iPhone Apps for Health Providers, a Path Emerging?

Photo by rosmary via Flickr

Last year we did a series of posts on Electronic Medical Records and Electronic Medicine. One of those articles, “Electronic Medicine, iPhones and Path-Dependence” noted the emergence in Electronic Medicine of the iPhone and the Blackberry. We also noted that the iPhone and Blackberry constitute “an advantaged path” (already in the pockets of roughly 64% of doctors, early popularity further attracting skilled labor, financing, and support) and that these platforms might be capable of playing a part in allowing us to avoid building a costly high tech Tower of Babel: offering “flexibility, interoperability, liquidity of information, and the ability to substitute technologies as the need arises.”

We wrote the following:

A Washington Post article, “New Tool in the MD’s Bag: A Smartphone,” states that “Nationally, about 64 percent of doctors are now using smartphones, according to a recent report by the market research company Manhattan Research.” Georgetown’s medical school has recently begun requiring them, and Ohio State’s is handing out the iPod Touch (sans phone) to its students. Mike McCarty, the chief network officer at John Hopkins Health Systems, “believes that smartphones will soon assume a permanent place in medicine.”

As such, designers have engineered applications to suit the needs of those doctors. And as a matter of path-dependence, presumably they will continue to do so. WaPo states that “the iTunes app store lists 674 applications related to medicine available.” There are iPhone and Blackberry apps to “pull up instructional diagrams and videos for patients, write electronic prescriptions and check basic information,” “look up drug-to-drug interactions, to view X-rays and MRI scans,” and even determine pill names derived from physical descriptions.

As we posted a while back,

In the words of Dr. Farzad Mostashari,  an assistant commissioner in New York City’s health department and head of the much heralded Primary Care Information Project (which is functioning as a sort of I.T. Department for many of the City’s doctors using EMR),  “There’s no way small practices can effectively implement electronic health records on their own. This is not the iPhone.”

Later, we noted that in their NEJM article,  No Small Change for the Health Information Economy, Kenneth D. Mandl, M.D., M.P.H., and Isaac S. Kohane, M.D., Ph.D. suggest that it should be. That

As do Professors Sharona Hoffman and Andy Podgurski, the authors of “No Small Change…” stress the need for flexibility, interoperability, liquidity of information, and the ability to substitute technologies as the need arises.  To do this they propose governmental encouragement of the use of a platform with interoperable applications (blog builders, think: “plug ins” and “widgets”)

similar to the iPhone.

We also noted in that post, “Electronic Medical Records: It’s Not too Late to Build the Tower on an Interoperable Platform,” that

Perhaps the good news here is that the relative scarcity of EMR implementation thus far means that we can yet still devise an interoperable system without rendering substantial but incompatible investments obsolete. Which is to say that we are not yet too far down nine different non-intersecting roads and that “a communicative Tower” can still be built, and sustained, on a Platform.

Now, it seems the path is beginning to emerge–and that interoperable system may actually be the iPhone and Blackberry platforms–which, it seems, are already sitting in doctors’ pockets.

And now via email from NursingSchools.net, an interesting list:

The 15 Most Forward Thinking iPhone Apps for Doctors & Nurses

It’s amazing how much we use our phones for anything but phone calls. The widespread use of applications, driven by the explosion of iPhone sales, has helped to redefine just what we’re able to do with our phones in all walks of life and work. The medical profession has been one of the biggest beneficiaries of iPhone app development, with life-changing tech showing up in nursing schools and hospitals nationwide. Some gather information from patients in new ways, while others help medical professionals better sort and understand that information. They’re all designed to help those in the medical field do their jobs in revolutionary ways. Here are some of the most forward-thinking and revolutionary iPhone apps out there for doctors and nurses:

