Mobile health technologies improve communication with patients

Mobile health technologies, such as smartphones, tablets and cloud computing, have revolutionized the way physicians interact with and treat patients and their use continues to evolve in orthopedics.

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 proportion is anticipated to reach 81% by the end of this year, 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 alternative 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.

Wireless devices improve the efficacy and efficiency of communication with practices, colleagues or patients and allow “on-the-fly learning” for physicians, Christian Veillette, MSc, MD, FRCSC, a shoulder and elbow surgeon at the University Health Network Arthritis Program and Assistant Professor at the University of Toronto, told Orthopedics Today.

“You no longer need to find a computer, sit down and look information up on a wired device,” he said. “You can pull this up on your smartphone, whether it is with an actual browser, or through an app that specifically accesses the information or people you may need to answer a particular question at the point of care.”

Connecting orthopedists to patients

This ease of access, along with the tablet computer’s unprecedented versatility, assures that smartphones and tablets are not likely to be left behind on the kitchen table like their print counterparts.

“Pre-2005, there were few smartphones,” Orrin I. Franko, MD, co-editor of Orthopedics Today’s Ortho Apps column and 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.”

Mobile technologies connect practices by allowing orthopedists and other physicians to monitor health conditions from anywhere and integrate these technologies into patient care, Veillette said. Many physicians use their smartphones or tablets to take photographs and show patients videos or images of their conditions or potential surgeries, he said.

Physicians in other fields are using mobile health (mHealth) to monitor patients; for example, cardiologists use wireless technology to follow patients with congestive heart failure and endocrinologists monitor the condition of patients with diabetes. Veillette believes in the future, mHealth will enable orthopedists to monitor patients’ mobility after a procedure and automatically synchronize the data with patients’ health records.

Matthew Ockendon, MBBS(Hons), BSc(Hons) FRCS(Tr&Orth), an orthopedic surgeon at The Robert Jones and Agnes Hunt Orthopaedic and District Hospital in Shropshire, England, noticed it was easier for patients to measure their own knees with a smartphone than with a professional goniometer, so he invented the app, Knee Goniometer.

“We have done some work with other health care professional volunteers and are getting reliable results,” Ockendon told Orthopedics Today.

In orthopedic practices, tools on smartphones and tablets have begun to replace some traditional methods. For example, Ockendon has invented apps that allow orthopedists to template X-ray measurements by “snapping a picture,” scaling it and templating it on a smartphone. Ockendon cautioned that mHealth “augments” physician practices and could never replace the face-to-face interactions of traditional consultation.

“Perhaps you can get more data over a longer period to bring into the consultation to help the decision-making process rather than you replace the consultation altogether,” he said. “If you have somebody else doing their exercises, you can encourage them remotely and gain some feedback.”

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 security concerns about remaining Health Insurance Portability and Accountability Act (HIPAA) compliant in an mHealth 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.

MHealth 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 counter top,” 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 anyway less secure than online banking.”

Apps and EHRs

As more U.S. medical practices move toward meeting federal goals for universal adoption of electronic health records (EHRs) by 2014, many expect the role of mHealth in ensuring continuity of care to grow as the ability for apps to integrate with EHRs improves. Some mobile apps integrate right into the hospital’s IT infrastructure to securely load the fully functional EHR application, such as Citrix Receiver, Veillette said. 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.

Ockendon stressed the need for a universal system that would unite patient records in a common interface, but “no such panacea exists,” he said. The Office of the National Coordinator for Health Information promoted the Smart Apps Initiative at the recent Medicine 2.0 Conference in Boston to develop apps for integration with any EHRs, Vaillette said.

“It is taking the integration of apps into electronic health records to the next level and providing that platform, and there are dozens of electronic health record vendors, but it would be nice if you had an app that plugs into one electronic health record, all based off of the same platform so you do not have to develop individual apps for each electronic health record,” Vaillette 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.

Integration of EHRs with the cloud

There is talk about integrating EHRs with the cloud, but it may pose some security risks, Niall Johnston, BComm, vice president of business development and co-founder of medical app company, 3D4Medical.com, in San Diego, Calif., told Orthopedics Today. Cloud resources are more susceptible to hackers. Security for cloud and EHR integration are still in their “infancy,” according to Veillette.

