Invited Guest Editor
Schmitt, T. (2013). Invited Editorial: Smartphone healthcare apps: Tricorder quality yet? Online Journal of Nursing Informatics (OJNI), 17 (3). Available at http://ojni.org/issues/?p=2854
As a nurse practitioner with long standing practices in rural and underserved areas, where the majority of my patients lack adequate if any health care insurance or resources, there continue to be many times when I want a medical Tricorder like Dr. Leonard (Bones) McCoy had in the original Star Trek series. How wonderful to complete electrophysiological cardiac or simple radiological testing without having to implore patients to go to other places they cannot get to, to get tests they cannot afford, simply to have them return not having completed the ordered test. Oh, how I have longed for technology at the bedside. Now, such technology is no longer the stuff of visionary Hollywood creators.
Recent advances in smartphone technology have expanded my abilities to bring current information to my patients as quickly as possible. Like many health care providers I use Micromedex (http://www.micromedex.com/2/mobile.html), American Academy of Pediatrics (https://itunes.apple.com/us/app/american-academy-pediatrics/id526086606?mt=8), New England Journal of Medicine (http://www.nejm.org/page/about-nejm/mobile-applications), and IDdx infectious disease (http://www.iddx.info/) applications frequently (not to mention the calculator that is always readily available). Recently, after watching a brief news clip about smartphone use in healthcare (Rock Center, 2013), I was left wondering if my smartphone is a Tricorder in disguise? If so, can it save healthcare?
Topol (2013) is a leader in development, application, and analysis of the usefulness of smartphone apps and seems to be able to see the same problems I have in health care. Topol is the director of the Scripps Translational Science Institute (http://stsiweb.org/) and frequently presents on the theme of disruptive health care through technology (Weinstock, 2013). Topol proposed that specific smartphone applications (henceforth known as ‘apps’) and the soon, if not now, future of healthcare depends on bedside assessments and interventions, cost savings to the patient by making testing readily available in primary care offices, cutting out the middle men, picking the right pharmaceuticals, the recognition that each patient is unique, and a need for more patient participation and ownership of their own health, all of which he argued can be achieved through emerging smartphone technology (Rock Center, 2013).
Can we really overcome most of our healthcare woes by tapping into our smartphone? Well over 19,000 medical applications exist for iPhones with another 8,000 for android phones, and over another 20,000 more health and fitness apps for each device (184Apps.biz, 2013; App Brain, 2013). Smart phones can be more than devices to look up the latest information. With the proper space, know how, and finances smartphones can be used to take a patient’s vital signs, run an electrocardiograph, conduct an ultrasound, and even detect cancer (Buijink, Visser, & Marshall, 2013; Lippman, 2013).
While this real-life science fiction is taking place several hurdles are yet to be overcome. Regulation and oversight of the cost of apps, design, accuracy, and use is being debated. In contrast to the number of medical apps available, very few have actual FDA 510(k) approval status (Dolan, 2012). Further, smartphone companies are cracking down on medical device applications due to increasing pressure from the FDA (Husain, 2012). In 2011 draft recommendations for mobile app guidelines were developed by the FDA Center for Devices and Radiological Health, but continue to remain in ‘draft’ state (FDA, 2011). Training and proper use remains an issue. It would be wonderful to be able to run an ultrasound on every pregnant woman who enters the clinic or to check cardiac valve function instantaneously, but user training and error is critical enough that many healthcare systems require a radiologist to over-read or only-read such tests. Likewise, portability of results in smartphone form, while excellent for screening, may be an issue with the vast differences in electronic medical records.
Patient security is also forefront in the conversation and only adds more unanswered questions. If the federal government can watch our discussions, as needed of course, what ensures that patient health care data will be safe on smartphones? Will health care systems further restrict the use of such devices, limiting their application? As an extension of patient privacy and health care system liability will organizations demand knowledge about the mobile apps that health care providers are using? Will the health systems themselves require fees, paperwork, and testing if they know such apps are being used?
The great hope for the use of such apps is to make health care more unique, personal, and appropriate through faster, cost effective, and accessible devices. This remains a strong argument for the use of smartphone technology at the point of care. Topol (2013) suggested that patients need to take ownership and seize control of their healthcare through analyzing data from health care smartphone apps. While I whole-heartedly agree I continue to see large numbers of patients who cannot read, let alone analyze their phone data. Further, many of my patients do not even have more than a couple of pairs of shoes, let alone a smartphone. Unfortunately, until we fix this major flaw in our healthcare system I am afraid that many of the battles we fight will continue. If patients cannot access a provider or purchase basic hypertension medication, it will not matter whether I can screen them at the bedside for cardiomyopathy.