1. e-911: Emerging Healthcare Solutions is developing an app called e-911, which would allow a user to store critical personal medical information that’s sent to health care providers when they dial 911 from their iPhone. The benefits are clear and enormous: Instead of wasting time discovering a medical history, first responders would know instantly what the victim’s medical past looked like.
2. Epocrates: One of the most popular free medical apps available for the iPhone, gives doctors and nurses up-to-date information on thousands of drugs, lets them identify pills by physical description, and describes the effects of combining different drugs. A Stanford university doctor even made a video about how much he loves it. (Free)
3. ICD9 Consult: Never go hunting through a book to find a code again. This app lists ICD9-CM diagnosis codes and lets you search and browse by category. It includes more than 21,000 individual codes, making it a phenomenal portable tool for medical professionals. ($14.99)
4. Human Body Advanced Encyclopedia 3D Anatomy: Don’t let the clunky title fool you: Doctors and nurses everywhere should have this app on their iPhones. The app includes three-dimensional renderings of the body’s 14 anatomical systems as well as the ability to see all sides and angles of organs. It’s like having an anatomy textbook in your back pocket. ($3.99)
5. Medscape: From the WebMD people, this is a fantastic all-purpose app that’s packed with information on brand-name and generic drugs, clinical procedures, and more than 150 videos. (Free)
6. iRadiology: This app for students is also a good resource for doctors and nurses who’ve been working for years. It features more than 500 images designed to help users hone their detection skills and become better at reading film, CT, and MRI images. It’s a smart, progressive app because it operates under the assumption that knowledge is something you constantly build, and it helps medical pros stay at the top of their game.
7. Reach MD CME: This is an awesome app for doctors and nurses looking to further their education in unique and time-saving ways. Reach MD CME is an accredited app for continuing medical education that lets you download and listen to medical programs and then take the certification test all on your iPhone. (Free)
8. NeuroMind: NeuroMind is a smart, thorough app that helps residents and surgeons by acting as an index for a variety of brain-related surgical topics. It also provides a checklist of Safe Surgery items from the World Health Organization. (Free)
9. Drug Trials: If you’re a doctor or nurse, you need this app. Drug Trials is all about the latest drug tests, whether it’s an established drug being tested in new ways or an entirely new product being tested for the first time. This is one of the best ways to stay informed about what’s happening in drug research, and it also includes facts like eligibility requirements. (Free)
10. Informed RN Pocket Guide: The $9.99 cost is more than most apps, but nurses get a lot for that price with this in-depth app. The Informed RN Pocket Guide is a PDF version of the printed book, and it features a ton of helpful information nurses need to know, including metric conversions, pain assessment tools, pediatric care information, and even Spanish translations. Worth the buy.
11. Nursing Central: I take it back: This app is the pricey one. Nursing Central requires a subscription payment of $159.95 before you can view the content, but if you can afford it, it’s a worthwhile purchase. The constantly updated database covers more than 5,000 drugs, and it features info on all manner of diseases and treatments plus a dictionary with more than 60,000 (!) entries. If you don’t know it, this app does.
12. Nursing Pharmacology: A handy app for nurses that features flash cards designed to teach you the ropes of nursing pharmacology. Basic features, but helpful. ($0.99)
13. PubMed on Tap: This is the full version, not the lite one. The PubMed on Tap app searches PubMed for reference info and then lets you store PDFs or e-mail the results to yourself or someone else. For medical pros on the go, or those who need to do some quick research away from the computer, this app is a life-saver. ($2.99)
14. Skyscape’s Medical Bag: Call it the digital version of the classical little black doctors’ bag. This app includes a number of helpful tools, including more than 100 medical calculators and multiple articles on life support. ($1.99)
15. iMurmur 2: This app is a great fit for practicing doctors as well as med students. It’s got a library of actual recordings of different heart sounds, complete with accompanying descriptions and phonocardiograms. A must-have for cardiologists or any pro looking to brush up on the heart. ($2.99)

Use of APRNs in Primary Care Settings

Some health care problems must be addressed whatever happens with reform. High on the list is the supply of primary care professionals.  Shortages have been reported in Massachusetts, and primary care access concerns have been raised in national reform discussions.  The shortage of primary care physicians is often tied to their low income, compared to specialists, and the consequent diversion of medical graduates to specialties.  The shortage of primary (and in some areas, specialty) physicians has prompted recommendations for increased medical school enrollment and residency slots for all areas of medical practice.

The wisdom of pumping up physician supply has been questioned.   It has been noted that, beyond a low threshold, increasing specialty physician supply is poorly correlated with better outcomes, and that previous efforts to increase supply has made the rich richer and the poor poorer, as graduates have flocked to locales and specialties already well-served by physicians.

