Smartphone and tablet applications (apps) have become an integral part of clinical practice, research, and education for many physicians. Studies have demonstrated that 85 percent of attending surgeons, fellows, and residents in the Accreditation Council on Graduate Medical Education (ACGME) training programs own a smartphone, and more than 50 percent of them use a variety of apps in clinical practice.1
From a surgical standpoint, the $27 billion mobile app market has generated apps that can do everything from surgical simulation, to procedure illustration, to provision of instantaneous access to libraries of information.2 Searching for “surgery” on the iTunes App Store brings up more than 900 related apps; the same search on Google Play delivers approximately 500 results. Navigating this veritable jungle of apps can be a time-consuming and confusing process.
What are the best surgical apps? How are they actually used in practice? Have they changed the delivery of surgical care? This article addresses these questions by examining apps for clinical practice, research, and education with the help of some tech-savvy surgeons. And how did we find these app experts? Well, naturally with the assistance of apps and by sending out messages via the American College of Surgeons’ (ACS) Twitter account (@AmCollSurgeons).
Apps for clinical practice
Most physicians currently in clinical practice did not have access to apps during training, yet many are finding this type of technology can revolutionize the way they practice by facilitating preoperative, intraoperative, and postoperative care. Quoc-Dien Trinh, MD, a urologic oncologist at Brigham and Women’s Hospital, Boston, MA, describes how using apps such as drawMD to explain surgical operations to patients means he no longer has to carry around cumbersome stock drawings of anatomy. Now Dr. Trinh makes personalized drawings for patients using the anatomy templates on the app and can easily e-mail these images to them for future reference.
Contrary to the absence of apps during the training of most current surgical attendings, many present-day surgical trainees have never practiced medicine without them. For example, general surgery residents at the Medical College of Wisconsin, Milwaukee, are given iPads for use during rounds to access electronic health records (EHRs) and retrieve information. Apps that allow access to EHRs such as Citrix Receiver comprise a burgeoning field. Even patients have the opportunity to access their personal medical records through apps. For example, the Kaiser Permanente app allows health plan members to access their EHRs, review test results, book appointments, and refill medication prescriptions.
In addition to the availability of mobile EHRs, access to current guidelines at the point of care is a valuable advancement for trainees and clinicians. Several such guidelines in app format include the National Comprehensive Cancer Network’s (NCCN) guidelines for cancer care available via the NCCN Guidelines by Epocrates app; the American College of Chest Physicians’ antithrombotic therapy guidelines available through the CHEST app; and the Johns Hopkins ABX Guide app, which provides an impressive compilation of antimicrobial recommendations and guidelines, including some for surgical prophylaxis and treatment of surgical site infections.
Tablets and smartphones are rapidly replacing handwritten notes and pocket reference books for many trainees. Apps such as Evernote and Notability offer users the opportunity to write electronic notes, collect documents, store photographs, and record audio, while keeping all of this information together in a categorized, searchable electronic database. Similarly, trainees no longer have to tote around pocket-sized reference books as many of these are now virtual and subsequently are immediately accessible. “Of course you still have to know all the basics, but we really don’t have to keep everything in our heads anymore,” said Paula Termuhlen, MD, FACS, general surgery residency program director at the Medical College of Wisconsin, Milwaukee. “I am certain that readily accessible information will increase patient security and reduce human error.”
Edward Bender, MD, FACS, a cardiothoracic surgeon at Cape Thoracic & Cardiovascular Surgery, Cape Girardeau, MO, has been creating his own apps for the iPhone since 2007, some of which address the issues of patient security and human error. When Dr. Bender first started creating apps, none of the existing apps were particularly relevant to surgery. His first app, a risk calculator for cardiothoracic surgery called the euroSCORE calculator, uses recommendations from the Society of Thoracic Surgeons and allows for point-of-care calculation of operative risk to assist in decision making.
