Doctors & Mobile Devices

K Scott FFARCSI MSc

Declarations• I am an anaesthetist in a DGH in Northern Ireland

• I am low tech compared with everyone here

• I am not active online

• I am Foundation Programme Director for 65 FYs

Doctors & Mobile Devices

What can possibly go wrong?

Why?

• Connectivity• Mobility• Processing power• Camera

Other stores are available……

Accessorising

Caveats• Significant lead-time bias between data collection & publication

• People are growing up with technology & devicesliving with evolving technology & devicesjoining in quite late or only occasionally

• Stats/values are dependent on the source

• The internet is full of non-peer reviewed articles

Time Line1918 (Some) women get the vote in

United Kingdom of GB & Ireland

1965 Death Penalty abolished (in GB)1965 1st Race Relations Act

1973 1st call from a cell phone

• 1st website went live

2004 Facebook launched2005 YouTube launched

1978 laryngeal mask airways available

1986 propofol re-launched1990 sevoflurane launched in Japan

2007 iGel launched

Mobile Devices – why? • For the same reasons as everyone else has them• Additional usage for work-related reasons

• Social contact• To access & share information • To log data• To use apps• To takes pictures/videos• (Emergency contact)

• Management role• On call / baton phone

“Everything that used to be in the pocket of my white coat”

Analgesic Effect

http://www.livescience.com/50466-smartphone-game-injury.html accessed 01/05/2015

Sirkka L. Jarvenpaa & Karl R. LangStudy Jan – Oct 2001Published 2005

http://www.ism-journal.com/ITToday/mobile.pdf Information Systems Management Fall 2005 accessed 22/04/2015

Ubiquitous Technology• Rapidly evolving technology

• Distracting in classrooms & wardrounds 1,2,3,4,5

• Bypass Trust safety systems (policy library, appropriate websites)

• Patients might perceive their use as non-clinical 6

• The guidance has lagged behind the technologyThose tasked with producing guidance tend not to be the main users of the technology (? perception)

http://www.wolterskluwerhealth.com/News/Documents/White%20Papers/Wolters%20Kluwer%20Health%20Physician%20Study%20Executive%20Summary.pdf accessed 21/04/2015

Lucrative data is gathered by companies selling information

http://www.kantarmedia-healthcare.com/website-usage-qualitative-evaluations-december-2014 accessed 21/04/2015

http://www.kantarmedia-healthcare.com/digital-adoption-among-healthcare-key-opinion-leaders accessed 21/04/2015

Work-related Devices• BYOD? (own) COPE? (corporate-owned)

• Accountability? Who owns data stored?Where else is it stored?Who is accountable for it’s security?Who else can access this data?

• Personal use of company devices?

• Work extending tech?

The Data Controller is accountable for personal information regardless of who owns the device &

determines “purpose & manner” of processing

https://ico.org.uk/for-organisations/health/ accessed 22/04/2015

COW• Mobile on a cart• Patient data management (ICIP)• Ward rounds• Moving between bed spaces• Between patients• Reviewing obs & labs• Prescribing drugs• Reviewing PACS

• Battery • Connectivity• Multiple tasks for multiple patients

Social Media• General sites open access

• Facebook Harvard students’ intranet (Feb 2004)now has ~ 1.39 billion monthly active users1.9 billion mobile active users ~ 19% of population of this planetaverage 100 – 250 “friends” per user

• Twitter 284 million MAU, ~ 1 billion registered users

• Professional sites require recommendation or ID, niche sites etc

• Re-posting permanent record & may be “found” later likely to be taken out of contextlikely to be to detriment of index person privacy settings (38% in 2008, 63% in 2010, 93% 2012)

Accessed 20/04/2015

Is there research?

Accessed April 2014

Health on the Net NI = Queen’s Univ Belfast Medical Library

Guidance• Common Law obligation of “confidentiality”• Data Protection Act (1998)7

• BMAfor doctors & medical students (2011)• GMCguidance based on GMP & Confidentiality 2013 “standards

expected of doctors do not change because they are communicating through social media” 8 “social media can blur the boundaries”9

must v. should

• MPS & MDU clarification of GMC stance

• Defamation Law “the act of making an unjustified statement about a person or organisation that is considered to harm their reputation”.10

https://ama.com.au/sites/default/files/documents/Social_Media_and_the_Medical_Profession_FINAL_with_links_0.pdfaccessed 22/04/2015

So…• Reams of advice, guidelines, legal requirements

• Still online misdemeanours despite this guidancedisinhibition, dissociation, emotional “hit & run” 11

• Still naïveté at best• Still demands for upholding rights freedom of speech

• Public perception of professionalism is unlikely to change• No precise definition of “professionalism” or “appropriate”

• BUT social acceptance/behaviour lags behind the technology

Medical Apps• 100,000 mobile health apps on

market

• Worth ~ $4,000,000,000,000 (~ $26 billion by 2017)

• FDA oversight in USwill there be harm if the app does

not work as intended?

