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Original article
Interns and their smartphones: use for clinical practice
  1. P O'Connor1,
  2. D Byrne2,
  3. M Butt2,
  4. G Offiah3,
  5. S Lydon4,
  6. K Mc Inerney5,
  7. Brian Stewart6,
  8. M J Kerin2
  1. 1Department of General Practice, National University of Ireland, Galway, Ireland
  2. 2Department of Surgery, Clinical Science Institute, Galway University Hospitals (GUH), Galway, Ireland
  3. 3Department of Surgery, Royal College of Surgeons Ireland, Dublin, Ireland
  4. 4Department of Psychology, National University of Ireland, Galway, Ireland
  5. 5Whitaker Institute, NUI Galway, Galway, Ireland
  6. 6Department of Medicine, National University of Ireland, Galway, Ireland
  1. Correspondence to Dr P O'Connor, Department of General Practice, National University of Ireland, Distillery Road, Galway, Ireland; paul.oconnor{at}nuigalway.ie

Abstract

Purpose of the study Smartphone use among healthcare professionals has become widespread and will continue to grow in the coming years.

Study design In October 2012, a survey was distributed to 230 interns at two of the national intern training networks in the Republic of Ireland, asking how they used smartphones to carry out their clinical work.

Results It was found that out of 108 interns (47.0% response rate, 108/230), 94.4% (102/108) owned a smartphone. Of those respondents who owned a smartphone, on at least a daily basis for the purposes of work, 83.3% (85/102) made or received phone calls, 87.2% (89/102) sent or received texts, and 41.2% (42/102) sent or received emails on their smartphone. A total of 52.9% (54/102) had used their smartphone to take a work related picture. The most commonly used app was the British National Formulary. It was used daily by 30.4% (31/102) of respondents with a smartphone. The most commonly used website was Wikipedia. It was accessed at least weekly by 38.2% (39/102) of respondents with a smartphone.

Conclusions Smartphones are used by the majority of interns on a daily basis in order to perform their job. As such, there is a need for guidance on how patient information can be safely secured and transmitted using smartphones, their appropriate use, and any restrictions on the use of these devices in certain clinical settings. For interns in particular, advice is needed on the credibility of medical apps and websites.

  • Medical Education & Training

http://dx.doi.org/10.1136/postgradmedj-2013-131930

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    Introduction

    The smartphone has been described as a ‘mobile telecommunication device with advanced features such as medical applications, word processing, internet access, and other computing capabilities.’1 Among physicians, smartphones are becoming a key part of everyday clinical practice. The popularity of these devices can be attributed to their myriad of uses for both medical education and medical practice. Smartphones are routinely used for communication purposes and offer many advantages including quicker responses, the opportunity to text or email about non-urgent issues, increased communication or consultation between members of a multidisciplinary team, and increased communication about patients.2–4

    The ability to access medical knowledge through a smartphone also extends its use beyond that of a simple communication device. It is not only possible to access medical websites with a smartphone (eg, Medscape, Medline), but also to download specific medical software packages or ‘apps’ to the phone (eg, British National Formulary, BNF; Monthly Index of Medical Specialities, MIMS). To illustrate, the Apple App Store currently lists more than 500 000 medical apps that are available for download.5 Therefore, it is no longer necessary for interns to carry around paper copies of the BNF or MIMS as all of the information, and more, can be rapidly accessed through their smartphones.

    Several studies have examined how doctors are using smartphones and apps in their day-to-day lives and practice. In a survey of 3306 interns, fellows, and attending physicians across 27 medical specialities, it was found that 56% reported using medical apps in their practice.6 Payne et al5 conducted a similar survey among UK medical students and junior doctors. They found that 79% of medical students and 74.8% of junior doctors owned smartphones. The majority of respondents owned between one and five medical apps and both cohorts reported using the apps several times daily. The types of apps each group used also differed, with students reporting app use primarily for educational purposes while doctors typically used apps relating to their clinical practice such as medical calculator apps, or drug reference apps.

