A P A T I E N T K E E P E R W H I T E P A P E R

W H I T E P A P E R

1

Providing a Single, Integrated Mobile App and Other Keys to Successful Physician Adoption of mHealthExecutive SummaryPhysicians have long enjoyed a seemingly dichotomous relationship with technology. On the one hand, the field of medicine is very often on the forefront of technological advances like imaging, micro and robotic surgery and implantable devices that manage such critical bodily functions as maintaining a regular heart rhythm. Yet physicians still heavily utilize such time-tested, low-tech tools as a stethoscope or even a paper chart!

There are many reasons for this mixed adoption of technology, but at its core it’s very simple – physicians will adopt technology that is efficient and works for them, and by extension, for their patients. Historically, physicians have not placed Electronic Medical Records (EMRs) and similar technologies in the category of technology that works for them. Instead, they have chosen to sparsely adopt EMRs, often only with the threat of lost admitting privileges, or practice in hospitals and settings that don’t force them to use these systems. That is, until the advent of mobile devices like smartphones and tablets.

Physician adoption of mobile devices has the potential to profoundly impact the practice of clinical medicine. The rapid and deep adoption of smartphones and tablets by physicians has given rise to an entire sub-category of eHealth called mHealth. Simply defined as the practice of medicine and public health supported by mobile devices, mHealth has grown as a movement and even spurred HIMSS to create mHIMSS as a website and forum entirely focused on mobile technologies, workflow and data exchange. But while mobile devices were the critical first step in the mHealth movement, mobile medical apps that run on these devices will play an important role in the ultimate success of mHealth going forward.

This paper considers the evolution of mobile medical apps and the characteristics of these apps that are most likely to result in broad and sustained physician adoption. Ultimately, full clinical workflow support through a single app that integrates with EMRs and other clinical applications will be required to realize the full benefit of mHealth for both physicians and hospitals.

The Meteoric Rise of Mobile DevicesWith smaller form factors, greater speed and ease of use, it’s no wonder physicians’ adoption of mobile technology has consistently exceeded that of the general public. While close to 40% of American adults own a smartphone, mobile device adoption

Contents

1 ExecutiveSummary

1 TheMeteoricRiseofMobileDevices

2 TheStateofMobileMedicalApps

2 RemoteDesktopAccessFallsShortofExpectations

4 ASingleIntegratedMobileMedicalApp

4 SupportingtheEntireClinicalWorkflow

5 Nativevs.WebAppConsiderations

6 Conclusion–mHealthBenefitsPhysiciansandHospitals

A P A T I E N T K E E P E R W H I T E P A P E R

2

among physicians is markedly higher –almost any published survey or research finds it is more than double that of consumers1. Manhattan Research, a pharmaceutical and healthcare market research firm, conducted a study that indicated 72% of physicians were using smartphones in 2010 with adoption projected to rise to 82% in 20122. These numbers were up from just 30% in 2001 and 64% in 2009. Spyglass Consulting Group, a mobile computing marketing research firm, placed the number of physicians using smartphones at 94%3. And with 96% of medical students reportedly using some sort of smartphone, this trend seems likely to continue4.

The State of Mobile Medical AppsAs popular as mobile devices have become among physicians, they ultimately require mobile applications, specifically medical apps, to be useful in the clinical setting. But the state of mobile apps dedicated to medicine is diffuse, and in many cases the apps in use are more consumer- than physician-focused. Of the over 10,000 mobile apps categorized as “medical” currently on iTunes, many are more related to health and wellness, lifestyle, and fitness than the practice of medicine by physicians.

Figure 1. Top 20 Medical Apps on the iTunes Store as of January 2012

Fewer still allow physicians to effectively and efficiently utilize the information stored within a hospital’s EMR. Accordingly, less than 1% of hospitals currently make use of tablets in patient care settings5. This is projected to change in 2012, however, with physicians expected to expand their range of mobile activities to include direct patient care6. What’s driving this projected increase and how will hospitals and physician practices meet physicians’ demands for mobile technology?

Remote Desktop Access Falls Short of ExpectationsSeeing an opportunity for efficient, anytime, anywhere access to patient information via an intuitive interface, physicians have begun to approach and even pressure hospitals to provide them with access to EMRs on mobile devices (Figure 2). Yet a recent survey of members of the College of Healthcare Information Management Executives (CHIME)

A P A T I E N T K E E P E R W H I T E P A P E R

3

on smartphone use found that only 18 of the 52 hospitals responding said they allowed smartphones to access the hospital’s EMR and other systems7. And the majority of physicians using mobile health solutions — 63% of physicians according to a Health Research Institute report — are not connecting to their practice or hospital IT systems8.

For hospital IT leadership, the argument has shifted from “why won’t our doctors use our systems” to “how am I supposed to support, secure and integrate our systems with all of these mobile devices?”