“I think [the role of cloud computing] is in tight integration and on-demand synchronization is the key thing,” Ockendon said. “If I request an X-ray in one hospital, then want those X-rays on my tablet, then want to do some templating in another hospital and then want to look at the templating in the theater which is not necessarily connected, there is only one sensible solution to that — put things on servers of a third party so you can access the data from anywhere, but with that comes a significant problem of data security.”

Ockendon said true end-to-end data encryption is needed to protect patient data, and Johnston said there are already standards in place.

“Technology from a security perspective, from a password perspective and most importantly from a secure communications perspective, there are loads of standards in place,” Johnston told Orthopedics Today. “But you also have things like human error, people who are misusing applications. Everyone is working toward a common goal of making it as secure as possible.”

Public health outreach

Although the technological capabilities of mHealth are impressive, the human component remains essential to the success of any mHealth program or intervention. Lygeia Ricciardi, EdM, senior adviser for consumer e-health at the HHS, Office of the National Coordinator for Health Information Technology, 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 told Orthopedics Today. “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.”

This is the type of interaction that Ricciardi said HHS wants to achieve with mHealth interventions for U.S. patients with chronic diseases, such as diabetes and cardiovascular disease.

“We want to use mHealth 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 mHealth 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 as well as communication.

In developing countries, more people can afford lower cost smartphones and some groups have begun using smartphones for data capture. Some countries also give patients rewards through their smartphones to buy into wellness, Veillette said. Apps often break through the language barrier in these countries as well, such as Johnston’s 3-D animated hip, knee, shoulder, ankle and foot apps.

“A lot of our apps are used around the world where they may not have access to vital information specialists in the particular area to educate people on conditions that they may have,” Johnston said.

Future of mHealth

As more health care providers begin using their smartphones in the clinical setting, ensuring that tools are reliable, accurate and consistent through pre-implementation testing and post-implementation monitoring are the goals for mHealth.

According to Ricciardi, the three key requirements for mHealth to be successful are: that it provide specific, actionable information, that text services or apps be evidence-based and that mHealth programs be regularly evaluated.

“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 mHealth technology,” Ricciardi said.

Veillette sees technology expanding the ways physicians connect to patients with chronic diseases such as osteoarthritis in the continuum of care through constantly evolving mHealth technologies.

“I think the whole future of mHealth is about connecting these different areas (communication, education and patient care) within this continuum of care and developing novel models of care that allow us to interact with a patient when they are not just in the hospital or clinic and capture data in seamless automated fashions that flags them if they are running into problems or if they are not doing well after surgery or with a specific treatment, rather than having the usual timed follow-up appointments at 2 weeks, 6 weeks, 3 months, 6 months, or 1 year,” Veillette said. “Mobile apps and decision support systems can be put in place that allow people to manage certain health problems more effectively on their own, take more initiative in managing their overall health and flagging when certain criteria threshold are met for preventive care or a specific intervention.”

Veillette’s colleagues in the University of Toronto Orthopaedic Sports Medicine Program have developed and piloted a mobile app that allows patients to keep pain diaries, complete specific outcome measures and take pictures of their incisions after ACL reconstruction. Johnston is developing an app that lets specialists create custom PDFs of the patient’s condition using images taken in 3-D animations and email them to patients to help them understand their conditions and available treatment options.

“In the future, health care providers will be using mobile technologies in ways I cannot even imagine at this point,” Franko said. “No one is throwing away their smartphones anytime soon, so medical software developers will continue to find new ways to integrate with mobile technology.”

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 Nicole Blazek and Renee Blisard Buddle

Will the rapid proliferation of mHealth technology pose a threat to patient confidentiality?

Any technology — indeed, any device or intervention — has the potential to be misused

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 safe-guarding 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.

The need to protect medical information and patients’ privacy are well-known concerns and receive much attention in states’ statutes and federal legislation

Innovative information technologies offer a spectrum of health care applications, including the Internet (mHealth), smartphones and tablet computers (mHealth), electronic health records (EHRs), medical databases and the emerging telemedicine industry. In areas where 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 states’ statutes and federal legislation — most notably through HIPAA. As interest in and the development of EHR increases, the need to assure patients’ rights is particularly important, especially since 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, even banking, 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.