were reported in accordance with the MOOSE (Meta-Analysis Of Observational Studies in Epidemiology) Checklist.

Results Literature Review The literature search yielded 38 articles (Table 2), of which, 23 that referred to mobile applications in surgical practice were included. Three were reviews of plastic

surgery applications.8-10 There were 8 orthopedic articles in total. Six of which evaluated mobile applications as a measurement tool for clinicians, a short review of the most popular applications, and a survey of mobile application use by clinicians.11-20 There was one article that described the development and evaluated a research and educational application for maxillofacial surgeons in training.21 There were 2 articles based on ear, nose, and throat applications, one described the use of an application to morph the nasal contour prior to surgery and the other was a review of iPhone applications for otolarynologists.22,23 Applications for colorectal surgery, neurosurgery, and urology were covered in single reviews.24-26 There were 5 ophthalmology articles in total, of which 1 was in French and 2 were in German, and were excluded from the study.27-29 The 2 ophthalmology articles that were included were both reviews. The first of these described the use of an image capture application that utilised the iPhone’s camera, and allowed the manual adjustment of various image capture settings.30 The ability to individually adjust the image capture settings, combined with the help of a handheld external lens, allowed the capturing of the fundus of the eye with excellent results according to the review.30 The second ophthalmology article was also a review. It described the usefulness of smartphones (iPhones in particular) for the field of ophthalmology in various ways, including patient and physician education, investigations, and as a reference tool.31

Review of Applications A search through Apple’s iTunes App Store for iPhone iOS brought back 500 applications exactly. The specialties with the most applications were plastic surgery, orthopedics, neurosurgery, urology, cardiac surgery, and general surgery (Figure 1). There has been a rise in the number of applications in all specialties for the iPhone iOS (Figure 2).

Plastic Surgery The most widely available surgical applications on Apple’s iPhone iOS App Store were related to Plastic Surgery. The search result for “Plastic surgery” on the iPhone iOS App Store identified 126 applications (Figure 3 ; Appendix 1 [The online appendices are available at http://sri.sagepub.com/content/by/supplementaldata]). In all, 106 of the plastic surgery applications were patient-centered applications, which advertised the service provided by a particular surgeon or clinic. This has increased from 54 in a recent review by Workman et al8 in 2012. These apps were educational with regard to procedures offered and provided photo-morphing software for specific body parts. Plastic surgery applications allowed


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Kulendran et al Table 1. MOOSE Checklist.a Reported on Page Reporting of background should include Problem definition

1

Hypothesis statement

1

Comments

Type of exposure or intervention used Type of study designs used

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Study population Reporting of search strategy should include Qualifications of searchers (eg, librarians and investigators) Search strategy, including time period used in the synthesis and key words

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There are currently a diverse and large number of surgical applications available on smartphones. There is existing taxonomy for surgical smartphone applications. Identify surgical applications available on iOS and Android platforms There were 500 surgical applications and 33 identified peer reviewed publication using PubMed and Google Scholar Table 2 Narrative reviews, observations studies, clinical controlled trials Studies identified were all clinical.

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Clinicians (MK, AC, JN, SP)

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Effort to include all available studies, including contact with authors Databases and registries searched Search software used, name and version, including special features used (eg, explosion) Surgical App FlowChart (separate document)

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Search for the following keywords: application$, smartphone$, app$, app*, surgery, surgical, surg*, general surgery, general surg*, bariatric$, urology and plastic surgery, ortho*, orthop(a)edic, cardiac surgery, cardiothoracic, and neurosurgery All available studies included. No need to contact authors N/A N/A

Description of study outcomes

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Surgical App FlowChart (separate document) Method of addressing articles published in languages other than English Method of handling abstracts and unpublished studies Description of any contact with authors Reporting of methods should include Description of relevance or appropriateness of studies assembled for assessing the hypothesis to be tested Rationale for the selection and coding of data (eg, sound clinical principles or convenience) Documentation of how data were classified and coded (eg, multiple raters, blinding, and interrater reliability) Assessment of confounding (eg, comparability of cases and controls in studies where appropriate) Assessment of study quality, including blinding of quality assessors, stratification or regression on possible predictors of study results Assessment of heterogeneity

