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Mobile health technologies facilitate efficient communication in ophthalmology
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The use of mobile health technologies in ophthalmology has increased tremendously since the release of smartphones and tablets, with new developments allowing for greater efficiency and communication between physicians and patients.
In June 2011, there were more wireless devices in the United States than people, and more than 73% of physicians owned a smartphone — a 22% increase from 2008. This was anticipated to reach 81% by the end of 2012, according to estimates from the Manhattan Research Group.
Since Apple launched the iPhone in 2007 and the iPad in 2010, smartphone and tablet prices have steadily decreased, with other manufacturers emerging and more mobile carriers offering cheaper data plans to support these devices. Once considered specialist items, smartphones and tablets are becoming essential tools for many health care providers.
According to William B. Trattler, MD, OSN Healio.com/Ophthalmology Board Member, mobile technology allows him to quickly and efficiently communicate with not only his patients, but also the staff members within his office.
William B. Trattler, MD, looks forward to the efficiency that mobile devices can bring to patient scheduling and staff interaction.
Image: Trattler WB
“We use text messaging within our office with our employees,” he said. “For example, if I’m in the surgery center or at an off-site location, the quickest way to communicate with my staff is to use text messaging. So, we’re using simple phone technology in that way also.”
Mobile connection to ophthalmologists
Ease of access and unprecedented versatility assure that smartphones and tablets are not a passing fad.
“Pre-2005, there were few smartphones,” Orrin I. Franko, MD, lead app editor for Journal of Mobile Technology in Medicine, said. “Now, we see practically ubiquitous adoption of what is essentially a mobile computer that is unbelievably versatile in terms of memory, wireless Internet access, high-resolution color screens and camera capabilities. It basically has every tool you can imagine and fits in your pocket.”
Orrin I. Franko
In his office, Trattler uses Eyemaginations LUMA, which is a software program that allows physicians to “create educational presentations for your patients from a robust library of HD quality animations featuring split-screen views to show condition development and point-of-view perspectives,” according to Eyemaginations’ website.
“The animated program and short videos help me explain conditions to patients and answer questions they may have — for example, ‘What are narrow angles? What is a cataract? How does cataract surgery work?’” Trattler said.
Uday Devgan, MD, OSN Healio.com/Ophthalmology Section Editor, also uses mobile technology in his office to explain conditions and treatment regimens to his patients.
“I show patients pictures of their eyes, their retinas and their test results on a flat-screen monitor,” he said. “This helps me to explain the relevant findings to them.”
Trattler said his office is working on a more efficient way for patients to schedule appointments online, as well as to receive messages from his office on their own mobile devices.
To create a more efficient way for his patients to contact him with questions regarding their surgery, Trattler also provides his cell phone number to some surgery patients, as well as corneal cross-linking patients.
HIPAA and DICOM integrated technologies
In 2010, Jeff Tangney, CEO of Doximity, launched an online mobile technology.
“With Doximity, physicians can use their iPhone, iPad, Android device or computer to quickly connect with any U.S. physician to collaborate on patient treatment or identify the appropriate expert for patient referrals,” according to its website.
The key component of Doximity is its compliance with the Health Insurance Portability and Accountability Act (HIPAA).
According to Tangney, Doximity is an electronic platform that allows for physician-to-physician messaging, faxing and discussion of clinical cases in a HIPAA-secure environment that protects patient confidentiality.
Another component of Doximity is its required physician identity verification process and open API (currently in beta), which enable collaboration with the Digital Imaging and Communications in Medicine (DICOM) grid. DICOM, according to its website, “is a global information-technology standard that is used in virtually all hospitals. Its current structure is designed to ensure the interoperability of systems used to produce, display, send, query, store, process, retrieve, or print medical images and derived structured documents as well as to mange related workflow.”
Any physician with a verified Doximity account can use those login credentials to access DICOM’s medical image exchange platform.
“Just as someone can use their Facebook account to log in to a third-party application, doctors can access DICOM grid’s cloud-based solution through their Doximity account,” Tangney said.
DICOM is also required by all electronic health record (EHR) systems that include imaging information in patients’ records.
Cloud computing
Cloud computing, whereby users on a network access data stored on a remote secure server via a Web browser or app housed on a smartphone or tablet, makes the amount of space available to store data limitless. Cloud computing also offers solutions to HIPAA compliance concerns in a mobile health world.
Health care data breaches that involved patient information increased 32% from 2009 to 2010 in a network of 65 health care organizations, according to data from the Ponemon Institute’s Second Annual Benchmark Study on Patient Privacy and Data Security.
During the 2 years before the study’s publication in 2010, 60% of participants reported that they experienced more than two data breaches, with each participant experiencing an average of 2.4 data breaches during the study period. A lost or stolen computing device was among the top three causes given for these security breaches, along with unintentional employee action and third-party error.
Some hold that cloud computing will make situations such as these less likely.
