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No Internet? No problem

Ensuring access to clinical decision support even when Internet is spotty or nonexistent.

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   By Denise Basow, M.D., August 2013

Studies have found that two out of three clinical encounters generate a question, yet only 40 percent of those questions are answered. If they were all addressed, it could change up to eight management decisions each day – a clinically significant impact.

This can prove challenging, however, for clinicians providing medical care in resource-limited settings where medical staff frequently practices with inadequate access to colleagues who possess specialized training or resources. In these locales, a single clinician may act as internist, obstetrician, pediatrician and surgeon, and frequently do so with insufficient information resources to effectively address the broad range of health issues affecting patient care or the guidance needed from specialist colleagues.

In addition to user-support challenges, access barriers are prevalent in these areas. Internet connectivity is unreliable, and many hospitals do not have computer access on the wards. For clinicians in these settings, a mobile phone is often their only connection to clinical decision-support (CDS) resources.

Indeed, smartphones have quickly become the primary means by which individuals are accessing the Internet. According to a 2011 Pew Internet Project report, 25 percent of smartphone owners go online primarily using their phone, approximately one-third of who have no high-speed home broadband connection. For clinicians, this problem extends beyond their homes and into the hospital setting, as well.

With the explosion in the growth of mobile devices, healthcare practitioners are like any other consumers looking for new and improved ways to manage their lives and the lives of their patients online. As such, clinicians are increasingly reliant on a growing number of so-called mHealth applications to access critical clinical support at the bedside. When they lose the wireless or network access their mobile apps require, however, there can be a direct impact on the quality of care they provide.

For clinicians in the typical U.S. hospital, that loss of connectivity is an occasional frustration. For clinicians in resource-limited settings, it is a daily struggle. To mitigate this challenge, clinical decision-support apps that offer full access to locally stored clinical content are invaluable, and can even be lifesaving. To ensure users are accessing the most current information, the best apps will routinely verify and update requested content when connections are available.

Research published in the Global Public Health Journal supports this. The study surveyed participants in the Global Health Initiative, a partnership between Wolters Kluwer Health and the Global Health Delivery (GHD) Project at Harvard University. The descriptive research study suggests that providing evidence-based medical information resources via the Internet can improve healthcare provider knowledge and clinical practice.

Consider the experiences of Dr. Eda Kim, a physician with Mercy Medical Center in Cambodia, who shared the following in a community forum for Global Health Initiative grant recipients on “We use (evidence-based support tools) so often for clinical care. Just this week I had to figure out when we could stop lamuvidine therapy for a patient with Hepatitis B who had been started on lamuvidine monotherapy. The mobile application has been great for blackouts and for trips to the villages when I don’t have Internet access.”

My favorite story comes from a physician in Ecuador. The doctor wrote us to share how using our CDS app on his mobile device was making a difference. He mentioned how it was difficult to think about carrying textbooks and other reference materials when you’re worried about carrying around water and medicine as you visit patients. Now, he has his water in one hand, medication in the other and all of the resources of the CDS app are on his mobile phone, tucked away in his pocket.

At Maputo Central Hospital in Mozambique, the staff uses a CDS app at the bedside to make clinical decisions. Even without network connectivity, clinicians are still able to access all clinical information, graded treatment recommendations and even graphics to support care-management decisions.

Dr. Susannah Graves, who works at Maputo Central Hospital, explained in the forum: “We use clinical decision-support tools in the medicine department library, and on handheld devices on the ward. We look up information at the bedside when a clinical question comes up. This has recently become much easier to do since installing the offline version of the app on the handheld devices since the Internet here is extremely slow (when it is working at all).”

In the United States, the Society for General Internal Medicine (SGIM) awards a one-year UpToDate subscription to up to 20 clinicians working in resource-limited settings around the country. To date, dozens of subscriptions have been donated to clinicians and organizations that provide medical care or related services to poor or underserved populations in the U.S.

One such recipient, Dr. Robert Moon, board certified in internal medicine and geriatrics, appreciates having remote access to clinical decision-support tools in his work caring for the homeless and uninsured across multiple community clinics in California, as well as in mission work overseas.

“Whether I’m practicing in my local community or in Kenya or even Tijuana, the main benefit of being able to access historical and current medical advice and information is making the most of what I’m given in any situation,” says Moon. “Not only can I refresh my memory on signs of advanced disease, but I can access details on regional medicine and what is available in the area I’m working in.”

Dr. Moon values having “anytime access” to advice on conservative medicine and non-drug methods for treating anything from insomnia to muscular pain, details he says he learned in medical school but hasn’t had to put into practice because of more modern methods. Still, the modern way isn’t always the practical way.

“I work in a mobile medical unit and with community clinics, where the medicines we have access to are extremely limited,” he says. “I have a short list of medications that are only $4, which only covers a fraction of the medical problems my patients present with. I like knowing what’s historically been used and receiving localized recommendations in real time, no matter where I am.”

At the Harvard Medical School AIDS Initiative in Vietnam (HAIVN), an international NGO with offices in Ho Chi Minh City and Hanoi, Vietnam, staff access to clinical decision-support tools was previously limited to times when they could access both desktop computers and a reliable Internet connection. Lately, however, they have begun turning to tools on their mobile devices. This proves particularly useful on rounds and when providing clinical mentoring at HIV clinics in the remote provinces.

In the community, Dr. Donn Colby, medical officer and director of HAIVN, wrote that the availability of clinical decision-support tools on mobile devices has greatly improved the accessibility for staff in Vietnam where 3G service is now available in most provinces except for very remote mountain areas and only costs a few dollars per month. Staff is able to access clinical decision-support tools while providing on-site clinical mentoring at provincial HIV clinics, making expert consultation immediately available to clinicians and patients.

Healthcare costs represent an increasing percentage of gross domestic product for many countries, and it’s growing. This rising trend has created an urgent need to put in place innovative and cost-effective methods for delivering healthcare, especially in areas where funding is scarce. While presenting great opportunities for healthcare systems, mHealth or mobile healthcare still faces several hurdles before there can be full adoption. Access to evidence-based support tools on mobile devices, even in areas of limited or no connectivity, is one place to start. 

About the author

Denise Basow, M.D., is vice president, general manager and editor-in-chief, clinical decision support (UpToDate). For more on Wolters Kluwer click here.

Tags:  Smartphones