N/A N/A

Surgical App Reference list of all 21 studies fitting inclusion criteria FlowChart searched (separate document) Surgical App Yes—Flow diagram FlowChart (separate document) N/A Nil found 2

Full article searched

N/A

N/A

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Table 2 and Results section

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Table 1. (continued) Reported on Page Description of statistical methods (eg, complete description of fixed-or random-effects models, justification of whether the chosen models account for predictors of study results, dose– response models, or cumulative meta-analysis) in sufficient detail to be replicated Provision of appropriate tables and graphics

Reporting of results should include Graphic summarizing individual study estimates and overall estimate Table giving descriptive information for each study included Results of sensitivity testing (eg, subgroup analysis) Indication of statistical uncertainty of findings Reporting of discussion should include Quantitative assessment of bias (eg, publication bias) Justification for exclusion (eg, exclusion of non–English language citations) Assessment of quality of included studies Reporting of conclusions should include Consideration of alternative explanations for observed results Generalization of the conclusions (eg, appropriate for the data presented and within the domain of the literature review) Guidelines for future research Disclosure of funding source

Comments

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Page 2–List of games in surgery; Page 4—table of articles reviewed; Page 8—Bar chart of total proportion of applications; Page 9—Rise in number of applications in past 4 years according to specialty

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a From Stroup DF, Berlin JA, Morton SC, et al; for the Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) Group. Meta-analysis of Observational Studies in Epidemiology. A proposal for reporting. JAMA. 2000;283:2008-2012. doi:10.1001/jama.283.15.2008. Transcribed from the original article within the Support Unit for Research Evidence (SURE), Cardiff University, United Kingdom. February 2011.

patients to view aesthetic operative outcomes of previous patients from the clinic. All applications also provided biographical information of the clinician(s) providing the service. Other patient-based applications included a plastic surgeon locator tool (10 apps), in addition to providing patient education material. Most clinician-focused applications in plastic surgery allowed access to published research material and allowed for inter-professional networking (12 apps). Of the research applications, the PSEN (Plastic Surgery Education Network) and the Canadian Journal of Plastic Surgery application allowed access to abstracts of the major American colleges and subscribers could download the original article and browse through the contents of upcoming societal conferences. The other educational applications suitable for trainee clinicians were a question and answer application (Bradows Plastic Surgery Q&A

Review), an application that used photos and videos showing operative procedures (Kapositas Plastic Surgery Reference), a flash card application (Plastic Surgery) and one that prepared clinicians for plastic surgery board exams. uBurn Lite is a clinically useful application that helps clinicians calculate the percentage burns and prescribing fluids according to the Parkland formula.

Orthopedic Surgery In total, 79 applications were related to orthopedics (Figure 4; Appendix 2 [The online appendices are available at http://sri.sagepub.com/content/by/supplementaldata]). Of these applications, 61 were oriented toward clinicians. Two applications were accredited guides for orthopedic training (The Orthopedic Hyperguide and OITE [orthopadeic in training exam] Strategy). Five


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Kulendran et al Table 2. Studies Identified From the Literature Search. Author(s)

Specialty

Type of Article

Study Details

Conclusions

Payne et al (2012)2

Nonspecific

Original study

257 medical students, 131 junior doctors

Workman and Gupta (2013)8

Plastic surgery

Review article of applications

Amin (2011)9

Plastic surgery

Narrative review

Peters et al (2012)11

Orthopedics

Research article; 50 prospective cases

Identified 161 applications on the Apple App Store. Search for plastic surgery apps on other markets did not find apps Gives 16 examples of existing apps many of which are suitable for the general surgical trainee Intraoperative level indicator application (Angle, Smudge Apps) and a protractor application (Protractor Lite, YJ Soft) to improve acetabular improvement

Qiao et al (2012)12

Orthopedics


Evaluated the reliability and measurement error of smartphone-aided Cobb method measurement

Shin et al (2012)13

Orthopedics


Use of an inclinometer in comparison to goniometric measurements of shoulder motion

