Recently, the Agency for Healthcare Research and Quality’s popular webM&M featured a case study with a 21st-century twist: During rounds, an attending physician decided to stop a patient’s warfarin until further testing could be done. The accompanying resident started to enter the stop order using her smartphone, which could access the hospital’s computerized system, but was interrupted by a text-message from a friend about a party. The resident replied to her friend but then forgot to complete the stop order. The patient continued to receive warfarin and two days later developed hemopericardium. He eventually required emergency open-heart surgery. (Full details of the case are available at www.webmm.ahrq.gov.)
Reading this brings to mind the Geico commercial, “Do people use smartphones to do dumb things?” Except what is a joking matter in other contexts is far more serious in a medical setting, where patient safety may be compromised. Are cases such as this one rare and sensational exceptions, or in the face of technological progress have many of us lost our common sense?
A VALUABLE TOOL
Electronic “gadgets” have rapidly become part of life for most Americans, and their presence in clinical settings is a given. A survey conducted last year by recruitment firm Jackson & Coker found that 80% of practicing physicians used some type of portable electronic device, whether a smartphone, a tablet computer, or similar technology.
The integration of mobile technology into clinical practice has provided distinct advantages. No more risk for misinterpretation of bad handwriting, went the early joke, and while that is an improvement, smartphones and their electronic kin have aided the mission to reduce mistakes by delivering information to a clinician’s fingertips in any environment.
Since her first day of practice as an NP a decade ago, Clinician Reviews editorial board member Julia C. Pallentino, MSN, JD, ARNP, has had an electronic device—initially a PDA, now a smartphone—in her hand when she walks into an exam room. “My main reason when I started was that I was a medical malpractice lawyer until I started practice, and I certainly knew I didn’t know everything,” she says. “This was a simple, direct, easy way to look up things I did not know—predominantly, medications.”
Even now that she’s an experienced provider, her smartphone is a valuable tool for accessing information about medications and checking for potential interactions with the other drugs a patient might be taking. “I work in a specialty practice [GI Associates of Tallahassee], so there are a lot of medications in other practice areas that I’m not as familiar with,” Pallentino says. “So I will look those up at times, just to see their effect and what they do, as well as check for interaction issues. A lot of patients express that they’re impressed to see that I check things like that.”
At the University of Washington Medical Center in Seattle, CR editorial board member Lyle W. Larson, PhD, PA-C, uses his smartphone to call up a patient’s electronic medical record, complete with vital signs, notes from previous encounters, and even graphs charting a patient’s lab results over the course of his/her hospital stay. If he has implanted a pacemaker, Larson can access a chest x-ray to show patients what that looks like, where the wires are in the heart, and whether they have fluid in their lungs.
“That makes things a lot more efficient, and it significantly improves the interaction with patients, in my opinion,” he says. “When you show patients what you are looking at, and they can see a picture or a graph, then that helps them understand. A patient who understands what’s going on is a happy patient.”
Both Larson and Pallentino find smartphones less intrusive than laptops, which were an early step in the technological evolution of patient care. “[A smartphone] is not nearly as present in the room as a computer is,” Pallentino points out. “There are very good reasons to have a computer in the room, but you have to work very hard to make sure it doesn’t become the focus of the interaction.”
That viewpoint has been borne out in patient feedback. “When we look at patient satisfaction surveys,” Larson says, “it’s almost universal: ‘The doctor paid more attention to his computer than he did to me.’ That’s a problem, but with smartphones it has gotten a bit better.”
POTENTIAL FOR DISTRACTION
That being said, the attention that a clinician pays to his or her smartphone remains an issue. In one of the more remarkable surveys on this topic, perfusionists admitted to using their phones during cardiopulmonary bypass procedures to send text messages (49.2%), check their email (21%), surf the Internet (15.1%), and post on social networking sites (3.1%). Is this appropriate behavior?
It is this type of distraction that led to the error in the AHRQ webM&M case. While negative outcomes are (as yet) rare, clinicians’ mixed use of their smartphones—for professional and personal purposes—is not.
“One of the ugliest things I’ve seen is the very strong tendency for clinicians, while they’re in the patient’s room and the patient is talking to them, to either check their email or update their Facebook account,” Larson says. “I actually caught two residents on rounds who were texting each other about how ‘lame’ rounds were going.”
Pallentino agrees that clinicians should not be answering personal phone calls or sending status updates to social networking sites while they’re with a patient. However, having reviewed the AHRQ case, she observes that something similar could have occurred if the resident had been standing at the nurses’ station inputting the stop order and either received a work-related phone call there or had a colleague stop to consult.
“Anything that could interrupt your train of thought could have interrupted that process,” she says. “I certainly think there will be things that go wrong on smartphones, but I’m not sure they will be that much different from things that have gone wrong without smartphones. Overall, I really think their benefit outweighs the detriments.”
COMMON SENSE IS NOT SO COMMON
While the technology keeps advancing, clinicians who enjoy staying on top of the trends may need to remember some of the good old-fashioned lessons of Common Sense 101.
“Smartphones are a double-edged sword,” says Larson. “They allow you to do things more quickly, but because you do things more quickly, you don’t necessarily stop and think about what you’re doing.”
“I think smartphones can be a great resource, but people have to use their common sense and concentrate on what they’re doing,” says Michele Kauffman, JD, PA-C, Chair of the PA Department at Gannon University in Erie, Pennsylvania. “Finish your documentation and charting. Take the time to double-check yourself. Go back to the old standbys and don’t let [technology] be a distraction.”
Pallentino also points out that technology should never be considered foolproof, observing that in the AHRQ case, the clinicians involved all seemed to assume that the order had been completed and acted on. “Nobody ever checked again, assuming the warfarin had been stopped,” she says. “Maybe that’s a warning, too: Don’t totally depend on something being done. You should still be looking at the information and make sure that what is supposed to be done is being done.”
There may come a day, however far off, when the use of mobile technology in clinical settings is regulated by policies and procedures at individual institutions. “Unfortunately, the implementation of policies will probably be in response to an incident like [the AHRQ case],” Kauffman predicts, “where there was a poor outcome because of misuse or abuse.”
Before that happens, let’s hope that clinicians—even those who have never known a world without mobile technology—recall their primary purpose: providing quality patient care. “When you go into a room to see a patient, that patient is the most important person in the room,” Larson says. “And you listen to the patient, you look at the patient, you talk to them.”
Certainly using smartphone technology, or any other electronic device, can improve aspects of patient care. But even when you ignore personal messages and interruptions, there are professional shortcuts that might just as easily cause you to lose focus.
Larson has seen colleagues create templates for their patient notes and simply copy and paste text from one visit’s record into another, changing a few words here and there to update it. That may be convenient and save time. But when you do that, Larson says, “you are no longer treating the patient, you are no longer thinking about the patient—you are treating the chart.”