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There's an app for that: Clinicians are using apps to improve care

When Dr. Yaron Elad is having a hard time convincing a patient that a test is unnecessary, he sometimes pulls out his smartphone right in the exam room.

Elad, a cardiologist at 
Cedars-Sinai Medical Center in Los Angeles, uses the phone to give the patient information from Choosing Wisely, an app developed by the ABIM Foundation to help cut down on wasteful treatments.

“It can be helpful to have backup when you're talking to patients,” Elad said, saying the app gives him the support he sometimes needs to convince a patient of his opinion.

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He's not alone in the practice. Consumer technology has a way of seeping into healthcare, so it's no surprise that more and more providers are turning to their mobile devices to help make diagnoses, communicate with their peers and get work done.

“Overall, apps are promising the same thing that they promise to any user in their daily life: simplicity and convenience,” said Brian Kalis, managing director of digital health and innovation for Accenture's health business. “It's the same simplicity and convenience you see and expect from what you get as a consumer.”

Provider-facing apps range from reference to communication tools to versions of the electronic health record. The goal, with all, is improving patient care. Sometimes, that happens by engaging the patient, as with Elad's use of Choosing Wisely. Other times that happens by having more information readily available at one's fingertips, as with reference apps.

These tools, developed by third parties or by health systems themselves, aren't ideal for everything. Compared with large monitors, smartphones and tablets are not, for example, good for interpreting images, said Dr. Seth Berkowitz, a radiologist and director of informatics innovation at Beth Israel Deaconess Medical Center in Boston.

The TAKEAWAY:

Providers are turning to their phones for clinical-decision support and other tools.

“Can you make a diagnosis based on a 5-inch screen? No, it'd be ridiculous to do that,” Berkowitz said. But what the apps do provide is certainly helpful. “The ability to get this data when you're out of the hospital or even in the hospital just walking between wards is a huge benefit.”

Such access to data would seem to raise concerns about the Health Insurance Portability and Accountability Act and privacy. But app makers have figured out ways to work within the law's limitations, encrypting and anonymizing protected health information. In fact, apps have even helped providers manage HIPAA issues they were already facing on mobile devices, such as storing diagnostic photos or sending texts to one another.

Taking advantage of these benefits comes down to how proactive individual providers are, since few health systems are deploying apps across the enterprise, Kalis said. “The opportunity exists for health systems to provide some of these solutions for clinicians,” he said, “but a number of the solutions in use today are solutions that clinicians are choosing on their own to support their own workflow.” That's likely a smart move, since studies have shown that mobile devices help providers better document patient records, retrieve information more quickly, and coordinate care more effectively.

And now, here's a look at some of the types of apps that aim do that.


clinical-decision-support
USE: Give providers data via mobile devices, 
including when they're with patients.
EXAMPLES: VisualDx, UpToDate, Figure 1, 
Epocrates, Medscape

Primary-care providers often encounter patients' skin problems before any other providers, including dermatologists. Figuring out what's going on can be tough for those outside of the specialty. “Non-dermatologists have a very difficult time analyzing a lesion and describing it properly,” said Dr. Art Papier, CEO of VisualDx.

His app gives them some help, using machine learning to automatically categorize lesions based on images taken with phones. Then, after users input information about location and other symptoms, it displays possible matching diagnoses. As with other apps, providers might use this one in front of patients for education purposes. “More and more clinicians are using these tools right in the exam room, and the patients like it,” Papier said. “This represents a transition from memory-based care to the patients preferring that their doctors use these tools, because it shows they care enough to look it up.”

Another clinical-decision support app, UpToDate, provides a slew of clinical information, such as drug interactions and summaries of evidence and recommendations. A physician might use it, for example, when encountering a condition for the first time, as 
Dr. Shannon Heinrich did when she treated a patient with a rattlesnake bite. “UpToDate combines physiology with what you need if you're the 'boots on the ground,' and that is invaluable,” Heinrich wrote on the UpToDate website.

Providers can also more actively seek out information from each other. For example, on Figure 1, which is like Instagram for doctors, instead of posting images of food and vacations, clinicians post medical images of their patients, teaching and getting advice from their colleagues. “You're seeing app developers bringing experiences we all have in our day-to-day lives into the clinical context,” Kalis said.

Perhaps the most well-known reference app is Epocrates, which was acquired by EHR vendor Athenahealth in 2013. “Our goal is providing rapid clinical answers to questions that healthcare professionals have while they're in front of their patients,” said Al Bhattacharya, head of product for Epocrates at Athenahealth. Because there's an increasing amount of technology in patient rooms, Epocrates developers want their app to be used as quickly—and effectively—as possible. “It's a little bit different than other consumer apps out there where they're really trying to keep you in the tool,” Bhattacharya said.