Walter et al (2012)15

Orthopedics

Research article; comparison of 30 radiographs

PACS images were compared with smartphone measurements in the clinical setting

Franko et al (2012)16

Orthopedics

Research article; 60 subjects

Franko (2012)17

Orthopedics

Systematic review

Payne et al (2013)21

Maxillofacial surgery

Case study

Comparison of a scoliogauge, iPhone app compared a standard scoliometer by 4 orthopedic providers (attending, fellow, resident, and nurse practitioner) A review of 61 orthopedic applications. Those with greater than 10 reviews were further analyzed. Also a National US survey of 476 residents regarding smartphone use Explains the process and the app development and structure

78% owned a smartphone. (70% iPhone, 20% Google Android); 73% of mostly used apps by doctors were procedure related. Majority of respondents owned 1-5 medical apps. Doctors used medical apps for up to 20 minutes per day. Found the highest rated applications were used by consumers and allowed user to upload and morph photos. Very few plastic surgery applications aimed at senior trainees and surgical trainees. Good results. All acetabular cups were placed within a narrow range in the safe zone with 0.9. Interobserver reliability for HVA and IMA (r = 0.93 and r = 0.79, respectively) Intraobserver reliability (r = 0.97, r = 0.93). Pearson correlation value between 0.9994 and 0.9996 for clinicians and health care workers

Larrosa et al (2013)22

ENT

Pope et al (2010)23

ENT

Clinician survey; 21 Comparison of a photo tracing ortolaryngologists method against an iPhone application to project surgery outcomes for rhinoplasty. Review Reviews applications dividing them into: general, otology, rhinology, head and neck, podcasts, and basic sciences.

Few highly ranked orthopedic applications and type of applications available are not in the categories most desired by residents and surgeons (textbooks, techniques, board review, and billing) 1,207 international downloads. Customer reviews discussed. Customer rating 4/5 stars. The test subjects rated the iPhone application as superior to that of the photo tracing method (P < .05) Great promise for smartphones from a clinical and educational perspective.

(continued)


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Table 2. (continued) Author(s)

Specialty

Type of Article

Study Details

Conclusions

O’Neill and Brady (2013)24

General surgery

Review

Search of most popular smartphone apps stores for colorectal themed apps.

Abboudi and Amin (2011)25 Tseng (2012)26

Urology

Review

A search of the iPhone App Store

68 application identified in total; 29 applications were patient education tools; 8 were education for clinicians; 6 apps were symptom diaries for patients with IBS; 4 apps were cancer support. Identified 39 urology applications.

Neurosurgery

Review

A comparison between neurosurgical apps available in the United States and Australia. Search on Apple App Store.

Ockenden and Gilbert (2012)19

Orthopedics

Research article

Measurement of fixed flexion deformity using a Lafayette goniometer versus smartphone measurements in 5 subjects.

Haddock et al (2013)30

Ophthalmology

Journal article

Describe in detail a relatively simple technique of fundus photography in human and rabbit eyes using a smartphone and an inexpensive application.

Chablani et al (2012)31

Ophthalmology

Journal article

Describes various tools available on smartphones, for the examination of an ophthalmic patient.

42 apps were identified. Only 2 apps were not available in both countries. Guidelines (6), pathology (6), calculator (6), surgery (3), reference (4), anatomy (2), exam (2), journal (3), patient information (6), and conference (4). The iPhone goniometer had an interobserver correlation r of 0.994 compared with 0.952 for the Lafayette. The intraobserver correlation was 0.982 for the iPhone and 0.927 for the Lafayette. The data sets for both instrument correlate closely (0.947). The described technique of smartphone fundus photography was able to capture excellent high-quality images in both children under anesthesia and in awake adults. Excellent images were acquired. Smartphones can be use for ophthalmic photography and image management, and the usefulness of education-based applications.

Abbreviations: PACS, Picture Archiving and Communication System; HVA, hallux valgus angle; IMA, intermetatarsal angle; IBS, irritable bowel syndrome; ENT, ear, nose, and throat; N/A, not applicable.