“Without the app, many surgeons only use the scoring system retrospectively to assess risk,” Dr. Bender said. The potential for future surgeon-created apps complementing clinical care delivery is considerable. The ACS National Surgical Quality Improvement Program (ACS NSQIP®) is in the process of developing an app for the ACS NSQIP Risk Calculator. As another example, one of many apps enabling patients to play an active role in their health care is pApp. Currently under development by Synappz Medical Apps in the Netherlands, this program allows physicians to create mobile apps for their patients that could be used to track postoperative pain medication use, vitals, inputs and outputs, and other information.3,4
Apps may also be used for operative planning and intraoperative assistance. For example, Mobile MIM is a U.S. Food and Drug Administration (FDA)-approved free iPad and iPhone app that allows viewing of numerous imaging modes including X ray, ultrasound, computed tomography, magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography when users cannot access other imaging workstations. This app, which pairs the Mobile MIM viewer with MIMCloud, a Health Insurance Portability and Accountability Act-compliant Internet server that allows users to store and share medical images, has sophisticated functions, including multiplanar reconstruction and radiodensity measurement. Images can be securely downloaded and subsequently viewed in any setting, whether during discussions with patients or in planning operations.
Surgeons are also starting to use iPads and other tablet devices intraoperatively for image viewing and operative assistance.5 Some surgeons, such as a group from Kobe University in Japan, place sterile covers over iPads and then use imaging software such as OsiriX to view interactive digital imaging and communications in medicine (DICOM).6 Thus, surgeons are able to view images on a Picture Archiving and Communication System (PACS) without needing to scrub out or leave the operating table.
Similarly, Fraunhofer MEVIS has recently created an app that takes 3D images and reconstructs the location of deep structures such as blood vessels or tumors in a patient’s liver.7 Not only does this capability allow for better preoperative planning, but it can also provide intraoperative support. Using an iPad and integrated camera, these 3D reconstructions can be superimposed on the liver itself during the operation, rendering intrahepatic structures “visible.”7-9 Overall, the potential for app usage in clinical surgical practice is extensive: coding assistance, dictation modalities, preoperative planning, intraoperative decision making, postoperative monitoring, guideline reviewing, EHR accessing, and radiology viewing. For a representative sample of these apps that facilitate clinical care in surgery, see Table 1.
Apps for research and literature review
In addition to influencing clinical practice, apps can have a large impact on the accessibility of journal articles. Dr. Termuhlen said she uses journal apps to stay up-to-date on the latest literature. “I read so many more articles now that I have access to them from anywhere. I bring my iPhone everywhere, and screen through abstracts whenever I have a few minutes of downtime,” she said. For keeping current on innovations in surgery, Dr. Trinh recommends Twitter’s smartphone app. By following leaders in his field on Twitter, he is able to keep up with groundbreaking scientific and clinical advances and journal articles.
Some journals—such as the New England Journal of Medicine, The Lancet, the British Medical Journal, Plastic and Reconstructive Surgery, Annals of Surgery, and The Journal of Trauma and Acute Care Surgery—have apps that provide access to articles. The ACS has an app for the Journal of the American College of Surgeons (JACS), which allows a user to read journal articles, save articles for later, or download PDFs. (See Table 2, for an overview of all the apps offered by the College.) A user also may create a personal library of articles across journals for future reference by saving them to a file hosting service such as Dropbox, which allows customers to store documents and photos in sharable folders for instantaneous access from numerous devices, both online as well as offline.
Another valuable app for organizing and staying current on the latest research is Docphin. Docphin, similar to Read by QxMD, acts as an integrated portal to the journal article libraries of institutions or hospitals. Users save their institutional login to their device for portable access to libraries of information. With the iPad app recently launched this summer along with its existing iPhone and Android interface, Docphin allows users to browse the latest abstracts from their favorite journals, obtain alerts when articles with certain keywords are published, and read landmark papers in each field. However, as Dr. Trinh noted, apps for journal articles are still in their infancy. He hopes that eventually these apps will become more sophisticated by allowing users to publicly comment, highlight content of interest, post links, and discuss findings, thereby creating a virtual community of readers that will help inform and put new journal articles into the context of the literature at large. (For an overview of several representative research and literature review apps, see Table 3.)