EHR-access
USE: Give doctors a way to consult patient records on the go.
EXAMPLES: Epic Haiku, Cerner PowerChart Touch

Far and away, the smartphone app Elad uses most often is Haiku, the mobile version of his hospital's Epic EHR. Several times a day, he'll consult it to look at progress notes, imaging studies, blood work, patient schedules, and patients' locations in the hospital. He also relies on the app for notifications; if he chooses, it will alert him, for instance, when a new test result is available.

Increasingly, EHR vendors are offering mobile versions of their software, accepting that providers aren't always in front of desktop computer screens. Some of these apps go beyond serving as a mobile display of EHR information to take advantage of the medium. For instance, like imaging-specific apps, Haiku and PowerChart Touch allow providers to upload images directly into patients' records.

Some mobile versions of EHRs aren't actual apps but mobile web portals. That's the case for the custom EHR that Berkowitz frequently accesses through the Safari browser on his iPhone. “We're fortunate that our EHR is web-based,” he said, since it allows him and others to easily jump in and out of the system when they're away from desktop computers. Web applications have their downsides, too. They're unable to take advantage of some smartphone features, like fingerprint sensors, Berkowitz said.

Still, provider use of mobile EHR functionality isn't what it could be. Just 21% of organizations surveyed said most clinicians use mobile EHR functionality, while 39% said none of their clinicians do.

business-networking
USE: Like Facebook, but these apps keep doctors up to date with job postings and their peers' activity.
EXAMPLE: Doximity

Doximity developers and executives intend the app to be a time-saving tool that, in turn, improves patient care. What started as an identity-management platform is now an array of networking, workflow, and learning tools used by 995,000 members. “At our core, we are a professional network,” said 
Dr. Amit Phull, Doximity's medical director. Because the network rules limit membership to physicians, they can share clinical information without violating HIPAA, according to Doximity. Those members send more than 30,000 secure messages to each other every day, and two-thirds of members are active in any given quarter. Why does Phull believe the network is successful? “Physicians tend not to spend time doing stuff that's unproductive or frustrating,” he said.

Like Facebook, Doximity delivers personalized news to its users, who also get personalized medical news on Facebook itself and can earn continuing medical education credits by reading articles on the Doximity platform. Like LinkedIn, Doximity has job listings, an offering that includes a heat map, which lets users compare salaries across the U.S.

Just as Doximity shares features with other social networks, it also shares features with other technologies. Take the fax and phone: On Doximity, users can send and receive digital faxes without using a physical fax machine. They can also call patients directly from their own phones. The app masks their personal numbers with numbers that look like they're coming from the healthcare organizations they represent.

self-developed
USE: When a healthcare system can't find an app it likes, it makes its own.
EXAMPLES: Eyerad, developed by Beth Israel Deaconess Medical Center, and an app from Carolinas HealthCare System

Berkowitz and other providers at Beth Israel Deaconess wanted to show patients images at the bedside. But they had no way of doing it. So Berkowitz designed Eyerad, a BIDMC-only app that gives providers access to images on their mobile devices. “I built it because I enjoy discussing imaging findings with patients,” Berkowitz said. “It's a much better discussion when you can actually show them the picture.” Another use, he noted, is for providers to use it remotely for clinical consultations. “The ability to get this data when you're out of the hospital or even in the hospital just walking between wards is a huge benefit,” he said.

Berkowitz also built an app that lets providers take photos with their own smartphones and upload the images to an EHR. “Doctors don't want this data on their personal devices, but at the same time, doctors do want to use the device they have in their pocket,” he said. Berkowitz predicts apps like this, that allow providers to use their own phones for clinical purposes, will become more prevalent, especially as providers use their smartphones more often to connect to internet-enabled medical devices, like stethoscopes and ultrasounds.

Providers are also using their smartphones to communicate with each other, sometimes texting—despite recommendations not to. Carolinas HealthCare System is in the midst of developing a new tool for provider-provider communication. “We took all those communication pieces and put them together,” said Craig Richardville, the system's chief information and analytics officer. The tool will serve as a secure texting platform and will send notifications from multiple clinical systems, including the EHR.

Home-grown apps have been a boon to Beth Israel and others, but using them is a balancing act. “There's a back and forth where I'm always pushing to use these things as a tool, but we do need to realize they can also be a distraction,” Berkowitz said.

consumer
DEFINITION: Doctors are consumers and rely on consumer apps too.
EXAMPLES: Evernote, Simplenote

“You want some way of keeping notes,” Berkowitz said, pointing to apps like Evernote or even Apple's stock iOS Notes app. He himself uses Simplenote, a minimalist cross-platform app. While the apps are convenient, providers still must be careful about privacy. For instance, he said Apple's Notes app is useful because it syncs with the cloud, but, he added, “it'd be great if you could do that with patient information, but obviously you can't.” Evernote and most other note-taking apps, including Apple's Notes, aren't HIPAA-compliant, which means that, technically, providers shouldn't be using them for protected health information.

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