    Currently, there is only limited research examining the use of smartphones by interns, with none focused on how interns use all of the possible functions of a smartphone (phone, text, email, picture, apps, and web access) to carry out their clinical work. However, the pervasive usage and acceptance of smartphones in medical practice has raised a number of important concerns from both patient safety and confidentiality perspectives. Concerns have been raised over the trustworthiness of the information sourced through medical apps or the internet, the distraction caused by devices, the security of patient related information stored and transmitted by the devices, and the potential of such devices to impact negatively on professionalism.3 ,6 ,7

    The purpose of the research reported in this paper is to survey Irish interns (internship is the first year of clinical practice for doctors in Ireland) to obtain information on how they are using their smartphones during their work as a intern. The objectives of the study are to obtain information on:

    • the proportion of interns that use smartphones to perform their duties

    • the frequency and purpose of communications (telephone, texts, and emails) made and received by interns on a smartphone in the performance of their duties

    • the frequency and purpose of the use of the camera on a smartphone in the performance of the interns’ duties

    • which medical apps and websites were being used/accessed by interns via a smartphone and the frequency of use/access.

    Method

    Procedure

    Interns from two of the six national intern training networks in the Republic of Ireland were asked to complete an online anonymous questionnaire about how they use their smartphones to carry out their job. The intern network coordinators for the two intern networks emailed the web link to the survey in late October 2012 to 230 interns. A reminder email was sent in mid-November 2012. Ethical approval was obtained before commencing the research.

    Questionnaire design

    To construct the questionnaire the following steps were carried out. First, a review of the literature was conducted and other questionnaires examining smartphone use by healthcare professionals were reviewed. Based upon this review, a draft questionnaire was developed. The questionnaire was designed to assess the use of the core functions of a smartphone: telephone; send or receive text messages; send or receive emails; function as a camera; and access apps and websites. For the communication (telephone, texts, and emails) and camera functions of the smartphone, the purpose was to obtain information on the frequency of use and the reason for use.

    To obtain information on the names and frequency of usage of apps and websites accessed by the interns, advice was also obtained from four interns who regularly used apps and websites during their clinical work. Based upon this information, the questionnaire required respondents to specifically rate the frequency with which six apps (BNF, MIMS, Oxford Handbook of Clinical Medicine (OHCM), Medscape, MD on call, and the University College Hospital Galway intern guide) and four websites (Wikipedia, Medscape, Mayo Clinic, and patient.co.uk) were accessed. However, the questionnaire was also designed to allow the respondents to include information on their use of medical apps and websites other than those mentioned above. The draft online version of the questionnaire was reviewed by interns (n=6), senior physicians responsible for intern training (n=4), and medical educators (n=2). Based upon these comments, changes were made to the instructions and some of the questionnaire items to improve clarity and understanding.

    Data analysis

    The data were collected using Surveymonkey (an online questionnaire hosting site), and analysed using IBM SPSS Statistics V.20.0 and Microsoft Excel. Descriptive analysis was carried out in order to obtain information on: the frequency and purpose of the use of smartphones for communication (telephone, texts, and emails); the frequency and reasons why pictures were taken with a smartphone; and which medical apps and websites were being accessed and the frequency of their use/access.

    Results

    Of the 108 respondents (47.0% response rate, 108/230), a total of 102 (94.4%, 102/108) reported owning a smartphone. Of those interns who owned a smartphone, 66.7% (68/102) owned an iPhone, 26.5% (27/102) owned an android phone, and the remaining 6.9% (7/102) owned another type of smartphone (eg, Windows phone, Blackberry). To simplify the text for the rest of the article, ‘respondent’ will refer to all questionnaire respondents who owned a smartphone, with the percentages calculated based upon the 102 respondents who owned a device.