Developing mobile medical applications takes time and experience that is often in short supply and can divert resources from maintaining product development and support of core desktop and web-based applications. As a result, many traditional EMR vendors have focused on using software such as Citrix and other remote desktop applications to provide remote access on mobile devices. These efforts ultimately fall short of satisfying physicians as they provide spotty performance and access to EMRs that are mostly windows-based and require a mouse to navigate rather than being designed specifically for a mobile device operating

system or to work with a touch screen interface. Furthermore, any user interface or experience shortcomings present in portal or desktop EMRs are only magnified when accessed remotely from smaller mobile devices. In effect, remote access results in an arguably worse experience than with the portal or desktop EMRs those physicians have avoided in the first place. This very experience was recently reported in a CIO Magazine article entitled ‘iPad in Healthcare: Not So Fast’: “Every one of the clinicians returned the iPad, saying it wasn’t going to work for day-to-day clinical work.”9

In the context of the familiar Gartner Hype Cycle, this and similar examples indicate the market has reached the Peak of Inflated Expectations and begun to realize a more thoughtful approach to mobile medical apps is required (Figure 3). Real advances in mHealth will require mobile medical apps designed specifically for the devices on which they run.

Figure 2. Physician interest in performing various tasks wirelessly Source: PricewaterhouseCoopers HRI Physician Survey, 2010

A P A T I E N T K E E P E R W H I T E P A P E R

4

Figure 3. Hype Cycle of Mobile Medical Apps

The Hype Cycle of Mobile Medical Apps was created by the author and does not necessarily reflect Gartner’s view of the marketplace. Gartner has not reviewed this Hype Cycle and does not endorse it.

A Single Integrated Mobile Medical AppOne approach to emerge has been the development of point-apps to satisfy one specific aspect of the clinical workflow. Unlike simple remote access, these apps are developed specifically for mobile device form factors and operating systems. However, because each app supports a specific task, a physician must access one app to view lab results, another app to view images, still another app to review clinical notes and so on.

Worse, each of these apps are rarely if ever integrated with one another, repeating a common failing of most traditional core Hospital Information Systems (HIS) whereby physicians must log into multiple separate systems, locate the patient in each and the associated result(s) for each aspect of the workflow. In effect, the physician must manually locate and integrate information from multiple, disparate systems for a single patient, which more closely resembles a paper-based workflow than an efficient electronic one.

“Doctors have indeed found a tool that naturally fits with their lifestyles and workflow needs, and the future is going to need to include mobile integration with [EMRs] and other clinical applications,” said Brian Ahier, a health IT evangelist for Mid-Columbia Medical Center in The Dalles, OR, and a health IT blogger. Without integration, individual apps will struggle to achieve sustained adoption to the extent they require physicians to manually integrate information from disparate sources. A single mobile app that integrates information from multiple existing hospital systems is a critical consideration if mobile medical apps are to avoid a shortcoming often found in portal or desktop systems.

Supporting the Entire Clinical WorkflowWith the introduction of the iPad and other popular tablets, physicians have already begun to expect mobile support for their entire clinical workflow and not just view-

A P A T I E N T K E E P E R W H I T E P A P E R

5

only access to clinical results. They are no longer satisfied with viewing results on their mobile device only to search for an available computer terminal or laptop to enter orders, sign documents, reconcile medications, document care and ultimately bill for their time. To require otherwise is to erode the very efficiency that has drawn physicians to mobile devices in the first place.

Native App Web App

Code Base Objective-C(iOS),Java(Android) HTML5,JavaScript,CSS

Openness Platform-dependent–Appleisclosed,Androidisopen

Open

Platform reach Codebasegenerallyspecifictoeachdeviceplatform/OS

Codebasecanrunacrossmultipleplatformsusingthesamebrowser

Use of APIs AccesstoabroadarrayofAPIsthatmakeuseofdevicefeatures(e.g.,camera,motionsensors,etc.)

MorelimiteduseofAPIsanddevicefeatures,expandingwithHTML5,etc.

Distribution model ViaappstoreslikeiTunesandAndroidMarketplaceandother,emergingsub-storeslikeHapptique

InsomecasesviaappstoresorovertheInternet

Release management Controlled3rd-partydeveloperandappstore,mayrequirereviewprocess(Apple).Privatestoresforcustomappdistribution

Continuous–releaseavailabletoandtakenbyALLimmediately

Supportability Requiresinstallationandupdateoftheappontheenduser’sdevice

Usersalwaysaccessthelatestversion/releasefromtheirdevice

User interface GreatercontrolofUIandcustomization Limitedtodevice/browsercapability

User experience GenerallybetterusabilityduetoUIcontrolandperformance

Applicationperformance,downloaddelaysandlackofuniformityacrossbrowserscandetractfromuserexperienceifnotproperlyoptimized

Performance Betterapplicationperformance Goodapplicationperformance

Offline access Yes,canaccessdataindisconnectedstate GenerallymusthaveWi-Fiorcellularconnectivity,althoughchangingtosomeextendwithHTML5andwidgets;verydifficulttokeepdatainsync

Background operation Canruninthebackgroundtoenablepushingofnewdata/alerts

Mustbeopenandrunningtoreceivenewdata/alerts

Data access Useraccessesdatathatisascurrentasthelastsynchronization

Useraccessesdatathatisascurrentasthedatarepository/server

Security Dataencryptioninmotionduringsync,andatrestonthedevice

Dataencryptioninmotion,limiteddatastoredonthedevice

Figure 4. Native vs. Web App Comparison

Native vs. Web App ConsiderationsSoftware developers and hospitals have options when it comes to mobile apps and how they are developed and deployed. They can opt for device/OS-specific native apps or mobile browser-specific web apps. Each has its advantages and disadvantages highlighted in Figure 4.