Apps for education
Apps are also revolutionizing clinical education. As Dr. Termuhlen observed, “Instant access to information is more efficient, and the graphic nature of the iPad is great for surgeons since most of us are visual learners.” Dr. Termuhlen said that iPads allow surgeons to present graphic information in an accurate and visually appealing way and anticipates the creation of atlases and maps that could revolutionize the teaching of anatomy and surgical techniques.
In terms of delivering more traditional textbook-based content, apps continue to be of limited use, and those text-based apps that do exist are often quite expensive. For example, at press time, the Sabiston Textbook of Surgery was available from the App Store for $204.99 and Zollinger’s Atlas of Surgical Operations could be purchased for $249.99. Nonetheless, apps create the opportunity for future widespread availability of interactive multimodality textbooks and learning resources.
Moving beyond traditional print textbook content, iBook Author allows users to create textbooks and other types of books for the iPad (see Table 4). These iBooks could be used for patient reference, trainee instruction, or individual review by taking text, pictures, videos, and interactive diagrams and turning them into customized textbooks. One example is the Cleft Lip & Palate Program book developed by Boston Children’s Hospital, MA. In addition to books, informational resources such as UpToDate have mobile apps of summarized, easily accessible, and searchable information that is readily available and allows for the immediate answering of questions.
More interactive educational apps range from quiz apps, including Surgery Board Weapon for the American Board of Surgery In-Training Examination and board review, to those that actually allow a user to perform simulated surgeries. Although simulation in app form is still in its infancy, simulation apps are starting to appear, such as Touch Surgery and vCath. As Dr. Bender said, “Apps in surgery don’t have to be dry. They can be ‘game-ified,’ or made fun in the form of a contest or a game.” An example is the Are You Smarter than Your Attending? app, which was a medical quiz app offered in 2012 by CVOffice—a developer of mobile applications for health care professionals—presented in collaboration with the American Association for Thoracic Surgery. The quiz questions were written by the American Board of Thoracic Surgery, and at the end of the 10-week competition two winners were awarded a free journal subscription and free meeting tuition.
The College offers an educational app, MyATLS, to complement and build upon the Advanced Trauma Life Support® (ATLS®) course. Available for use on an iPad or other tablets, it allows users to access key resources, including algorithms, calculators, and video, regarding trauma care. In addition, there is an informative, yearly app for the annual ACS Clinical Congress that includes scheduling capabilities, session descriptions, room locations, and more.
Apps are also being used for case and knowledge assessment. Jonathan P. Fryer, MD, FACS, assistant professor of surgery at Northwestern University’s Feinberg School of Medicine, Chicago, IL, described how the faculty at that institution use an iPhone app to assess residents’ levels of autonomy and skill in the operating room based on resident self-assessment and attending evaluation.
For attending surgeons, apps could provide opportunities for continuing medical education (CME). Although existing apps such as Epocrates CME and MedPage Today offer alternatives for fulfillment of medical CME requirements, they currently offer a paucity of surgery CME opportunities. However, the potential for future interactive surgical education and assessment tools is great.
Some surgeons believe something is lost when a user switches from a paper format to digital. Luke Selby, MD, a general surgery resident at North Shore Long Island Jewish Health System, NY, described how apps can be ideal for quick and immediate references during the day, but how reading large chapters or articles can be hard on an iPhone. “It’s great for looking up quick facts, but I don’t like to read textbooks or articles on the iPhone,” he said. “I know that some read on their iPhone or iPad, but I definitely still prefer books.”
Apps can affect education outside the U.S., as well. Robert Riviello, MD, director of global surgery programs at the Center for Surgery and Public Health at Brigham and Women’s Hospital, Boston, said that putting textbooks and teaching materials onto iPads could be a cost-effective way to bring these materials to resource-poor settings and aid in clinical education abroad. Health eVillages is already engaged in these types of efforts. The not-for-profit organization provides tablet computers with custom-made educational apps to support health professionals in selected low-income countries.10
Apps may also be an effective means of communication in low-resource settings. Milind Chitnis, MD, a pediatric surgeon who works on the southeast coast of South Africa, said that with “the universal availability of smartphones, we use smartphone apps for communication…with our colleagues working in deep rural areas and also with our patients’ parents.” He said that they mainly use WhatsApp Messenger, because it is a “cheap, fast, and effective way of communication.”