Figure 1. The proportion of surgical applications available on the iOS platform.

applications used common classification systems for joints and fractures, including one that recorded patientreported pain and functionality postoperatively in order to monitor progress for research and clinical purposes (Joint Score). There were 10 general orthopedic applications that concentrated on trauma care, the management of fractures, information regarding bone tumors, and intra-articular steroid injection techniques. Orthopedics was the

specialty with the most virtual surgery applications (5 apps) that focused on the hip, knees, carpel tunnel, and upper limb surgery. There were 6 applications that used the smartphones to measure anatomical parameters such as Cobb’s angle and assess the range of shoulder movements.12,13 The Top Ortho application gives a comprehensive review of other orthopedic applications available on the iPhone iOS App Store. Podcasts are commonly used as a teaching aid and anatomy applications often combined radiological images to aid learning. There were 3 limb anatomy applications in total. Hand Fed produced research-based applications for orthopedic surgery, which allowed access and sharing of abstracts for hand surgery, general orthopedics, and sports injuries through social media. There were 17 such research- or conference-based orthopaedic applications. Applications aimed as an mobile learning tool were geared for trainees at all levels, from iBones, which helped students learn the name of bones to American Orthopaedic Surgery, Leg Fractures, and Ortho


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Figure 2. The trends in the number of applications for each surgical subspecialty from 2009 to 2013.

Figure 3. Proportion of 126 plastic surgery applications dedicated to patient education (88%), clinician education (2%), and research (9%).

Traumapedia, which were pitched at a level suitable for the more senior trainee. Applications for patients (18 apps) included educational tools for shoulder, foot, and hip injuries, which encouraged symptom, based self-diagnosis. Many of such applications were produced by an individual clinic with contact details to facilitate consultations. Newly evolving applications included those relevant to hospital management such a as an application that identified the Current Procedural Terminology codes used in the United States to facilitate billing of all services provided by the practitioner. Private companies are beginning to provide software, which is part of a clinical measurement system (eg, intraoperative implant positioning, Dash Smart Instrument Technologies) requiring the purchase of additional external hardware for clinical use.

Neurosurgery There were 41 neurosurgical applications (Figure 5; Appendix 3 [The online appendices are available at http:// sri.sagepub.com/content/by/supplemental-data]). Nineteen neurosurgical applications were clinician centered. Of the clinician-focused applications, 13 were educational and used images or videos to teach trainees about either

Figure 4. The proportion of 72 orthopedic applications dedicated to clinician training (2%), clinician networking (1%), student education (5%), patient education (28%), textbook (1%), classification systems (6%), general orthopedics (14%), radiology (7%), research (23%), measurement tools (6%), anatomy (4%), and commercial (4%).

common operative procedures or trauma management. Two of the applications primarily used grading systems for common neurosurgical conditions (NeuroMind and Neuro Toolkit). They are an educational application focusing on neuroendosurgery (Aesculap Neuroendoscopy) and an interventional based application that calculated the rate on embolization of a cerebral aneurysm (Neurovascular Intervention). The highest rated application in neurosurgery was aimed at patients and explained spinal pathology with 3-dimensional animation (Pocket Brain). There were in total only 4 applications suitable for explaining information to patients (iSpineCare, mLumbarPosteriorInterbodyFusionCage, mLumbarLam-inectomy, and mLumbar MicroDiscectomy). There was one virtual surgery application and no specific application targeted at sharing neurosurgical research, only applications which were in conjunction with conferences. Similarly to orthopaedic surgery there were 2 commercial applications one which


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Figure 5. The proportion of 41 neurosurgical applications dedicated to clinician education (65%), research (22%), patient education (9%), and virtual surgery (4%).

illustrated the functionality of a gravitational valve and the other, which allowed clinicians to check the stereotactic co-ordinates during procedures via a mobile application.

