Cell phone monitoring quality improvement
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Patients were excluded from the study if they suffered from chronic pain or psychiatric disturbances, took narcotic morphine-like medication for pain on a regular basis, or had an allergy to local anesthetics or morphine-like medications.
All patients received an information sheet discussing the purpose of the study and had the opportunity to discuss the process with the study coordinator. After written consent was obtained by the study coordinator, each patient met with the coordinator for approximately minutes before their surgery to learn how to use the mobile device and review the different indicators they would be asked to answer on the mobile device each day. Patients were also shown how to take a picture of their surgical wound site using the mobile device. Prior to discharge, patients were given either a smartphone or a tablet with half of each study arm receiving one or the other.
Patients practiced taking photos with the study coordinator to ensure they understood how to take pictures with the device. In addition to the one-on-one consultation with the study coordinator, each participant was provided with an education booklet with details on how to use the mobile app device and answer questions regarding security and confidentiality. The education booklet also included illustrations on how to frame the body and angle the camera to take pictures.
These parameters were based on the most effective view required by surgeons to assess the wound site. Study participants continued to have their regularly scheduled face-to-face post-operative visits with the surgeon in keeping with normal care processes. The three participating surgeons used a mobile interface or desktop computer to access patient data. Scores on question items that fell outside the normal range of defined parameters were immediately flagged in the database for quick viewing.
Being flagged meant that the app sensed an extreme on the value scale as a response. The surgeon could then phone the patient to enquire why the extreme score had been registered. The app updated every 5 minutes. Daily photographs were reviewed by surgeons to assess the recovery of the surgical site and wound and to determine if healing was progressing normally and without complications. Four sets of data were gathered for this study including 1 data from the mobile app that was entered by patients in the pilot study while recovering at home, 2 post-recovery follow-up feedback surveys with patients, 3 post-recovery interviews with patients, and 4 post-pilot feedback surveys with participating surgeons.
The mobile app recovery indicators included a visual analogue scale VAS for pain and Likert questions from the Quality of Recovery QoR-9 questionnaire. The QoR-9 is an earlier version of the Quality of Recovery QoR questionnaire, which has been extensively utilized and validated to assess the quality of life of patients after surgery [ 14 ].
The QoR is composed of 40 items organized into six dimensions: Despite the comprehensiveness of the QoR, the feasibility of using this questionnaire as a daily self-administered assessment tool is limited due to survey length. In consideration of time and the frequency of conducting the assessments, the QoR-9 is much more appropriate for the purpose of daily remote monitoring and provides insight into patient quality of recovery and outcomes of care. Reporting began from the day of discharge up to a period of 6 weeks dependent on patient recovery time for each procedure.
The patients were asked to complete the app survey once per day at the outset but not reminded in any way. At the outset, we asked the patients to answer the survey in the morning when they took their first set of pain medications. This was in an attempt to standardize the responses. Figure 1 depicts the screenshots and provides an example of the indicators as viewed on the mobile devices. Examples of the touch screen interface of the patient portal, including the visual analogue pain scale, an example of the QoR 9 question on postoperative nausea, and the visual analogue scale for fluid in the postoperative surgical drains.
During the second follow-up visit to the surgeon, the mobile device was returned and patients were invited to fill in a post-recovery survey evaluating their recovery as well as their experience using the mobile device. The study coordinator was available while patients filled in the survey to provide clarification when required and answer patient questions about the study. In the event the patient was unable to complete the survey without assistance, the survey was read aloud by the coordinator and completed in a structured interview manner.
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Patients in the study were also invited to participate in a study evaluation interview. The interview focused on the patient recovery experience using the mobile device, user-friendliness of the mobile device and app, and suggestions for improvement. After the study was complete, the 3 participating surgeons were asked to fill out a post-pilot survey with 13 open-ended questions evaluating their post-operative recovery experience using the QoC Health technology platform.
This survey included questions on overall experience, user-friendliness of the portal, changes that could improve the app and portal, potential impact on care and reduction of patient post-op visits, and potential for the solution to identify complications. As there was no change in the current medical standard of care, there was no risk to patients by participating in the study. No patient was discharged from the hospital unless they met the standard discharge criteria applied to all patients, and all standard practices of post-surgical care were followed.
All patients were coded, so that identifiers were absent from survey and interview data. Data sheets containing subject identifiers as well as subject identifications numbers were stored separately from data sheets containing subject identification numbers only. No identifiers were or will be included on any hard copy data sheets that link with health information ie, only identification numbers are used , and password-protected databases are used.
Pictures of patients were related to the surgical site only, and no patient identifiers were used.
Canadian Medical Protective Agency was also consulted in regards to medical legal liability and the participating surgeons. Their only stipulation was that of maintaining standards of privacy and security of patient data. Patient data collected using the mobile app is double encrypted on the server and the phone. Modern infrastructure design leveraging distributed infrastructure as a service IaaS and cloud computing services SaaS for seamless accessibility, redundancy, and scalability were also utilized.