So what is the proper policy response to a shortage of primary care physicians?  Physicians claim exclusive control of a broad swath of professional practice.  They dominate primary care, and exclusively control a more and more finely differentiated series of specialty fields.  With power comes responsibility, one might think.  Richard Cooper, a leading analyst of physician supply, commented in 2002 (at a time when many saw a surplus, not a shortage, of physicians) in an article with colleagues on the ramifications of this broad near-monopoly in a profession with falling production and fixed supply:

The sociologist Andrew Abbott has observed that “a profession whose jurisdiction is excessive must increase its productivity or expand its numbers.” Conversely, “when a powerful profession ignores a potential clientele, paraprofessionals appear to provide the needed services.” These statements characterize the dilemma that physicians now face. Their ability to increase their productivity is limited by their declining work effort. Their ability to grow their numbers is hostage to the belief that surpluses exist. And organized medicine has embarked on a vigorous campaign to thwart expansion of the NPC [non-physician clinician] disciplines. Yet it was shortages in the past that motivated state legislatures to remove the barriers to licensure for NPCs and to enlarge their range of privileges, and it is perceived professional opportunities that stimulated the creation of new disciplines and the expansion of existing ones. (footnotes omitted)

So, health reform efforts have emphasized access to primary care for its beneficial effects, while the supply of primary care docs has suffered a flight to specialty practice.  Is it, as Cooper suggested, time to rethink the place of non-physician caregivers on the front line of primary care?  As advanced practice registered nurses (”APRNs”) have gradually increased their scope of practice, studies and meta-studies have found that outcomes are equivalent when services are provided by a physician or APRN, and patients satisfaction measures may favor nurse practitioners.

But what about the nursing shortage?  It may be that expanding the profile and responsibilities of APRNs could further efforts to recruit and retain nurses.  Talented, hard-working nurses have long been concerned that their career path is limited; their salary steps are few and shallow, and they are unable to gain responsibility and autonomy commensurate with their training and experience.  Facilitating RNs’ graduate education to allow licensure as advanced practice nurses would enrich their career paths and encourage then to remain in the profession.   To move in this direction, those states that have not done so could expand the scope of licensure of APRNs to permit more fully independent primary care practice options.   The length of time needed for education and training would be long, but not as long as for physicians; compensation would have to be increased to reflect a higher level of training and responsibility, but not to the compensation level of physicians.

The path to regularizing the scope of practice for APRNs is described in a 2008 consensus document endorsed by 39 national general nursing and nursing specialty organizations.  A 2009 report from the Connecticut Office of Legislative Research described that state’s APRN scope of practice:

Advanced practice registered nursing is defined as the performance of advanced level nursing practice activities that, by virtue of postbasic specialized education and experience, are appropriate to and may be performed by an APRN. The APRN performs acts of diagnosis, and treatment of alterations in health status and must collaborate with a Connecticut-licensed physician. In all settings, the APRN may, in collaboration with a licensed physician, prescribe, dispense, and administer medical therapeutics and corrective measures and may request, sign for, receive, and dispense drug samples.

The required “collaboration” with physicians was also described:

The law defines “collaboration” as a mutually agreed upon relationship between an APRN and a physician who is educated, trained, or has relevant experience that is related to the work of the APRN. The collaboration must address a reasonable and appropriate level of consultation and referral, patient coverage in the absence of the APRN, a method to review patient outcomes, and a method of disclosing the relationship to the patient.

The physician oversight rule is typical, and has been the source of tension with APRNs.   Physicians can be suspicious of APRNs, and it has even been suggested that physicians may avoid working with them as APRNs gain more autonomy — a reaction that could be fueled by concerns with APRNs’ competency and training, or by a desire to weaken a source of competition for control of the profession.

APRNs might fill the primary care end of the physician practice spectrum, should physicians continue to flee primary care for more remunerative specialties.  There are genuine professional competency issues to work out, but they ought not be resolved by physicians as a matter of naked market power.  In addition, the terms of appropriate collaboration between physicians and APRNs need to be ironed out, to protect patients while avoiding the possibility of anti-competitive refusals to deal with APRNs.  Many researchers and physicians welcome the emergence of APRNs as partners in primary care practice.  Further research on the proper autonomous practice settings for APRNs will serve the interests of patients, and can guide planning for the future of primary care.