General Surgery There were in total 180 general surgical applications in the iPhone iOS App Store (Figure 6; Appendix 4 [The online appendices are available at http://sri.sagepub.com/content/ by/supplemental-data]). Of these applications, 144 were clinician focused. Of these applications, 7 were flashcards to aid revision, 6 were recognized textbooks, and 2 applications included podcasts of common operative procedures. Four applications could be used to recall surgical instruments used in the operating theatre. Six applications were revision tools for common UK and US board exams. There were 12 general applications that helped with every day management of the surgical patient. Of the specialist applications 2 concentrated on trauma including the My ATLS application by the American College of Surgeons. Other clinician-focused applications included 7 operative electronic logbooks, 3 applications which assessed operative risk and a sentinel node tool for breast surgeons. Two applications were patient safety based, including an electronic consent form and a World Health Organization patient safety checklist. Three of the applications allowed clinicians to network regarding case studies. Seventeen of the applications were more suited to students and provided a combination of information and question-and-answer styled format. Eight applications were anatomy based, of which 4 were e-versions of well-known textbooks. There were 6 research based applications and 4 applications used for coding of surgical procedures costs. There were 14 colorectal applications, three of which were endoscopy related aimed at both the physician and bowel preparation for patients. The remainder of colorectal applications were aimed at patients with inflammatory bowel disease and the management of rectal bleeding. There were 27 vascular surgery applications in total which predominantly provided patient information regarding surgery or were affiliated to a research conference.

Figure 6. The proportion of 180 general surgical applications aimed at trauma (1%), general applications (6%), colorectal surgery (7%), vascular surgery (17%), nursing (2%), risk assessment tools (1%), surgical protocols (2%), logbooks (3%), student education (9%), patient education (12%), anatomy (9%), research (2%), management (3%), virtual surgery (2%), flashcards (4%), textbooks (3%), operative procedures (1%), surgical instruments (2%), preparation for board exams (4%), pain management (2%), networking (2%), and commercial (4%).

Of the applications suitable for patients 3 were pain diaries, 4 applications provided general information regarding wound care, definition of surgical terms and patient information regarding operative procedures. Two applications were aimed at individuals with cancer or their family, including one that had a list of all cancer institutes in France. There were 2 emerging themes for applications in general surgery. The first being interactive virtual surgery applications allowing trainees to use the touch screen function on the smartphone to maneuver through a surgical procedure such as an appendicectomy (Touch Surgery). This particular application allows users to simulate both plastic surgery and orthopedic procedures. The other emerging theme for applications is follow-up care for those who have undergone bariatric surgery, which accounts for 18 of the patient-centered general surgical applications.

Cardiac Surgery There were 36 cardiac surgery applications in total (Figure 7; Appendix 5 [The online appendices are available at http://sri.sagepub.com/content/by/supplementaldata]). All applications but one were clinician focused. Eight of the clinician-focused applications were risk assessment tools calculating preoperative risk of in-hospital mortality for surgery. Of the other 10 clinician focused applications, 2 were well-known textbooks, the other a guide for cardiac nursing and 3 for the evaluation of the cardiac patient. There were single applications looking at surgical instruments, lung cancer staging and the practical management of pneumothoraces. Other


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Figure 8. The proportion of the total 121 opththalmology applications that focused on patients (34%), clinicians (23%), medical students (14%) and research (12%). Figure 7. The proportion of 22 cardiac surgery applications that focused on clinician education (59%), research and networking (21%), virtual surgery (7%), clinical calculator (3%), logbook (3%), anatomy (3%), and clinical protocol (3%).

applications illustrated guidelines for the use of antithrombotic therapy, an application for computed tomography imaging and a surgeon’s logbook. There were 2 virtual cardiac surgery applications available and 7 applications based on National Conference proceedings. The single application aimed at patients provided information regarding cardiac surgery.

Urology There were 44 urology applications in total (Appendix 6 [The online appendices are available at http://sri.sagepub .com/content/by/supplemental-data]). Eleven of these applications catered for the patient and were educational regarding urological cancers, stone disease or were voiding diaries. Fifteen of the applications were educational and clinician focused on board exams. Pathology-based apps were tools to communicate pathology to patients. Other applications included a risk stratification tool calculating an unfavorable outcome after prostate biopsy, a professional networking application, and an application designed for students wanting to find a urology training number in the United States. AC Simulation produced a 3-dimensional applications well suited for explaining urological pathology to patients.