Both quantitative and qualitative analyses were performed. Descriptive statistics were generated for demographic variables. Overall satisfaction with use of mobile device was scored from 1 poor to 4 excellent , and means were generated. Frequencies were generated for categorical variables.
Qualitative information from the evaluation survey and interviews were assessed for common themes. We enrolled 65 patients in the study, and Table 2 shows a summary of the demographic data for both orthopedic and breast patients. All of the patients completed the study protocol.
Mobile Devices and Apps for Health Care Professionals: Uses and Benefits
The program was downloaded on to a standard device mobile phones and tablets and loaned to the patient for the period of the day pilot. Few technical issues arose during the pilot. In total, there were ten technical inquiries from the 65 patients during the pilot. All of these inquiries related to the patient attempting to access the Internet for personal use on the managed device. All devices and connections worked well throughout the study and were returned on the final follow-up visit. Patients were asked to log in daily to complete the QoR-9 data not presented here.
The mean number of logins over the day study period was The mean number of logins was higher in the first 14 days post-op compared to the days post-op for both breast patients The mobile app aggregate response profile data to post surgery quality of recovery indicator questions QoR 9 modified is available in Multimedia Appendix 1. Patients were also asked to upload photographs of the surgical site on a daily basis. Over the day period, photos were uploaded by the breast patients and by the orthopedic patients.
Mobile apps can also be used directly to conduct simple examinations for visual acuity or color blindness, as well as blood pressure or glucose level. Thank you some much for this information and it will help me a lot. While a good script is a great safety net, being able to improvise with confidence can be the secret to exemplary service. As a result, complications were observed in real-time and allowed for the identification of complications prior to scheduled follow-up visits. Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency.
Two potential surgical complications were detected through surgeon viewing of the photographs. Figure 2 shows one of the breast reconstruction patients who was identified with increasing erythema at day 12 post-op. One orthopedic patient was also identified with increased erythema at 5 days post-op. There were no patients who presented clinically with complications that were not identified through monitoring of the mobile phones. Patient-entered pictures showing left breast of a breast reconstruction patient following insertion of a tissue expander, where the surgeon identified an increasing erythema at 10 days post-op.
The sequence of pictures and dates are shown. The patient was placed on antibiotics over the phone on Dec. The camera quality on most mobile phones is capable of detecting subtle changes in skin tone. On a scale from 1 poor to 4 excellent , the mean score for overall satisfaction with using the mobile handheld device was 3. All patients responded that they would be willing to use the handheld device during a future post-op period. All three participating surgeons completed the follow-up. Each surgeon followed a mean of 22 patients using the platform.
All of the surgeons responded that the platform was user-friendly and intuitive. Specific aspects that enhanced the experience included the easy-to-navigate design, the portability to monitor patients outside of hospital perimeter, and the ability of the technology to improve time efficiency. Concerns raised by one surgeon focused on how much additional time would be required by care providers to monitor multiple recovering patients on an ongoing basis.
The surgeon or care provider can view the patient's quality of recovery all on one screen. The photos show the patient's "selfies" of the surgical site with the date. The QoR-9 questions are listed with the responses. Question 3 is highlighted red because of the abnormally high pain score entered by the patient. The "spark line" represents every score as a point of data on that particular indicator since the start of the monitoring.
The pictures can be enlarged by tapping on them. Follow-up visits for patients enrolled in the pilot were scheduled in the usual pattern for each surgeon. When asked whether the surgeons would feel comfortable canceling a follow-up visit if they saw patients were recovering well through the Web portal, all surgeons indicated they would consider canceling the 6-week follow-up for orthopedic surgeries or the first or second follow-up visit for breast-reconstruction surgeries.
For canceled follow-up appointments, the orthopedic surgeons indicated that replacing the in-person consultation with a phone call was not an efficient option, and they considered phone calls to be an outdated mode of communication. Rather, surgeons were willing to send an electronic confirmation with personalized feedback to the patients who were progressing well and had their follow-up canceled.
This study provides evidence that the use of mobile app monitoring with breast reconstruction and orthopedic surgery patients is feasible and acceptable to patients and surgeons. Patient adherence in using mobile app technology has been demonstrated previously in chronic conditions [ 16 ].
However, this pilot study has demonstrated that adherence is also high in acute post-operative patients discharged from hospital within 24 hours after surgery. Patients were asked to log on to the device on a daily basis for 30 days post-operatively. Patient adherence was high; on average, in the first 15 days post-op, patients logged on to the device This decreased considerably in days Logan et al have also reported that adherence also decreases over time in hypertensive patients using mobile devices for blood pressure monitoring [ 16 ].
However, with post-operative patients it may be directly related to the type of questions asked of the patients. A modified questionnaire incorporating different questions relating to features of daily activity ability of the patient to independently get dressed or return to work may be more relevant in weeks 3 of a day recovery profile. Patient satisfaction was very high in this pilot study of breast reconstruction and orthopedic surgery patients. This patient data supports the acceptance of this type of mobile monitoring. These findings are consistent with other studies evaluating the acceptance of the use of mobile technology in other medical conditions including hypertension, congestive heart failure, and diabetes [ 16 - 19 ].