• Tighter review v. stifled innovation

http://www.fda.gov/downloads/MedicalDevices/.../UCM263366.pdf accessed 22/05/2015http://www.motherjones.com/environment/2015/01/medical-apps-not-helping accessed 22/04/2015

Medical Devices are Registered with MHRA

• Medical Device Directive 2012(MEDDEV 2.1/6)

• Stand-alone software• Stand-alone medical devices• Decision support software

• = trading standards (CE mark)• ≠ efficacy or clinical validity

• Only for “information”, “entertainment” or “research” are unacceptable disclaimers from company

https://www.gov.uk/government/publications/medical-devices-software-applications-apps/medical-device-stand-alone-software-including-apps accessed 22/04/2015

https://www.rsm.ac.uk/events/events-listing/2014-2015/sections/telemedicine-ehealth-section/tef03-mainstreaming-medical-apps-reducing-nhs-costs-improving-patient-outcomes.aspxaccessed 22/05/2015http://apps.nhs.uk/ accessed 22/05/2015http://www.medicalapps.co.uk/ accessed 22/05/2015http://www.imedicalapps.com/ accessed 22/05/2015

https://www.rcplondon.ac.uk/sites/default/files/apps_guidance_factsheet_revised_april.pdf accessed 07/05/2015

• If it uses patient-specific information, it is a medical app

• It should be CE marked

• NOT an endorsement

• Reporting problems to MHRA

• Apps that diagnose, support diagnosis or clinical decisions, make calculations to determine diagnosis or treatment, or are used for any medical purpose are classed as ‘medical devices’.

Published 29 April 2015

Latest ….

Distraction• Distraction is common in the workplace 12

clinical reasons“pings in pockets” – automatic look : ignore or answer

• Risk of a medication error ↑12.7% with each interruption12 Interruptions every 2-10 mins α clinical location/task5,12

clinical interruptions & comms alerts (bleep, phone, email)

• 1-24 mins to regain focus on interrupted task

• Perfusion 201113 study on behaviour during CPB~50% used cell phones (text, email, OSN)~75% thought it was unsafe (~ 25% safe…)

• Resulted in cardiac tamponade as warfarin e-prescription was not completed

• Resident responded to a text about social event on BYOD14

(using a blended device)

• Cognitive distraction15 • Conversation NOT holding phone• no difference with hands-free

• Inattention(al) blindness

• Most of us are NOT multi-taskers• Rapid toggling BETWEEN tasks and/or screens• We need to exercise better cognitive control

& ignore internal & external distractions (inc strong emotions)

• FOCUS

https://www.gov.uk/using-mobile-phones-when-driving-the-law accessed 01/05/2105

Does a trainee count?

Possibilities• Rising awareness of distraction as a patient safety concern• Another new industry for the clinical workspace

• Suggestions abound16 sterile cockpit strategyno interruption zonesexplanation of need > education agree acceptable reasons for useagree acceptable alert tones (if any)wifi hotspots (control location & time)restricted & friendly zonesno email periods (talk to colleagues)“mindfulness”17 & Focus

• CHANGE THE CULTURE rather than more policies and education

It’s all about protection18…• Protection of Reputation of the profession of the

professional of the organisation

• Protection of Privacy of patient information of the professional’s personal informationof corporate information

• Protection of Productivity efficiency minimising distraction

PATIENT SAFETY

References• 1 Payne,K., Wharrad, K., and Watts, K. Smartphone and medical related App use among medical students and junior doctors in the United

Kingdom (UK): a regional survey. http://www.biomedcentral.com/1472-6947/12/121 • 2 Langmia , K., Glass, A. Coping with smartphone distractions in the classroom.

http://aejmc.us/spig/wp-content/uploads/sites/9/2014/03/tjmc-w14-langmia-glass.pdf • 3 Katz-Sidlow, RJ., et al. Smartphone Use During Inpatient Attending Rounds; Prevalence, Patterns and Potential for Distraction

Journal of Hospital Medicine. 2012;7(8):595-599. • 4 Wu,r. et al. 2011. An evaluation of the use of smartphones to communicate between clinicians: a mixed-methods study.

Journal of Medical Internet Research. http://www.jmir.org http://www.ncbi.nlm.nih.gov/pubmed/21875849• 5 Martin, G. Smartphones in the clinical environment: a help or hindrance? Australian Medical Students Journal. http

://www.amsj.org/archives/3240 • 6 Millar et al. Why Physicians Should Share PDA/Smartphone Findings With Their Patients: A Brief Report. Journal of Health Communication:

International Perspectives Volume 17, Supplement 1, 2012 DOI: 10.1080/10810730.2011.649102 • 7 https://www.gov.uk/data-protection/the-data-protection-act The Data Protection Act accessed 07/05/2015 • 8 http://www.gmc-uk.org/static/documents/content/Doctors_use_of_social_media.pdf accessed 07/05.2015 • 9 http://www.gmc-uk.org/guidance/ethical_guidance/21170.asp Maintaining a professional boundary between you and your patient

30/04/2015• 10 Defamation Act 2013 http://www.legislation.gov.uk/ukpga/2013/26/enacted • 11 The Online Disinhibition Effect. Suler,J. CYBERPSYCHOLOGY & BEHAVIOR ; 7 (3), 2004 http://www.samblackman.org/Articles/Suler.pdf • 12 Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication

administration errors. Arch Intern Med. 2010;170(8):683-690. http://www.ncbi.nlm.nih.gov/pubmed/20421552 • 13 Smith, T. Darling, E. Searles, B. Survey on cell phone use while performing cardiopulmonary bypass.

http://www.ncbi.nlm.nih.gov/pubmed/21593081 • 14 AHRQ M&M. Dec 2011 Halamka, J. Order Interrupted by Text: Multitasking Mishap http://webmm.ahrq.gov/case.aspx?caseID=257 • 15 http://www.who.int/violence_injury_prevention/publications/road_traffic/distracted_driving_summary.pdf?ua=1 • 16 Gill, P., Kamath, A., Gill, T. Distraction: an assessment of smartphone usage in health care work settings.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437811/pdf/rmhp-5-105.pdf • 17 AHRQ M&M. Feb 2014. Bayea, S. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness.

http://webmm.ahrq.gov/perspective.aspx?perspectiveID=152 • 18 Cain, J. (2011) ‘Social Media in Healthcare: The case for organisational policy and employee education’. American Journal of Health-System

Pharmacy, vol.68, June, pp.1036-40

Thank you for your attention