Published 2008-03-31 in iHealthBeat.
More and more doctors are using smartphones — essentially PDAs that can make phone calls — in their daily lives, yet few of them are integrating the devices into their clinical practice. New clinical software designed specifically for smartphones is helping to overcome some barriers, yet there are other roadblocks preventing smartphones from becoming much more common in medicine than they are now.
As the average cell phone becomes “smarter” and telecommunications companies aggressively expand mobile networks, consumers in both developed and developing countries increasingly have a wireless computer in their pockets, according to Joel Selanikio, a pediatrician in Washington, D.C. Selanikio’s not-for-profit company DataDyne.org makes open-source public health data collection software for PDAs and cell phones. The software is used by the World Health Organization, the World Bank and other organizations around the globe.
Unlike laptops and tablet PCs, smartphones are small enough to carry everywhere, their battery life lasts longer than a clinical shift and they have no standby or hibernation waiting times.
Yet, however convenient, many physicians are reluctant to carry and learn how to use smartphones in their medical practice. Others find it difficult to enter data into the devices using handwriting recognition. A further barrier is that hospital IT departments must provide support for doctors using the devices.
The medical software sector has seen a flurry of activity surrounding the smartphone market in the last few months. Epocrates recently announced the availability of its drug reference software for BlackBerrys, while Skyscape announced the release of all its medical textbooks for the BlackBerry platform. Thomson Healthcare has been providing medical software for BlackBerry devices since 2006.
The publicity surrounding the release of Apple’s iPhone prompted yet another wave of companies pledging support for its platform. eClinicalWorks practice management software is designed for Web browsers, including those operating on iPhone, as is the American Academy of Family Physicians’ CEND Personal Health Record Web site and Life Record’s electronic health records software.
Unbound Medicine, a provider of evidence-based medicine content, announced in July 2007 that its clinical references Web site works on iPhones. Meanwhile, Epocrates announced the availability of iPhone software at an Apple press conference in February.
All of this is in addition to the existing products from medical software vendors for handheld computers and smartphones running the Palm, Pocket PC and Windows Mobile operating systems.
The technology advances come at a time when sales of nonsmartphone handhelds continue to fall. IDC estimates that worldwide sales in the third quarter of 2007 were just under $730,000, a 40% drop from the 1.2 million units sold during the same quarter in 2006.
Rises in smartphone sales are much greater than this drop. In-Stat estimates double-digit growth every year for the next five years by traditionally PDA-centric vendors like Palm, as well as newer smartphone vendors like BlackBerry and the most recent and famous entrant, Apple.
At Virginia Commonwealth University Medical Center, a pilot study with emergency department physicians has been successful enough to justify providing smartphones to each physician in the hospital.
The devices access data from a central EHR system run by Cerner. Physicians also can use their smartphones to search textbooks and the Internet, send and receive e-mails, and make and receive telephone calls with hospital staff. The hospital’s investment largely is covered by the increased charge capture from enabling billing by the bedside with the same PatientKeeper software that provides the Cerner medical records for patient care.
IT teams are still learning how to get the best value from technology like smartphones. At VCU, two earlier pilots uncovered problems with nonsmartphone PDAs, as wireless connectivity was not reliable enough for clinicians, and certain smartphones could not meet clinicians’ need to use several applications simultaneously.
The spread of methicillin-resistant Staphylococcus aureus infections is leading to questions about hospitals’ hygiene policies for clothing and devices, including smartphones. Infections associated with handheld computers are less significant than those spread by not washing hands, explained Anatole Menon-Johansson, a U.K.-trained physician completing a master’s degree in public health at Harvard University.
“Hands are by far the most important, then white coats, shirt cuffs, stethoscopes, ties, rubber hammers, ophthalmoscope, whatever else is in your white coat pocket, and only then cell phones and PDAs,” Menon-Johansson said.
The cost of integration can also be significant for hospitals. However, if hospitals do not make an investment in supporting smartphone technology, physicians using smartphones either have to double-document, entering data into both their own handheld computers and the central medical records system, or they fail to reap the advantages of up-to-date information by patients’ bedsides.
Getting accurate data on how many physicians use smartphones in their practice is difficult because the term “use” can be defined in a broad range from taking practice-related phone calls to data storage, computing and Internet research.
According to Thomson Healthcare research, about 31% of physicians in this country use smartphones in their practice. The Diffusion Group, a consulting firm specializing in IT, estimates higher — that nearly half (49%) of U.S. doctors used smartphones in 2006.
Leaders in both the medical and information industries predict smartphone use in physicians’ practices will grow rapidly across the globe. Selanikio of DataDyne predicts African countries will be among the most rapid adopters of wireless smartphone technology because of the relative dearth of land-based computing options.
In the United States, according to research by the Diffusion Group, smartphone use by physicians will increase to 70% over the next three years.
Eliezer Yudkowsky of Overcoming Bias fame has written a fabulous blog post showing why people consistently underestimate time requirements for their projects. This is also know as the “planning fallacy”. The fallacy occurs even when you ask people to adjust for it:
A clue to the underlying problem was uncovered by researchers who found that asking subjects for their predictions based on realistic “best guess” scenarios, versus asking subjects for their hoped-for “best case” scenarios, produced indistinguishable results.