“As we move into a cloud-based mobile computing world, little patient information will actually be stored on phones, and therefore, little information will be at risk for theft,” Franko said.
As more U.S. medical practices move toward meeting federal goals for the universal adoption of EHRs by 2014, many expect the role of mobile health in ensuring continuity of care to grow as the ability for apps to integrate with EHRs improves.
The Epic EHR system in use at Franko’s institution has two apps available to review patient information: Haiku for the iPhone and Canto for the iPad. However, he said a major limiting factor is that these are read-only systems.
“The apps are beautiful aesthetically. They are well done, but you cannot place orders on them or write notes,” Franko said.
Mobile health may improve patient privacy in the long run.
“If you walk into any hospital in the world, you will see paper charts all over every countertop,” Franko said. “People bank online. They have all of their finances online. I do not see how a mobile phone connected to a cloud-based database is in any way less secure than online banking.”
Public health outreach
Although the technological capabilities of mobile health are impressive, the human component remains essential to the success of any mobile health program or intervention. Lygeia Ricciardi, EdM, senior adviser for consumer e-health in the Office of the National Coordinator for Health Information Technology of the U.S. Department of Health and Human Services, said facilitating communication between patients and physicians and encouraging improved self-care are top priorities for her program.
“It is important not only to think about how technology can improve the delivery of health care services, but also about how it can help to engage patients in their own health,” Ricciardi said. “Mobile phones and smartphones offer several distinct advantages to other forms of digital technology for public health efforts, one of which is reaching populations in underserved areas.”
The advent of telemedicine has provided the greatest ophthalmic benefit in the area of noncommunicable diseases, such as diabetic retinopathy screenings in India, according to a study published in the Journal of Mobile Technology in Medicine.
The study discusses several challenges to serving low-resource areas, such as the affordability of equipment and services and the accessibility of trained eye care professionals.
Solutions to these prevalent problems include commercially available slit-lamp adaptors for smartphones and the world’s smallest ophthalmoscope that is compatible with mobile phones, the study said.
This is the type of interaction that Ricciardi said the Department of Health and Human Services wants to achieve with mobile health interventions for U.S. patients with chronic diseases, such as diabetes.
“We want to use mobile health to shift the health care model from the more traditional model, in which patients see their health care providers only when they are sick, to one in which patients are encouraged to be a partner working toward the shared goal of staying healthy or managing a chronic condition,” she said.
Ricciardi said specific groups of patients within the United States are more likely to benefit from mobile health campaigns than others. These groups include racial and ethnic minorities and those living in urban areas, which have some of the highest uninsured populations.
For members of underserved populations who may not have personal computers, mobile phones often serve as the primary source of information and communication, she said.
Current technologies
Recent advances in mobile technology include the use of mobile apps at ophthalmology conferences, such as the annual meetings of the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery.
According to Trattler, both meetings have mobile applications that help physicians determine the location of events and provide a list of the lectures to attend.
Other recent mobile technological advances include the ability to perform eye exams with an iPhone and teleophthalmology.
The iExaminer (Welch Allyn) hardware and app turn the PanOptic Ophthalmoscope into a fundus imaging device that allows physicians to store and print patient images and videos, according to its website.
According to iMedicalApps, teleophthalmology is “the electronic exchange of ophthalmic information to provide remote eye care services.”
A recently completed study compared the diagnostic capability of an iPhone against a standard computer workstation in evaluating fundus images taken remotely of diabetic retinopathy patients.
“The [kappa] coefficient between the gold standard workstation display and iPhone images to detect retinopathy-related changes for both readers was more than 0.9. The image quality of the iPhone was scored high by the ophthalmologists,” according to the study authors.
In 2012, the Office of the National Coordinator for Health Information Technology held a contest for researchers to develop a multidisciplinary ocular imaging application.
“The ‘Ocular Imaging Challenge’ tasks developers with creating an application that improves interoperability among office-based ophthalmic imaging devices, measurement devices, and electronic health records,” according to a press release.
The winner was TSG Innovations with the application TSGiView, “a software package that provides an interoperable work environment for eye care clinics.”
Future of mobile health
As more health care providers begin using smartphones in the clinical setting, ensuring the mobile tools are reliable, accurate and consistent through pre-implementation testing and post-implementation monitoring are the goals for mobile health.
According to Ricciardi, the three key requirements for mobile health to be successful include providing specific, actionable information, evidence-based text services or apps, and a regular evaluation of mobile health programs.
“It is going to take a concerted effort on the part of health care providers to encourage patients to engage in improving health care using mobile health technology,” Ricciardi said.
Other limiting factors include the relatively small screen size on smartphones, amount of space available to store data, short battery life and no standard keyboard for those who wish to type, but technology is evolving at a rapid pace to meet these needs. Voice recognition software is becoming increasingly accurate and popular, virtually eliminating the need to type.
Trattler said he looks forward to the development of a mobile app that would make EHR records more accessible.