A P A T I E N T K E E P E R W H I T E P A P E R

6

With improvements in HTML5 and other technologies, web apps are getting better at closely approximating native app performance and experience. Two of the bigger considerations related to mobile medical apps and physicians, however, deal with performance and release management. Given their relatively faster performance and response to end user gestures/taps, native apps will generally be the better choice for physicians. Regarding release management, healthcare organizations often employ strict upgrade and installation procedures; and not all releases will be candidates for installation in all environments and scenarios. When a web app is released, however, it is available for all users at once. For at least these two reasons, it’s likely that native apps will continue to enjoy preferred status among physicians and healthcare organizations.

Conclusion – mHealth Benefits Physicians and HospitalsPhysicians are increasingly being challenged by decreasing reimbursements and increasing patient loads. In mobile devices and mobile medical apps, they see an opportunity to positively impact their practice of medicine through expedited decision making with ready access to information on their patients, decreased time spent on administrative tasks and ultimately more time spent with their patients (Figure 5)8.

Figure 5. Percent of physicians who said mobile health would have these impacts Source: PricewaterhouseCoopers HRI Physician Survey, 2010

Given physicians’ affinity for efficient mobile workflow support, a sound mobile medical app strategy should be a key component of a hospital’s strategy for improving patient safety while also achieving Meaningful Use in Stage 2 and beyond. Many hospitals were able to achieve the 30% adoption threshold in Stage 1 through the use of existing Emergency Department systems, but this approach will not work for the higher thresholds expected in Stage 2, which will likely require 60% of medication, laboratory and radiology orders to be entered electronically (a 50% increase over Stage 1 CPOE adoption along with the addition of two common order types). Additionally,

56%

Expedite decision making

39%

Decrease administrative tasks

36%

Increase collaboration among physicians

26%

More time with patients

24%

No affect

A P A T I E N T K E E P E R W H I T E P A P E R

PatientKeeper, Inc., 880 Winter St., Suite 300, Waltham, MA 02451 · P: 781.373.6100 · F: 781.373.6120 · www.patientkeeper.com

About PatientKeeper: PatientKeeper®, Inc., the leading provider of physician healthcare information systems, enables physicians and hospitals to focus on their patients, not technology. PatientKeeper provides highly intuitive software for physicians that streamlines workflow to improve productivity and patient care. PatientKeeper’s CPOE, physician documentation, electronic charge capture and other applications run on desktop and laptop computers and popular handheld devices and tablets. PatientKeeper’s software integrates with existing healthcare information systems to create the most effective solution for driving physician adoption of technology, meeting Meaningful Use and transitioning to ICD-10.

01/12 WP - Mobile App 186-341

© 2012 PatientKeeper, Inc. All rights reserved. PatientKeeper® and the PatientKeeper logo are registered trademarks of PatientKeeper, Inc. All other trademarks and brands referenced herein are the properties of their respective holders.

research indicates more than 20% of hospital orders are placed verbally, a practice that is increasingly associated with higher risk of poor outcomes and the target of a JCAHO Patient Safety Goal10. With a mobile application that supports the full clinical workflow in hand, physicians could more efficiently and safely place these orders electronically through Mobile CPOE, thereby improving patient safety while simultaneously contributing to Meaningful Use adoption.

1 Smartphone Adoption and Usage. Pew Internet & American Life Project. July 11, 2011.

2 72 percent of US physicians use smartphones. Manhattan Research. May 5, 2010.

3 Study: Physician Smartphone Adoption Experiencing Exponential Growth. Spyglass Consulting Group. July 23, 2010.

4 Today’s Medical Students are the Most Technology-Savvy Yet. Epocrates. September 29, 2010.

5 Less than 1 percent of hospitals fully use tablets. West Wireless Health Institute. January 2, 2012.

6 Physicians Will Expand Range of Mobile Activities to Include Administrative and Patient Care Tasks by 2012. Manhattan Research. March 3, 2010.

7 Physician smartphone popularity shifts health IT focus to mobile use. American Medical News. August 23, 2010.

8 PricewaterhouseCoopers HRI Physician Survey. September 2010

9 iPad in Healthcare: Not So Fast. CIO Magazine. November 7, 2011.

10 Kaplan JM, Ancheta R, Jacobs BR. Clinical Informatics Outcomes Research Group. Inpatient verbal orders and the impact of computerized order entry. J Pediatr 2006; 149:461 7.