Ophthalmology There were 121 ophthalmology applications for iPhone iOS (Appendix 7 [The online appendices are available at http://sri.sagepub.com/content/by/supplemental-data]). Of the patient-centered applications, 23 advertised a service either by an individual surgeon or clinic (Figure 8). There were 6 applications which could be used a test of visual acuity. Eight of the applications were patient education focusing on macular degeneration and glaucoma. There were 3 applications that could be used as a patient self-management tool such as reminders to take out contact lenses. There were 28 applications aimed at clinicians,

Figure 9. There were 97 android applications of which 43% were Generla Surgical, 30% Ophthalmology, 17% Plastic surgery, 6% Orthopaedics and 4% Cardiac Surgery.

of which 17 were educational, providing knowledge about general pathology and management. Of the clinician applications, there were 8 applications considered to be clinician tools. There were multifunctional applications that allowed surgeons to take photos of the eye, share images, and demonstrate pathology and procedures with patients. None of the patient tool applications were free to download; prices ranged from £1.99 to £399.00. There were 16 applications that were suitable educational materials for medical students, of which 6 were flash cards and 2 were textbooks. There were 14 research-based applications, of which 9 were conference proceedings. The remainder provided ophthalmology news on current devices. There were 14 applications that were used as calculators suitable for clinicians focusing on optics. Finally, there were 5 anatomy applications.

Applications for the Android Platform There were 97 surgical applications in total on the android platform (Appendix 7 [The online appendices are available at http://sri.sagepub.com/content/by/supplementaldata]). Of these, 48 were general surgical applications, 24 plastic surgery applications, 6 orthopedics, 6 cardiothoracic surgery, and 12 bariatric surgery patient-orientated applications (Figure 9). There were 20 general surgical clinician education applications. Six applications were revision guides aimed at clinicians, 3 were textbooks, 2 were applications that


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provided paid access to e-books in surgery. The remainder were applications for everyday clinical practice. There were 5 general surgical anatomy applications, 2 applications provided information suitable for those undergoing varicose vein surgery. Eight of the general surgical applications were educational and suitable for students. Similar to the iPhone applications, the majority of plastic surgery applications available on the Android platform were commercial in nature, provided patient information (22 apps in total). One provided a plastic surgery conference program and the other was aimed at clinicians. Of the 7 orthopedic applications, 3 were virtual surgery applications that were similar to those found on the iPhone but were from a different developer. The remainder of orthopedic applications included one that provided patient information for those undergoing knee surgery, a reference tool for clinicians, a conference application and anatomy of the ankle joint. There were 6 cardiothoracic applications covering clinician education regarding cardiothoracic surgery, risk assessment, research-based applications, an anatomy lecture series, and a virtual surgery application. Ophthalmology had the second greatest number of applications after general surgery on the Android platform (43 in total). The majority of the 16 patient-centered applications were retail-focused (9 applications). There were 15 clinician applications, of which 5 were multifunctional tools. The remainder were student educational applications.

Discussion There has been a significant rise in the number of surgical applications on smartphones in the past 5 years (Figure 2). Although the majority of surgical applications run on iPhone iOS, the Android application platform is also gaining popularity with nearly a 100 surgically relevant applications, 41% of which are available on the iPhone iOS App Store. As the sophistication of such applications rise, we are left with many ways in which to augment teaching, improve clinical practice and the patient pathway. For example, the virtual surgical applications help clinicians practice and memorize important steps of common surgical procedures in a visual and interactive format, while simultaneously providing feedback to help improvement. Such applications are also patient friendly and help address the patients’ expectation of the procedures during the shared decision-making process. The combination of auxiliary links to podcasts, YouTube videos and networking capabilities makes surgical applications an ideal platform for sharing clinical knowledge within a professional circle. Many of these applications however lack endorsement or regulation by clinical or other governing bodies. This review has shown that 88% of all applications were of a commercial nature and 12% were affiliated with either an institution or and association. The US Food and