    Phone calls, texts and emails

    A total of 85/102 (83.3%) of the smartphone users who responded to the survey made or received a work related phone call, 89/102 (87.3%) wrote or received a text and 42/102 (41.2%) sent or received an email at least once a day. By far the most common reasons provided were to answer bleeps (phone calls only), obtain medical advice on a patient from a senior, and summarise the day's events with seniors (table 1). Examples of work related activities mentioned by no more than two respondents that are not included in table 1 were: to receive results; to receive job requests; to phone general practitioners; and human resources related activities.

    View this table:
    Table 1

    Frequency and purpose of work related phone calls, texts, and emails made or received using a smartphone

    Taking work related pictures

    A total of 52.9% (54/102 respondents) of respondents had used their smartphone to take a picture at work, with 22.5% (23/102 respondents) taking a picture at least once a week. For those interns who used their smartphones to take pictures, the most common reasons provided were: for research (28/102 respondents); to obtain help interpreting a result (ECG or chest x-ray) (19/102 respondents); and for advice on a wound or lesion from a senior team member (16/102 respondents).

    Access apps and websites

    A total of 73/102 (71.6%) of the smartphone-using respondents reported using at least one work related app a month, and 69/102 (67.6%) respondents reported accessing at least one work related website a month (see table 2 for more details).

    View this table:
    Table 2

    Number of different work related apps and websites accessed at least once a month

    Half of the interns accessed an app on at least on a daily basis (51/102; 50.0%). Details on the frequency with which the respondents reported using their smartphones to access apps to carry out a task are provided in table 3.

    View this table:
    Table 3

    Frequency of accessing apps to perform a task, using a smartphone

    The BNF app was the app most commonly used by the interns (31/102; 30.4%). Other apps mentioned, but not included in table 3, included ‘MD on call’ (used at least once a month by 16/102 (15.7%) of respondents) and a drug dosage calculator (used at least once a month by 9/102 (8.8%) of respondents). A total of 25 other apps were reported to be used by one or two respondents at least once a month (eg, MicroMedex, Epocrates).

    Details on the frequency with which the respondents reported using their smartphones to access websites to perform their work (or to carry out a task) are provided in table 4. Although websites were not used as commonly as apps, almost half of the smartphone owning interns reported accessing a website on their smartphone for a work related purpose at least once a month. The most commonly accessed website was Wikipedia, with 39/102 (38.2%) of the respondents accessing it in order to perform their job at least once a week. The next most commonly accessed website was Medscape (accessed by 26/102 (25.5%) of the respondents at least once a week).

    View this table:
    Table 4

    Frequency of accessing websites to perform a task, using a smartphone

    A website mentioned by respondents, but not included in table 4, is Medicines.ie (used at least once a month by 4/102 (3.9%) of respondents). A total of 12 other websites were reported to be used by one or two respondents at least once a month (eg, drugs.com, Melbourne consent).

    Discussion

    The majority of interns who responded to the survey used their smartphones many times a day for their clinical work. This use was mostly for communication, but smartphones were also frequently used to access medical knowledge via apps and websites. The findings from this research have implications for education and training, the confidentiality of patient information, patient safety, and quality of care.

    Communication and information exchange

    The smartphone is a very powerful tool for facilitating teamworking and communication between healthcare providers.8 However, there are also potential negative implications in terms of distractions and the inappropriate exchange of confidential patient information.

    As compared with pagers, smartphones can potentially minimise disruptions by allowing prioritisation of non-urgent communication.9 However, this is not to say they cannot be a source of distraction. This may be exacerbated by the fact that not only are the interns in the current survey receiving work related communication, but as it is a personal phone, they are likely receiving additional personal communications. It has been suggested that smartphone use can also negatively impact the relationship between doctors and nurses,10 lead to unprofessional behaviour,11 interfere with medical equipment,12 and be a possible source of infection.13

    The potential loss of confidential patient data is also a major concern with smartphones.14 ,15 If a healthcare professional was to lose his or her smartphone, all of the information on texts, emails, etc, could potentially be accessed by unauthorised personnel. It is possible to store sensitive data safely on a smartphone through encryption, password protection, or the download of software which can erase all data remotely.