“We’re using an onsite server at our office, so we’re trying to find a way to make it more accessible outside of the office,” he said. “If I’m in the surgery center and I need to review a patient topography, that would be helpful. That’s one thing we’re working on but don’t have access to yet.”
Devgan is also looking toward the future of mobile health.
Uday Devgan
“I can anticipate a time when we would be able to evaluate eyes via telemedicine,” he said. “Showing photos of the anterior and posterior segment, giving full data about the exam, and then including testing like topography and OCT imaging will allow an ophthalmologist to make a reasonable diagnosis and treatment recommendation remotely.”
Mobile technology is slowly catching up to the medical industry’s needs, according to Tangney.
“The doctor’s bag of the future will be filled with the mobile technologies that are now being developed to address these pain points,” he said. “Portability and immediacy of information access will better equip our doctors to provide the best care to their patients.”
Franko said he believes health care providers will use mobile technologies in new, innovative and unimaginable ways in the future.
“No one is throwing away their smartphones anytime soon, so medical software developers will continue to find new ways to integrate with mobile technology,” he said.
In the meantime, Franko encourages health care providers from a wide range of specialties to become more involved with designing apps to meet the needs of their respective professions. – by Ashley Biro, Nicole Blazek and Renee Blisard Buddle
References:
Digital Imaging and Communications in Medicine: DICOM. http://medical.nema.org/. Accessed Dec. 13, 2012.
Doximity. https://www.doximity.com/. Accessed Dec. 13, 2012.
Fox S. The Pew Research Institute Report on Mobile Health 2010. www.pewinternet.org/Reports/2010/Mobile-Health-2010.aspx.
For more information:
Will the rapid proliferation of mobile health, or mHealth, technology pose a threat to patient confidentiality?
Any technology has potential to be misused
Eike-Henner Kluge
Whether this happens depends on the user. Technology only facilitates, to a greater or lesser degree, the intent of the user. MHealth technology merely differs from other recording and communicating devices or techniques in that its use occurs in what is essentially a public forum. The Internet is unlike other means of communicating health data because it is susceptible to interception, alteration and misuse, to a much greater extent than what was previously possible. However, the technology itself provides a means of safeguarding privacy and ensuring confidentiality that do not exist with traditional paper-based methods of communication. Specifically, the encryption techniques and related methodologies that are available can assure a level of protection that was essentially unavailable before.
There is an old saying from computer programming: “The short circuit is between the keyboard and the seat.” In other words, it is the human element that poses the problem, not the technical parameters. If users of mHealth technologies follow appropriate protocols, privacy will not be threatened and confidentiality will be maintained. But no one can guarantee that users will not make mistakes. Laziness, cost-cutting measures and simple errors cannot be eliminated, whether at the design level or the user level. However, they can be minimized, at which point the question becomes whether the potential risk is balanced by the tremendous benefits in terms of access, quality and timeliness of health care delivery that mHealth technology offers. I believe the benefits outweigh the risks.
Eike-Henner Kluge, PhD, is a professor of philosophy at the University of British Columbia, in Vancouver, Canada, with a research focus in medical informatics and biomedical ethics. Disclosure: Kluge has no relevant financial disclosures.
Need to protect medical information, privacy well-known
Gil Siegal
Innovative information technologies offer a spectrum of health care applications, including the Internet, smartphones and tablet computers, electronic health records, medical databases and the emerging telemedicine industry. In areas in which information technology is restricted, cellular services are readily available. Thus, mHealth has the potential to alleviate some infrastructure deficiencies, helping increase telemedicine and mHealth potency. The need to protect medical information and patients’ privacy are well-known concerns and receive much attention in state statutes and federal legislation, most notably through HIPAA. As interest in and the development of EHRs increase, the need to assure patients’ rights is particularly important, especially because privacy can be breached relatively easily in the digital era. As more mHealth applications are developed to interface with EHRs, detailed assessments of where and when confidentiality might be breached are sorely needed. Transferring medical data to remote sites via mHealth may occur in several ways, depending on the medical specialty. In radiology, for instance, imaging studies are the most likely items to be shared. If a consultation is performed remotely, a patient’s entire medical record may be shared. Within surgical and psychiatric specialties, live video files are created and then stored, copied and transmitted. All of these instances involve informational risks that must be contained. Assuring that patients are informed about all possible risks and have provided necessary consent forms should be a priority for health care providers. However, the starting point for any such regulation to protect patients should aim to enable mHealth proliferation while containing confidentiality concerns. Halting the development of mHealth technology until all qualms are completely resolved is not an option. In an era in which every detail of a person’s life can be managed via the Internet, mHealth should be the next evolution of Internet technology-driven health care.
Gil Siegal, MD, LLB, SJD, is a professor of law at the University of Virginia School of Law, in Charlottesville, Va., the director of Center for Health Law, Bioethics and Health Policy at Ono College and an otolaryngologist at Tel Hashomer Medical Center, both in Israel. Disclosure: Siegal has no relevant financial disclosures.