530137 research-article2014

JHI0010.1177/1460458214530137Health Informatics JournalDexheimer and Borycki

Article

Use of mobile devices in the emergency department: A scoping review

Health Informatics Journal 1­–10 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460458214530137 jhi.sagepub.com

Judith W Dexheimer

Cincinnati Children’s Hospital Medical Center, USA

Elizabeth M Borycki University of Victoria, Canada

Abstract Electronic health records are increasingly used in regional health authorities, healthcare systems, hospitals, and clinics throughout North America. The emergency department provides care for urgent and critically ill patients. Over the past several years, emergency departments have become more computerized. Tablet computers and Smartphones are increasingly common in daily use. As part of the computerization trend, we have seen the introduction of handheld computers, tablets, and Smartphones into practice as a way of providing health professionals (e.g. physicians, nurses) with access to patient information and decision support in the emergency department. In this article, we present a scoping review and outline the current state of the research using mobile devices in the emergency departments. Our findings suggest that there is very little research evidence that supports the use of these mobile devices, and more research is needed to better understand and optimize the use of mobile devices. Given the prevalence of handheld devices, it is inevitable that more decision support, charting, and other activities will be performed on these devices. These developments have the potential to improve the quality and timeliness of care but should be thoroughly evaluated.

Keywords decision-support systems, emergency medicine, medical informatics, mobile health, review

Introduction Electronic health records (EHRs) are becoming more widespread in regional health authorities, healthcare systems, hospitals, and clinics in North America. EHRs have afforded healthcare professionals (e.g. physicians, nurses) the opportunity to access patient information anytime and in

Corresponding author: Judith Dexheimer, PhD, Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA. Email: [email protected]

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many locations in a healthcare organization (where there is a computer available). Such rapid access to patient information has made EHRs a valuable tool and an aid to providers where patient care-related decision-making is concerned. Historically, health professionals using desktop computers accessed EHRs. Desktop computers are located in specific areas of a healthcare organization (e.g. at the nursing station, at the end of a hallway) and cannot be easily moved from one location to another by a provider. With the development of varying types of mobile devices, EHRs and their components (e.g. provider order entry, medication administration systems, laboratory information systems) now allow providers to input and access patient information from any location in a healthcare facility. Over the past few years, we have seen the introduction and use of not only desktop computers but laptops, handheld tablets, or other types of portable devices (e.g. Smartphones, Personal Digital Assistants—PDAs) into healthcare facilities for general use by providers to input, access, and review patient information. These devices have also been used as a source of information. They provide ubiquitous access to decision-support systems (DSS) such as UptoDate®. These DSS can be used in the process of care (if accessible via a mobile device). Free access to the EHR within a healthcare organization can influence how healthcare professionals provide patient care. With current advancements in mobile devices and the introduction of new types of devices such as Smartphones and tablets, health professionals now have the ability and the opportunity to access EHRs and DSS in real time when caring for a patient (i.e. when there is a need to make a decision). Nowhere is such access to EHRs and DSS more important than in the emergency department (ED), where having rapid access to information is critical to being able to care for patients with life-threatening injuries or illnesses. Therefore, the nature and structure of care in EDs is conducive to the use of mobile devices. In the ED, patients are treated by a variety of providers who physically move from one location to another (e.g. from one treatment room to another). Mobile devices that provide access to the EHR and DSS allow patients to be easily followed for the duration of their ED visit and for care decisions to be made at the bedside. Therefore, the purpose of this scoping review is to shed light on the current state of the research literature focusing upon the use of mobile devices in the ED.

Methods Literature search We conducted a search of the literature to identify articles that studied the impact of mobile devices in the ED. Studies were eligible for inclusion if they (1) examined mobile devices such as wireless mobile computers, mobile workstations, PDAs, handheld computers, tablets, or Smartphones and (2) evaluated an intervention in the ED. Studies were excluded if they (1) focused on the design of software alone; (2) lacked an evaluation component; (3) studied a clinician or patient educational intervention only; (4) were a case report, abstract, survey, editorial, or letter to the editor; (5) were in non-English language; or (6) focused on the use of a mobile device for only image-display purposes (e.g. radiology report reading). We excluded articles that did not evaluate the effectiveness of an application or device being actively used in ED practice. The following electronic literature databases PubMed® (MEDLINE®),1 OVID CINAHL®,2 ISI Web of Science™,3 and EMBASE®4 were searched from their respective inception to 18 July 2012. In MEDLINE, all search terms were defined as keywords and Medical Subject Headings (MeSH®) unless otherwise noted; in the remaining databases, the search terms were defined only as keywords. The search strategy was based on the concept “emergency medicine” combined with concepts representing any kind of mobile implementation. Search terms included “emergency

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medicine” and any combination of the terms “tablet computer,” “phone,” “medical informatics,” “mobile,” “tablet,” “iPad,” or “PDA” and relevant plurals. The exact PubMed query is shown below: (emergency medicine OR emergency services, hospital) AND (tablet computer OR phone OR medical informatics OR mobile OR tablet OR iPad OR PDA). An additional MeSH term search was performed and the results included in the title and abstract review: (medical informatics AND emergency medicine AND computers, handheld).