Drugs Administration (FDA) has drafted regulatory requirements for mobile medical applications, which will include apps that are an extension of one, or more medical device(s) by connecting to remote patient monitoring devices or connecting to a Picture Archiving and Communication System server.32 Other applications under the FDA regulators include mobile applications that transform the mobile platform into a medical device and mobile applications that allow users to input patient-specific information will also be regulated by the FDA.33 Regulation of applications is essential as it is unreasonable to expect users to take responsibility for evaluating the credibility of information provided. The existence of a health care repository to help build useful applications for all users with the appropriate clinical guidance would address this gap in the current climate. The usefulness of surgical applications for the smartphone to facilitate training has been realized by the Welsh Medical Training Board, which has provided interns with mobile textbook applications. Similarly developing countries have even leapfrogged the e-health revolution by providing teaching material to medical students via mobile phones.34,35 Despite the huge rise in the number of applications available on both the iPhone iOS and the Android platform, there is a need to classify applications according to the audience they are intended for and the exact content of each application. We suggest that medical applications are further divided into those suitable for patients, clinicians, industry, students, and the general public. Each of these categories can be further divided, for example, industry can be subdivided into simulation, medical devices, and marketing application. Four percent of orthopedics and general surgical applications are commercial in nature, being medical devices. Medical device applications allow for greater interaction between major companies and their representatives allowing surgeons greater awareness of new products to enhance their practice. Of the 4 major surgical device brands, at present only Ethicon provides comprehensive applications illustrating its surgical devices openly to the general public. The “gamification” of medicine is a commonly used term and is defines as the use of game dynamics for more serious purposes. The rising number of surgically themed games seems to support gaming on a smartphone platform for this purpose. Although these gaming applications do not provide in-depth surgical knowledge to users, they do assess and test visuospatial skills, which are crucial for laparoscopic surgical skills. For example, the “Top Gun Study” found that surgeons who played video games more often performed better at laparoscopic surgery than those who did not.36 In addition to improving one’s technical skills, the use of mobile application may be an effective teaching tool to demonstrate and learn intricate surgical skill though cognitive task analysis. Cognitive task analysis is a new approach to surgical training that focuses on


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Kulendran et al decision making and identifies potential procedural errors and key steps required to teach trainees surgical knowledge in a more efficient manner (L. Wingfield et al, unpublished data). In the future, they may well be a validated tool to assess baseline technical skills and acquisition. While software applications undoubtedly play a significant role, we should also not forget the hardware that enables their use, for it is the hardware that allows developers the freedom to create such a wide variety of software applications that are rich in content. Smartphones have been around since the early 1990s, but were mainly enterprise devices that were prohibitively expensive37; the IBM Simon was one of them and it combined features of a personal digital assistant (PDA), a fax machine, a mobile phone, and a monochrome touch screen; however, it was relatively large and heavy. Over the rest of the 1990s, smartphones gradually decreased in size, improved in battery life, processing performance, and storage memory, gained larger monochrome LCD touch screens, had improved PDA functions, and eventually gained limited Internet and e-mail abilities. They had limited ability—if at all—to interface with personal computers (for exchange of electronic data) and lacked the ability to simply install new software applications; in general, one was limited to the software applications that came with the smartphone. It was not till the beginning of the 21st century that color LCDs became available on smartphones—the Nokia 9210 Communicator was one of them; it was also among the first smartphones to allow users to download and install software applications from third-party developers that did not originally come with the phone.38 Microsoft Office documents like Word, Excel, and PowerPoint were also able to be viewed and created on the Nokia 9210 Communicator—arguably a first for a smartphone. From the Nokia 9210 Communicator onward, many other smartphone makers continued improving their smartphones in various aspects especially those from Research In Motion, Sony Ericsson, Palm, etc. Processor performance increased, LCD touch screens increased in resolution and displayed ever-increasing range of colors, storage and random access memory increased, long- and shortrange wireless data communication capabilities became faster and more widely available, in-built digital cameras became more widespread, improvements in battery technology, and last but not least, the miniaturization of all the hardware components. With the continuous improvements in hardware, these allowed software operating systems and applications to become more complex and diverse, gradually leading to smartphones that could almost replicate the everyday functions a personal computer could perform, from work to entertainment—a true multimedia device. Perhaps, most important, smartphones became increasingly affordable to the average consumer. With the advent of Apple’s iPhone in 2007, smartphones entered a new era, principally because it was the

first smartphone to feature a color touch screen display that covered almost the entire face of the smartphone, and replaced majority of the physical buttons and keys found in majority of smartphones that preceded it. Instead, virtual buttons and keys were displayed on the touch screen itself, paving way for nearly limitless configurations of touch input based on what the user was doing with the smartphone at that particular time. Apart from its revolutionary touch screen, Apple’s iOS mobile operating system and iOS applications were arguably the first to truly provide a highly intuitive user interface and also provided web based content that was significantly closer to that of a personal computer Web browser. Apart from the fact that the iPhone provided rich multimedia capabilities for work and play, it was also the creation of an “ecosystem” that allowed relatively seamless integration of the iPhone with personal computers and Internet-based services such Apple’s iOS App Store and iTunes Music Store. This integration was paramount, as it no longer meant that the smartphones were standalone devices, but rather, part of an increasing array of electronic devices that could “talk” to one another. Every other major smartphone manufacturer has indeed followed the path set by Apple’s first iPhone, most notable are the various manufacturer smartphones that run Google’s Android mobile operating system. Every manufacturer has their own “ecosystem” for their smartphone, in addition to the “ecosystem” provided by the makers of the mobile operating system, for example, Google’s Android and Microsoft’s Windows phone. It should also be noted that at this point in time, Apple and Research In Motion are 2 major smartphone manufacturers that do not allow the installation and use of their mobile operating system in any other smartphone manufacturer apart from their own, whereas, Google’s Android and Microsoft’s Windows phone mobile operating system have both been licensed for use in many smartphone from different manufacturers. Inevitably, current smartphone hardware has improved tremendously, even compared with what was available only a few years ago. There are now multiple processors in most of the current generation of smartphones with a combined processing performance that was normally found in desktop computers a few years ago. In-built storage and random access memory also rival that of ultraportable laptop computers. Smartphone touchscreen displays have resolutions and color gamut that rival high-definition televisions. Current generation of smartphones also contain components not found in most laptop or desktop computers, such as gyroscopes, accelerometers, and global positioning sensors, which allow the detection of orientation, movement, and location respectively. To put the progress of smartphone technologies into perspective, we have graphically represented the increase in storage memory capacity (Figure 10) and display resolution (Figure 11) over the years. It should be noted that it is difficult to chart the


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Surgical Innovation

Figure 10. The growth of storage flash memory in smartphones from 2002 to 2013. Storage memory size for each year was taken from smartphones that had received positive reviews from a wide range of reputable reviewers and were also well received by consumers. Data were gathered from smartphones of different manufacturers.

Figure 11. The increase of smartphone display resolution from 2002 to 2013. Display resolution for each year was taken from smartphones that had received positive reviews from a wide range of reputable reviewers and were also well received by consumers. Data were gathered from smartphones of different manufacturers.

increase of processing performance over the years because of the fact that there are so many processor types and benchmarking tests—some tests work for some processors, while others do not. Also, current generation benchmarking tests may not work for older generation processors. However, taking the latest iPhone 5S and

comparing it with its predecessor, the iPhone 5—which is only a year older—credible independent tests have shown processor performance increases of more than 2-fold.38 This clearly illustrates the tremendous rate at which processing performance has been increasing. The same could also be said about cellular wireless data communication


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Kulendran et al technologies—4G download speeds are (in theory) nearly 7000 times faster than that of 2G, which was made available at the beginning of the 1990s. With such advanced capabilities and upcoming technologies, the usage possibilities of smartphones are truly limitless. This review has highlighted for the first time the rising utility of currently available applications for both surgeons and patients on a daily basis. The versatility of the surgical applications available means they have the potential for use in everyday practice and a greater need for such regular reviews to keep users up-to-date with current trends. Declaration of Conflicting Interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SP, AC, and JN are cofounders and directors of the Touch Surgery Application.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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