1. Wilson, Linda


Opportunities and challenges for nurses.


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Applications, or apps, related to health care that have been created for smartphones, tablet computers, and other "smart" mobile devices are emerging by the score. And as the number and types of apps grow, so do changes to nursing practice.


The types of mobile apps in the health care industry so far include the following:


* wellness and fitness apps that help consumers track steps, weight, pulse, and calories


* chronic disease-management apps that help physicians and nurses monitor patients' biological indicators


* telemedicine apps that facilitate virtual medical office "visits" between patients and providers


* clinical workflow-improvement apps that streamline communications and data management for nurses and other providers


* apps that allow patients to summon nurses or physicians



The emergence of these apps isn't surprising, given the proliferation of mobile technologies, particularly smartphones. In a study released in May 2015, Parks Associates, a research firm in Dallas, found that smartphones are now more common in homes with a broadband connection than computers. Broadband is available in about 75% of U.S. households. In 2012 the Pew Research Center found that 53% of all U.S. adults owned a smartphone, and of those, 52% used their phones to look up health information and 19% had at least one health app on their phone.


In the 2015 HIMSS [Healthcare Information and Management Systems Society] Mobile Technology Survey, about 30% of the 238 respondents said their institution either offers organization-specific apps for patients or is developing one. The most common type (73%) allows patients to access an electronic patient portal from a mobile device. These electronic portals allow patients to access a portion of their medical records, view upcoming appointments, and send e-mails.



Cedars-Sinai Medical Center in Los Angeles, which offers patients access to an electronic portal through a mobile app, has gone even further. This year it began accepting data transmitted from patients' mobile health apps into the hospital's electronic medical record system, according to Darren Dworkin, chief information officer at the center. By mid-May, hundreds of patients had begun to send their data, he said, adding that the most common types of patient-generated data were steps, pulse, and weight. Cedars-Sinai doesn't require physicians and nurses to routinely monitor these data, as hospital officials explain prominently on a Web page in the center's patient portal, My CS-Link.


In the near future at health care facilities nationwide, reviewing data generated from patients' mobile apps may become a part of nurses' routine both during an office visit and between visits, leading to improved care, says Robin Austin, DNP, DC, RN-BC, clinical assistant professor at the University of Minnesota School of Nursing, whose teaching and research involve health care informatics and patient engagement. "In the ambulatory setting, we may only get 15 to 20 minutes to see what is going on with a patient. In reality, there is a whole wealth of information we can be looking at," Austin says, adding that nurses can be at the forefront of such efforts.


Dworkin agrees, saying that nurses would spend less time entering data from patients' handwritten records or spoken comments and more time validating and correcting data already in the electronic system. But he also emphasized that nurses and physicians are more likely to use such information as the type of data available evolves from basic wellness information, such as the number of steps a patient takes in a day, to clinical data, such as glucose levels, that are more useful for monitoring and treating conditions.



Although health systems are experimenting with patient-generated data, telemedicine companies have developed apps to allow patients and physicians to conduct virtual medical appointments though a smartphone or tablet. "This is an emerging industry that is growing very fast," says Harry Wang, MS, MBA, director of health and mobile product research at Parks Associates.


One stumbling block to the growth of telemedicine could be a rule the Texas Medical Board adopted in 2015 that restricts virtual medical appointments in Texas to cases in which patients and physicians have established a relationship through a previous in-person session. The rule does allow patients to interact through telemedicine with physicians they haven't met in person if the patient is in a setting, even a home, in which "sufficient diagnostic equipment and a trained medical professional, such as a licensed vocational nurse, is available to assist in presenting the patient's vital signs and other objective medical information needed by the physician."


After the rule was released, a telemedicine company filed a lawsuit against the board. A judge subsequently suspended implementation of the medical board's rule until the case is resolved in federal court. In the suit, the company argues that the rule restricts competition from telemedicine providers. And more legal issues are likely to arise as the variety of app types and uses proliferate.



Not all health care apps involve patients directly; some benefit them indirectly by streamlining clinical processes. New York City's New York-Presbyterian Hospital, for example, developed an app that allows nurses to look up physicians' contact information and then call or send a text message to a pager directly through the app. In a pilot phase, the hospital gave approximately 160 employees, including about 100 nurses, a smartphone in 2015 that had the app on it.


And there are emerging apps that allow a patient to directly summon caregivers, for nursing, medical, or emergency care. Although many of the apps are free, some can be quite costly. For example, Vytaliz, which will summon an RN to the home and an MD virtually through videoconferencing, costs $129. Another mobile app, PulsePoint, alerts volunteers trained in CPR and willing to respond quickly if someone nearby is having a cardiac emergency. A city's fire department or emergency medical services system typically pays a $10,000 start-up fee for PulsePoint and then, depending on the city's population, pays between $8,000 and $28,000 a year. Other apps use global positioning systems to find patients and guide them to the nearest ED in an emergency situation or allow emergency medical technicians to send vital signs to a hospital or find the closest, most qualified hospital for treatment or even enable emergency personnel to summon helicopter transport.



The proliferation of mobile apps in health care isn't without its challenges for nurses. One issue is the increased pressure on nurses' time as they add technology education to their patient-care responsibilities. Indeed, nurses already help patients sign up for and learn how to use electronic patient portals, notes Mary Beth Mitchell, MSN, RN, chief nursing informatics officer at Texas Health Resources.


Another challenge is devising procedures that are realistic; for instance, who will be responsible for reviewing patient-generated data and deciding how often they must be reviewed? As Austin asks, "Are providers going to have to go in and look at every single record every single day because of new information coming in that might be missed?"


But Wang points out that the amount of data providers manage will decrease over time as software vendors develop mathematical algorithms to sort through patient-generated data automatically, alerting clinicians when a medical issue needs to be addressed.


Mitchell, too, expects the health care industry to resolve these issues over time. "We don't have all of the pieces aligned now that we will five years from now," she says.-Linda Wilson