Concerns
Although apps may add much to clinical education and health care delivery, several issues must be taken into consideration as they are incorporated into surgical practice. To begin, there is little to no oversight over the quality of the medical information apps provide, nor is there a medical, surgical, or government body that offers validation or approval of content unless the app is considered a medical device.11 For mobile apps that meet the criteria of medical devices and that could create risks to patient safety if they did not function correctly, the FDA has created a guidance document to delineate its regulatory authority.12 These regulations only apply to those apps that meet the definition of a medical device and are used either as an accessory to a regulated medical device, or transform a mobile platform into a regulated medical device.12 For mobile medical apps that meet this criteria, manufacturers have to satisfy requirements previously associated with the applicable device classification, including such factors as registration, quality system regulation, and labeling.12
A recent article by Connor and colleagues showed that only 35 percent of hernia apps had identified medical professional involvement in their design or content.13 Similarly, a recent article indicated that most apps related to weight-loss surgery were developed without any health professional guidance or input.14
As Dr. Trinh noted, the Apple Store screens for technical bugs but does not allow for rigorous peer review to guarantee the quality of the medical content. “The apps industry is the Wild West,” Dr. Bender added. “There is no peer review process, and it isn’t likely that we will have one any time soon since developers can just make disclaimers to avoid taking responsibility for the contents. Of course, each app must comply with Apple’s rules, ensuring that no copyright laws are broken or inappropriate content included, but it’s up to the user to be suspicious about their sources of information.” Dr. Bender suggests that professional societies like the ACS could play a key role in ensuring high-quality apps are identified and used in the future.
In addition to concerns regarding content, apps often contain advertising that allows companies to directly target physicians, potentially indirectly influencing prescribing and treatment practices. Connor and colleagues reported that 96 percent of the apps evaluated could be tied to commercial interests or links.13
Apart from verification concerns regarding content accuracy and the external or commercial influences of some surgical apps, Dr. Bender also warned users about the possible hazards of blind reliance on apps. “We must never forget the immeasurable variables of the patient-doctor relationship,” he said, reaffirming that “the calculator is just one of our tools.”
Conclusion
Applications for smartphones and tablet computers have permeated many areas of surgical practice including health care delivery, education, and literature review. Some surgeons have found creative ways to integrate apps into their surgical work. At the same time, however, potential areas of concern regarding apps use in surgical care remain. As the world of apps continues to expand and become more innovative, it is important that the surgical community investigate different ways in which apps can complement the profession while continuing to be mindful of the ways in which they influence clinical practice.
Authors’ note
Tables 1, 3, and 4 show representative lists of apps for surgeons in the categories of clinical practice, research and literature review, and education. These lists were developed by the authors based on information from the interviews featured in this article as well as review of the literature.
References
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- Lewis T. Augmented reality iPad app used in liver surgery to aid tumour resection. iMedical Apps. 2013. http://www.imedicalapps.com/2013/08/augmented-reality-ipad-app/. Accessed September 2, 2013.
- Fraunhofer MEVIS. Mobile Liver Explorer . 2013. Fraunhofer MEVIS. Available at: http://www.mevis.fraunhofer.de/loesungen/mobile-liver-explorer.html. Accessed Sept 2, 2013.
- Health eVillages. Health eVillages—apps save lives. 2013. Available at: http://www.healthevillages.org. Accessed September 2, 2013.
- Foreman C. U.S. Food and Drug Administration. Keeping up with mobile app innovations. FDA Voice. September 2, 2013. 2013. Available at: https://blogs.fda.gov/fdavoice/index.php/2013/03/keeping-up-with-mobile-app-innovations/. Accessed Sept 12, 2013.
- Mobile Medical Applications: Guidance for Industry and Food and Drug Administration Staff. 2013. Available at: http://www.fda.gov/downloads/MedicalDevices/…/UCM263366.pdf. Accessed October 19, 2013.
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