Overcoming barriers to technology access is the next goal. To address the glaring disparity among the patients who may need the technology the most grant funded programs must be developed where patients are provided with and instructed on smartphone and specific app use to improve their patient outcomes. Such programs must be monitored for patient health outcomes, changes in health literacy, and patient empowerment. If we can require a blood glucose monitor and diabetic testing supplies for diabetic patients, why not begin looking to smartphones as medical devices, with multiple applications and uses, not simply serving a single purpose? Health literacy in using such devices could be no more difficult than sitting with an educator for a brief period of time for demonstration and return. Imagine if we created an entirely new area of patient education, the smartphone educator! Further, clinicians who need this technology the most are those in rural and urban underserved medical areas. Smartphones with important bedside testing technology and the training to use them would be a boon to the medical providers that struggle to create adequate care for their patients. Access to such technology by these clinics should be a priority for federal and other health related philanthropic organizations funding objectives.
The FDA could also step up efforts to clearly define app use in practice, speed up the process of medical device approval, and ensure that such applications are not financially strapping to the companies that seek to improve the health of many. Finally, nurses need to be using routine and sound apps throughout their education and encouraged to seek out and evaluate smartphone apps for patient and clinician use at all levels of nursing education. Smart phones should become as common in nursing education as watches with second hands were only a couple of decades ago.
In the meantime, we should be learning more about how smartphones can enhance our practice, add such topics to our curriculums, hospital continuing education, and conference agendas, and continue to press the FDA for guidance. We also should enthusiastically embrace Topol’s (2013) ideas. We must think outside-the-box, to fix the healthcare crisis we remain in – creative destruction to build a revolution! We must also work together to facilitate the use of apps to improve patient care, decrease costs, and close the technological divide by providing smartphone technologies to our patients most in need of them.
184Apps.biz. (2013). Application category distribution. In App Store Metrics. Retrieved from http://148apps.biz/app-store-metrics/?mpage=catcount
App Brain. (2013). Most popular android market categories. Retrieved from http://www.appbrain.com/stats/android-market-app-categories
Buijink, A. W., Visser, B. J., & Marshall, L. (2013). Medical apps for smartphones: Lack of evidence undermines quality and safety. Evidence-Based Medicine, 18, 90-92. Doi: 10.1136/eb-2012-100885
Dolan, B. (2012). Analysis: 75 FDA – Cleared mobile medical apps. In Mobi Health News. Retrieved from http://mobihealthnews.com/19638/analysis-75-fda-cleared-mobile-medical-apps/
FDA. (2011). Draft guidance for industry and food and drug administration staff – Mobile medical applications. Retrieved from http://www.fda.gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm263280.htm
Haun, J., Castro, C., Wang, R., Peterson, V., Marinelli, B., Lee, H., & Weissleder, R. (2011). Micro-NMR for rapid molecular analysis of human tumor samples. Science Translational Medicine, 3(71), 71-87. Doi: 10.1126/scitranslmed.3002048
Husain, I. (2012). Exclusive: Apple is now rejecting new medical apps that include drug dosages. In iMedicalApps. Retrieved from http://www.imedicalapps.com/2013/06/apple-rejecting-medical-apps-drug-dosages/
Lippman, H. (2013). How apps are changing family medicine. Journal of Family Practice, 62(7), 362-367.
Rock Center. (2013, January 24). iDoctor: Could the smartphone be the future of medicine? Available from http://www.nbcnews.com/video/rock-center/50582822#50582822
Topol, E. (2013). The creative destruction of medicine: How the digital revolution will create better health care. New York: Basic Books.
Weinstock, M. (2013, July 29). Picturing a world with no hospitals. Hospital and Health Networks. Available from http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8200007622
Dr. Terri Schmitt is an Assistant Professor in the Chamberlain College of Nursing. She has previously worked with Southwest Baptist University and Florida Atlantic University. She received her diploma degree in nursing from St. John’s College of Nursing, BSN from Missouri State University, MSN with an emphasis as a Family Nurse Practitioner from Missouri State University, and her Ph.D. in nursing science from the University of Missouri Kansas City. She also maintains a practice in pediatric and adult endocrinology in south Florida. She is a fan of technology and assisted with EMR implementation, designed and wrote undergraduate and graduate nursing informatics curriculum, and utilized technology to connect with other nurses globally. She is in the process of relaunching the blog nursestory.com as a site where nurses can come to tell their stories while learning more about writing and publication. Her research interests include adolescent female health, body image, type I diabetes, social media, technology integration, and student learning.