Generally, it has been reported that patients have an overall positive attitude towards mobile technology [ 20 ]. In addition to feasibility of patients using the device, we have also demonstrated the feasibility of surgeons monitoring post-operative patients. Through the platform, the surgeons had a first-time view of daily patient recovery between discharge from hospital and the first follow-up visit through the use of the quality of recovery data and photographs. Observing the incisions in sequence allowed for a new type of indicator assessment for surgeons and an opportunity for intervening in the early development of post-operative infections.
The resolution and quality of cameras available on most mobile phones are now capable of detecting subtle color changes in skin tone. Evidence has shown that mobile devices allow HCPs to be more efficient in their work practices. The use of mobile devices has been shown to provide HCPs with numerous enhanced efficiencies, including: Research has shown that the use of mobile devices at the point of care has helped streamline workflow and increase the productivity of HCPs.
Studies that investigated patient record maintenance and revision found that more patient information was documented when a mobile device was used, reportedly because of ease of use in comparison to paper records. Several interesting trends regarding the use of mobile devices and apps in health care have been predicted for the future. As better health outcomes become the ultimate goal of the health care system, apps will be needed to fulfill that purpose.
Mobile device hardware and apps are expected to continue to improve, bringing additional and enhanced benefits to clinical practice. The role played by mobile devices and apps in health care education is also expected to grow. Several issues challenge the future integration of mobile devices and apps into health care practice.
The increased use of these devices by clinicians in their personal and working lives has also raised important medicolegal and ethical implications. It is also important that mobile medical apps that claim diagnostic or therapeutic efficacy be evaluated with regard to claimed outcome, as well as utility in clinical practice. Medical devices and apps are already invaluable tools for HCPs, and as their features and uses expand, they are expected to become even more widely incorporated into nearly every aspect of clinical practice.
The author reports that she has no commercial or financial relationships in regard to this article. National Center for Biotechnology Information , U. Journal List P T v.
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Lee Ventola , MS. The author is a consultant medical writer living in New Jersey. This article has been cited by other articles in PMC. Need for Mobile Devices at the Point of Care One major motivation driving the widespread adoption of mobile devices by HCPs has been the need for better communication and information resources at the point of care. Communication capabilities—voice calling, video conferencing, text, and e-mail 7. Informational resources—textbooks, guidelines, medical literature, drug references 7.
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Clinical software applications—disease diagnosis aids, medical calculators 7. How HCPs Use Mobile Devices and Apps Health care professionals use medical devices and apps for many purposes, most of which can be grouped under five broad categories: Information Management Write notes. Open in a separate window. Table 2 Medical apps for health care professionals 2 , 4.
Communication and Consulting Health care systems are often highly dispersed, encompassing multiple locations such as clinics, inpatient wards, outpatient services, emergency departments, operating theaters, intensive care units, and labs. Reference and Information Gathering Literature Research and Review Mobile devices are invaluable tools for HCPs to use to search or access medical literature, as well as other information sources.
Drug References Drug reference applications are generally used to access information including: Patient Management Clinical Decision-Making Mobile devices provide HCPs with convenient and rapid access to evidence-based information, supporting clinical decision-making at the point of care. Patient Monitoring The use of mobile devices to remotely monitor the health or location of patients with chronic diseases or conditions has already become a viable option.
Medical Education and Training Mobile devices play an increasingly important role in medical education as students and schools use more technology during training. Convenience Many mobile apps have made the practice of evidence-based medicine at the point of care more convenient. Better Clinical Decision-Making Many medical apps make mobile devices invaluable tools that support clinical decision-making at the point of care.
Improved Accuracy Mobile devices have repeatedly been found to improve the completeness and accuracy of patient documentation, an effect that has often been attributed to ease of use. Increased Efficiency Evidence has shown that mobile devices allow HCPs to be more efficient in their work practices. Enhanced Productivity Research has shown that the use of mobile devices at the point of care has helped streamline workflow and increase the productivity of HCPs.
Medical applications for pharmacists using mobile devices. Physicians share their favorite uses and apps. The smartphone in medicine: J Med Internet Res. The meaning of information technology IT mobile devices to me, the infectious disease physician. Smartphone and tablet apps prove useful in clinical practice. Bull Am Coll Surg. A systematic review of health care apps for smartphones. Use of personal digital assistants in clinical decision making by health care professionals: J Physician Assist Educ.
Evidence of effectiveness of health care professionals using handheld computers; a scoping review of systematic reviews. Medical application use and the need for further research and assessment for clinical practice: How smartphones are changing the face of mobile and participatory health care; an overview, with example from eCAALYX.
IPads and other drugs. Smartphone and medical related app use among medical students and junior doctors in the United Kingdom UK: Apple Inc; Available at: Accessed February 14, Accessed February 17, Apple helps MDs cut through medical app clutter. Accessed March 12, Why mobile health app overload drives us crazy, and how to restore the sanity. Physician adoption of health information technology: