Technology & Innovation

Training apps in the ER

January 23, 2013

Global

January 23, 2013

Global
Our Editors

The Economist Intelligence Unit

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Within moments of being alerted that an injured or sick child is being rushed by ambulance to the emergency room (ER) at David Grant USAF Medical Center, Dr Toree McGowen reaches into the deep pocket of her white coat, pulls out her iPhone and opens an application called PediStat. After plugging in the child’s age, weight and height (radioed ahead by the ambulance crew), Dr McGowan hands the phone to a nurse who sets up diagnostic and treatment equipment specifically sized to the child. Making these preparations before the child has arrived in the ER can make a critical difference in the patient’s survival, the doctor says.

PediStat is one of about 20 mobile apps that are becoming as commonplace as the stethoscope to emergency room doctors, especially recent graduates. Just a few years ago, before the age of smartphones and wireless tablets, ER doctors “would have their coat pockets filled with small reference books,” Dr McGowen recalls. “We’d be rushing about the ER from patient to patient with saddle-bags of books weighing us down.”

With a few taps, PediStat, a free app from QxMD, a unit of Qualcomm, provides ER doctors with the size of airway tubes and diagnostic choices based on blood and urine test results, as well as a list of procedures and the order in which to carry them out. The app also calculates precise drug dosages and lists potential drug interactions. “It’s invaluable when treating kids who present us with conditions we may not have seen before or only see rarely,” Dr McGowan says.

Although adoption of some new technologies has been limited, emergency room doctors have fervently embraced the app revolution. “In the past, doctors would have to rely on their memory, carry out drug dosing calculations in their head, refer to textbooks or computers located a distance from patient bedsides,” says Iltifat Husain, a third-year ER resident at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. “In the last few years, along with the emergence of mobile devices, there’s been an explosion of apps with more and more complex uses,” he says.

The US Food and Drug Administration (FDA) is currently considering creating a department to review and approve doctor-focused mobile apps to keep up with this trend; to date, however, there are no regulations in place for app use except for existing rules that protect patient privacy. And this is perhaps helping adoption.

The one use of apps that has attracted criticism, however, involves software that allows doctors to remotely monitor a patient’s vital signs. A recent study in the New England Journal of Medicine that reviewed the use of remote monitoring in 1,600 patients hospitalised for heart failure found that the software provided no added benefit. Apps for emergency rooms, however, rarely rely on remote monitoring.

Dr Husain, co-founder and editor of iMedicalApps, an online magazine that launched three years ago to review the flood of mobile technology available to doctors, is among a growing number of ER doctors lobbying colleagues and hospitals to integrate apps into the daily practice of ER medicine. “Given an ER doctor’s workload and the speed with which the doctor must access and evaluate a constantly growing body of information, mobile tools are both essential and revolutionising ER practices and training.”

Mobility is already changing the way medicine is taught in medical schools, according to Dr Husain. He points out that an increasing number of schools, such as the University of Chicago Medical School, and the University of Pennsylvania’s Perelman School of Medicine have purchased iPads and are encouraging students to use them for learning anatomy or when in wards taking care of patients.

Dr Husain argues that mobility is even more important in training ER residents after medical school. Wake Forest’s ER residency program is creating cloud-based software that allows doctors to communicate with one another for quicker consultations. The software will move documents and video to mobile devices from “static web pages,” he says.

Mobile access to information is, in some ways, not new to the medical profession. PEPID was created as a static PDA-based product in 1994 by Mark Rosenblum, a Chicago doctor, to replace notes and reference materials overflowing in his lab coat during his residency. The app’s popularity has grown with the spread of smartphones and tablets: approximately 50% of the 40,000 ER doctors in the US use PEPID today. “Doctors tell us that it’s like having an extra or peripheral brain with them at all times,” says Jenna Reynolds, PEPID’s marketing director.

As a result of PEPID and other apps, doctors no longer rely on wall-sized charts, for instance, where drugs for particular conditions are listed along with their interactions. “The problem with the handwritten charts is that they constantly had to be updated and often, through editing and re-editing, the charts become a confusing mess,” says Ross Donaldson, assistant clinical professor of emergency medicine at the David Geffen School of Medicine at University of California at Los Angeles, who helped create the app. 

Donaldson points to WikEM, an app that features treatment notes and checklists continually updated by practicing physicians, which has been downloaded by more than 20,000 ER doctors worldwide. Like PEPID, WikEM contains medical articles from the New England Journal, pieces from the Mayo Clinic and papers from other research publications in a searchable format. Several journals also provide digital versions through newly created apps.

“The old practice relied on doctors being very smart and memorising as much as they could, which is the focus still in many medical schools,” Donaldson says. “But there’s just too much to memorise now. No ER doctor, or training resident, should be making decisions in absence of up-to-date, real-time annotated information.”

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