Nor can it be adjusted for by asking for specific plans – in fact the more specific the plan the more people overestimate how much they can accomplish. Fortunately, there is something very simple you can do:
A group of Japanese students expected to finish their essays, on average, 10 days before the deadline. They actually finished 1 day before deadline. Asked when they’d finished previous essays, they said: “One day before deadline.”
So, the next time someone you are working with shows you a project plan (or worse still, a detailed project plan) ask them:
- how long did it take you to complete these tasks last time?
- what has changed between the last time and this time that makes you things will go more quickly?
If you think you do not know how to deceive yourself then you probably already know exactly how to do so. But, for the few innocents among us, I recommend the book “Mistakes were made (But not by Me)“. Frankly, I bought it for the name alone. Needless to say, politicians are over-represented, mainly because lying to others first requires a mastery of the ability to lie to oneself.
- Using the active voice for positive personal actions, and the passive for negative ones. For example, “I created this success” but “this failure happened”. This is a restatement of the principle that success has many fathers while failure is an orphan.
- Heaping general praise for positive actions by those in the in-group (e.g. “my friend did something great because he is a great person”) but only specific for out (e.g. “my enemy did something great”). Conversely, for negative actions, those in the in-group get specific condemnation (e.g. “my friend did something bad”) while general condemnation is reserved for those in the out-group (e.g. “my enemy did something because he is a terrible person”).
- Selective memory, including no correlation between confidence and accuracy. The latter point is particularly serious for the judicial system, where the degree of confidence of a witness is taken as an indication of the accuracy of their statements.
Trivers also mentions something that saddened me: the first world war was last in which the military died to protect civilians; since then, the reverse has been true.
Which brings us these statements:
- “I believe that success will be fairly easy.” — John McCain (9/24/02, CNN)
- “I believe that we can win an overwhelming victory in a very short period of time.” — John McCain (9/29/02, CNN)
- “The American people … were led to believe that this would be some kind of a day at the beach which many of us, uh, fully understood from the very beginning would be a very, very difficult undertaking.” — John McCain (8/22/06, CNN)
- “I knew it was probably going to be long and hard and tough. And those that voted for it and thought that somehow it was going to be some kind of an easy task, then I’m sorry they were mistaken. Maybe they didn’t know what they were voting for.” — John McCain (1/4/07, MSNBC)
Selective memory anyone?
Here is a simple framework – the US Army teaches its soldiers to ask the following questions after every major event:
- what did we set out to do?
- what happened?
- why was there a difference?
- what should we do next time?
As a university student in the 1970s Condoleezza Rice did the smart thing and learned to speak Russian. Today, the smart thing is to study Arabic. In Washington DC, a lot of people are trying to learn the language. One American I know found the experience so difficult that he switched to a diplomatic career in Europe. Another was so excited by the opportunities that he went to Iraq to help found “Lamp of Liberty“. I never heard from him since but can only wish him safety. And yet more and more Americans attend The Washington DC Arabic Language & Culture Meetup Club to practice their language skills. When I ask them why they are learning, many are uncomfortable. Some, I suspect, are trying to avoid telling an Arab that they want to become spies for the US government.
But Americans in particular, and the West in general, must learn how to communicate with Arabs.
Of course, Americans will try to use technology to for all of their problems. The results are increasingly impressive. Google’s Franz Och, a 35-year-old German working in the California headquarters, passionately discusses how he trains his software. Like Jean-FranÃ§ois Champollion looking at the Rosetta Stone 200 years ago, Och’s software looks at text for statistical evidence that two words in two languages mean the same thing. But he has a quantity of text that would have shocked his French predecessor. Every day he feeds long documents from the United Nations – both English and their Arabic language translations – into Google’s powerful computers. The results are freely available from Google’s homepage, and the Arabic version is at http://www.google.com/language_tools?hl=ar.
There is an opportunity here for Arabs. Sakhr Software USA, using tools of the original Kuwaiti company, has won contracts from the Department of Homeland Security for its translation software. At a party organized by the Bahraini Embassy I chatted to one of their programmers. He was proud of his company’s products but frustrated by how long it took to obtain the trust of the American government. A few months after that the hysteria of Dubai Ports began, but Arab businesses continued their work.
But the opportunity for Arabs is much larger than a business one: we can help Americans understand our Arab viewpoints, and why we hold these, rather than lamenting misunderstandings and fighting in frustration.
An interesting example is from the Wikipedia, a free encyclopedia that allows anyone to improve existing work. The Chinese government regularly censors access to the website. Jimmy Wales, its founder, was born in Alabama, 100 miles away from Ms. Rice’s birthplace. When Mr. Wales discusses China’s censorship, he does not say that China’s government is depriving its citizens from access to the Wikipedia’s knowledge, although it does. Rather, he says that censorship stops the world from hearing China’s viewpoints. Only those outside the censorship can write on the website – citizens from Taiwan, from Singapore, from America, and from all other countries that may have opposing viewpoints to the Chinese government.
So Mr. Wales encourages citizens from all over the world to contribute. There is, of course, an Arabic language website, which Mr. Wales often highlights. It is written by Arabs for Arabs but still mostly focuses on computing technology, reflecting the interests of its enthusiastic authors.
But more of us should be writing more. Because just as Ms. Rice was smart to learn to talk to the Russians, we should be smart and learn to talk to Americans.