    To access medical knowledge

    There is no organisation, or governing body, that regulates medical apps or websites to ensure that the content is current, valid, and reliable. Therefore, each healthcare professional is left to make that determination themselves. Visser and Bouman15 provide a list of questions to guide healthcare professionals as to whether they should download and use an app. These questions relate to clinical decision making, patient's privacy, and conflict of interest.

    Although the BNF and MIMS apps are electronic versions of the published paper based guides, the same may not be the case for other apps and websites such as Wikipedia. Although not rigorously peer reviewed, the quality of the information on Wikipedia may not be as poor as expected when compared to other more regulated sources of information.16–19 Wikipedia was found to answer significantly fewer drug related questions than Medscape (40% and 83%, respectively). However, there were no factual errors in Wikipedia identified in the study.18 Similarly, another study of drug information in Wikipedia identified the absence of information on dosage, drug interactions, and adverse drug events.19 Therefore, although the information on Wikipedia was not complete, it was not found to be incorrect.

    Limitations

    The main limitation of the study is that the survey was only carried out with a small number of interns in Ireland. However, the findings are broadly similar to other studies that have examined the use of smartphones by interns and medical students,4 ,5 and therefore the authors believe the findings are generalisable to interns in Ireland and other developed countries. Although the response rate may not be as high as would have been desired, it is good considering this was an unsolicited online survey, and higher than other published surveys of smartphone use by interns and medical students.4 ,5

    Implications of the findings and suggestions for further research

    We are certainly not suggesting a complete restriction on the use of smartphones in the clinical setting, and we recognise that they can have a positive impact on clinical care and teamworking. Nevertheless, there is a need for education and robust hospital policies on how patient information can be safely secured and transmitted using smartphones, the appropriate use and any restrictions on the use of these devices in particular clinical settings, and, particularly for interns, advice is needed on the credibility of medical apps and websites. This guidance is necessary to ensure that interns are not inadvertently using smartphones in such a way that they compromise patient safety or privacy.

    Main messages

    • Smartphone use among interns in Ireland is widespread.

    • Interns regularly use smartphones to communicate, take pictures, and access apps and websites for information.

    • Training must be provided to interns on the appropriate use of smartphones in order to address issues of data protection, security, patient safety, and professionalism.

    • Recommendations should be provided to interns on the appropriate use of unregulated apps and websites for the purposes of clinical care.

    Current research questions

    • What is the most effective method of delivering training in smartphone use to interns?

    • How can criteria be developed for classifying the reliability and validity of the information provided by medical apps and websites?

    • How can smartphone use by healthcare professionals be regulated most effectively, particularly as these devices start to be used as diagnostic tools?

    • What are the sociotechnical implications of switching from a pager based communication system to smartphones?

    Key references

    • Buijink AW, Visser BJ, Marshall L. Medical apps for smartphones: lack of evidence undermines quality and safety. Evid Based Med 2012;25:1–3.

    • Visvanathan A, Gibb AP, Brady RR. Increasing clinical presence of mobile communication technology: avoiding the pitfalls. Telemed J E Health 2011;17:656–61.

    • Visser BJ, Bouman J. There's a medical app for that. Student BMJ 2012;20:e2162.

    • Clauson KA, Polen HH, Boulos MNK, et al. Scope, completeness, and accuracy of drug information in Wikipedia. Ann Pharmacother 2008;42:1814–21.

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    Footnotes

    • Contributors All authors contributed to the article as authors as per the BMJ guidance on the issue.

    • Funding This research was partially supported through funding by the Health Services Executive Medical Education and Training Unit (HSE MET).

    • Competing interests None.

    • Ethics approval Ethics Board of Galway University Hospitals.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The data from the survey are currently only available to the authors. However, we would be happy to share the data with other researchers.