Review of identified studies Two reviewers reviewed the titles and abstracts of all articles identified using the keyword searches. All articles were reviewed by both reviewers and discussed. All disagreements between reviewers regarding the articles were resolved through discussion (i.e. consensus was reached about each article). Articles meeting the inclusion criteria outlined earlier in this article were pulled for full manuscript review. The studies were then examined for redundancy (e.g. findings of one study reported in two different reports) and duplicate results were removed. The full text of included articles was obtained. Following this, the two researchers then reviewed the full manuscripts. Again, disagreements were resolved through discussion until consensus was reached.

Analysis The two reviewers extracted relevant themes and data from the included articles. Several themes emerged from the data extracted from the articles, which will be outlined in greater detail in the results section of this article.

Results Included articles The literature search produced 6672 articles during the time period, with 4280 coming from MEDLINE, 53 from CINAHL, 1922 from Web of Science, and 417 from EMBASE. After removing 1281 duplicate articles, 5363 were further excluded based on review of the titles and abstracts. Of the remaining 28 articles, 18 were excluded (see Figure 1). A total of 10 articles met the inclusion criteria set in the study. Table 1 shows the findings collected from the included studies. The articles had a median publication year of 2008 (range 2003–2012). No articles discussed the same intervention.

Themes Several key themes emerged from our review of the literature. These included (1) descriptions of the types of mobile devices and how they were used in the ED, (2) the use of prospective designs, (3) the type of software used, (4) a focus on improved efficiency and speed when using mobile devices, and (5) ED location of mobile device use. These themes were extracted post hoc after study inclusion. These themes are discussed below.

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6672 Articles Pulled 1281 Duplicates Removed 5391 Screened 5363 Excluded 28 Retrieved 18 Excluded 10 Included

Figure 1.  Consort diagram of included studies.

Theme 1: Descriptions of the types of mobile devices.  Of the 10 studies, 7 employed handheld PDAs, with the remaining studies employing wireless mobile computers, wireless mobile workstations, and an iPod® device. Each of these devices was evaluated in terms of its ability to support effective and efficient work in the ED. It is interesting and worthy to note that the first Smartphone came on the market in 1994.15 The first tablet launch occurred in the 1980s,16 although it did not gain popularity until 2002.16 Yet, no Smartphones or tablets were evaluated as part of this body of research. Instead, PDAs were primarily studied and evaluated for their ability to support provider work in the ED. Although handheld devices are a useful technology, Smartphones and tablets have touch-screen technology that has not been fully evaluated in the ED, and it is unclear what the effects of this new generation of mobile devices would have upon health professional work (as compared to PDAs and mobile workstations). With the emergence and growth in popularity among both providers and healthcare consumers of touch-screen mobile devices such as the Apple® Smartphone and tablet (i.e. iPad®), it is important to study their impact upon ED settings as they are introduced to support patient care. Although the early studies performed on PDAs6,9–11 provide some insights, they do not take into account the introduction of the more sophisticated and user-friendly features and functions of these mobile devices on work, workload, and patient outcomes in the ED. There are significant differences between touch-screen mobile devices (e.g. iPhone®, iPad) and PDAs in terms of user interaction and the methodologies that were used to design and develop these new devices. These differences may influence the results of ED studies involving mobile device use, for example, more user-friendly touch-screen Smartphones may improve user efficiency. Additionally, the limited black-and-white interface and data entry that involved either buttonclicks or had to be performed with a stylus and a specific writing recognition system or stylus touch-typed keyboard that are part of PDA technology have been improved upon by technology designers as evidenced by the launch of a new generation of Smartphones and tablets that are easier to use and can do more.

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Radiology system— Lesionnaire

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PDA/iPod Touch/2 monitors

Richards and Harris8 Rivera et al.9

Roy et al.10

Rudkin et al.11

Shannon et al.12

Tews et al.13

Toomey et al.14

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Scores from PDA reading were higher than those for monitor for all observers and nonneuroradiology specialists

Handhelds, increased use of computerized prescribing in those who were using desktop prescribing No significant difference, though higher scores

Faster access,

Use of mobile devices in the emergency department: A scoping review.

Electronic health records are increasingly used in regional health authorities, healthcare systems, hospitals, and clinics throughout North America. T...
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