Introduction

An app (derived from application) is a software program that can be run on a hardware platform,1 most commonly on mobile devices (eg, smartphones or tablet devices). Ever-evolving mobile device technology has resulted in an unrivalled ability to access and disseminate up-to-date information at exceptional speed across a chosen population.

Medical apps are specific software programs used in healthcare, either by patients or clinicians. Those targeted at clinicians have the potential to improve patient care by allowing immediate access to medical and healthcare information, improving decision-making, reducing the number of medical errors and enhancing telemedicine capabilities.2–5

The rapid and organic growth of technology continually creates new challenges. These include personal information (including that belonging to patients) being exposed to online attacks, lack of quality control or new evidence overtaking available algorithms and guidance. The use of apps might contravene existing hospital and healthcare policies creating dissonance in health policy; previous bans on mobile devices may not be in line with National Health Service (NHS) Digital guidance, strategy and recommendations for trusts on how to manage the digital revolution in the UK and similar policy in Ireland.6–8 Finally, many apps require an internet connection to access information and resources or for intermittent updates.

Previous concerns about apps have been based on a theoretical fear of harm, and currently no study has examined the use of mobile devices and apps as part of patient care in paediatric or adult emergency departments or described their perceived benefits and potential risks.

The aim of this survey was to evaluate whether any harm has been caused by this technology, what hardware and software are provided to healthcare professionals and how this is used in paediatric emergency medicine.

Methods

The survey was disseminated to sites in Paediatric Emergency Research in the UK and Ireland (PERUKI),9 a research collaborative consisting of tertiary centres and district general hospitals. Site-lead investigators at participating sites completed a web-based questionnaire which was open from the 31 July 2017 to the 2 September 2017.

The survey was designed by the lead researcher and developed from previous literature examining mobile device and medical app use by clinicians and medical students.5 10 11 Refinements were made during multiple iterations, with input from the study team and the PERUKI Research Steering Committee, before arriving at the final version. The survey focused on departmental mobile app use, including general demographic information, harm, mobile device policy, guidelines for medical app use, Wi-Fi provision, mobile device and medical app provision, medical app recommendation, medical app design and commissioning processes, and enablers and obstacles to the use of this technology.

Survey responses were collected in SurveyMonkey (www.surveymonkey.com) and were analysed using Microsoft Excel (Version 16.18). Descriptive statistics were used to describe the data with inferential P values calculated using the single-ended Student’s t-test distribution. The answers from open-ended questions were analysed for single-word answers, such as the name of an app. For remaining answers, the lead author conducted a semantic analysis to identify the common themes, which were verified by the coauthors.

Ethics

This survey accessed clinicians via a research collaborative to assess their departmental practice and therefore did not require formal ethics review according to the Framework for Health and Social Care Research (UK).12 Consent was implied by participation.

Results

The survey was distributed to 54 sites, of which 46 (85%) provided complete responses. Demographic data, data regarding harm from mobile device and app use, mobile device policy and Wi-Fi provision, and mobile device and medical app provision are listed in table 1. No site reported any harm from mobile device and app use. There was wide variation in medical app guidance ranging from encouraging a number of institution-specific apps, the British National Formulary (BNF/BNFc) and Mersey Burns app, to very little guidance, which was not specified further. One trust is currently examining the use of WhatsApp to send anonymised pictures between on-call teams. Institutional mobile devices were provided at 19 (41%) sites. Some sites offered more than one device or a choice of devices for their staff to use. Apple iOS devices were the most frequently used device type. These were generally only provided to consultant staff; in one case, a charity-funded iPad was used in the resuscitation room. Medical apps were provided at 10 (52%) of the 19 sites providing institutional mobile devices.

Medical apps provided on the institutional mobile device or recommended (in 20 sites, 44%) for staff use are listed in table 2. Eleven (55%) of the 20 sites recommending medical apps, recommended apps that are free to download; 8 (40%) sites recommended a mix of free and paid for medical apps. One (5%) site recommending medical apps did not provide any for free. Only one (5%) site which recommended apps provided training regarding their use, covered as part of professionalism during induction.

Seventeen (37%) sites had designed apps as listed in table 2. The majority of the designed and commissioned apps were local reference and guideline apps. These were designed by in-house clinicians at four (24%) sites, in-house clinician and the in-house information  technology  (IT) department at four (24%) sites, an external IT company at three (18%) sites; six (35%) sites did not know who was involved in the design process.

Encrypted email was the most common method of sharing visual information such as photographs at 29 (63.0%) units. The departmental camera was the leading choice with which to take and share photos at 32 (69.6%) units. The use of messaging apps for sharing images including specialist encrypted messaging apps was much lower 7 (15.2%) and 2 (0.1%), respectively, seetable 3.

The factors influencing the use of app technology at the bedside are listed in table 4. The leading other comment (at six sites) was that medical app use is up to individual clinician choice. One site had to display signs to explain to patients that staff use mobile devices as part of patient care and not for personal use. Funding issues were highlighted at two sites, relating to both devices and apps. One site runs regular ‘Hackathons’ with the innovation department to develop apps. Another site reported significant hurdles in app development, despite the trust having an app development policy with regard to intellectual property (IP) rights, costs, security IT issues and content control.

Discussion

We have for the first time described the provision of hardware and apps in paediatric emergency departments in the PERUKI network. The use of mobile devices and apps was relatively low, with challenges in Wi-Fi accessibility and device provision. There was variability in policy and guidance on mobile device and app use at the bedside. The use of medical apps was mainly up to individual physician choice, with colleagues being the main enabler of the adaptation of this technology.

Only two-thirds of sites provide free Wi-Fi for staff use; such inequity between hospitals contributes to implementation difficulties. Mobile devices are only provided at a minority of sites and then generally only for consultants. Exceptions include an iPad in theresuscitation room to run the PaediatricEmergencies app at one site and the SimMan app for simulation training at another site.

Less than half of our responding departments had a mobile device policy covering the near-patient use of personal or institutional mobile devices. With the increasing and widespread use of this technology, it is important to have clear guidance to protect clinicians and patients and to avoid conflict. Local policies restrict the use of apps such as the BNF/BNFc app at the bedside at some sites, which is not in keeping with national guidance and strategy.6 13 A minority of sites provided guidance to clinicians on recommended or approved medical apps. While previous research has shown that clinicians are happy to use their personal mobile device in patient management,14 this is currently not possible at all sites. Local policies should reflect the  NHS digital ‘bring your own device’ guidance.6 This survey highlights challenges with the use of this technology in the clinical environment including patients, clinicians and management. It is therefore important that national guidance matches local recommendations and vice versa to avoid implementation challenges in delivering best digital practice.

No site reported harm from medical devise and app use in patient care. Most medical apps are not licensed with a regulator (Medicines and Healthcare products Regulatory Agency (MHRA) in the UK or Health Products Regulatory Agency (HPRA) in Ireland) as approved devices nor CE marked. Both regulators classify apps as medical devices if they calculate medicine doses, diagnose disease or give a risk score of having one.15 16 Regulatory approval can reassure both healthcare professionals and patients that the app has met certain requirements and that problems can be reported (via the Yellow Card scheme https://yellowcard.mhra.gov.uk/ in the UK or via www.hpra.ie in Ireland). MHRA-approved apps include Mersey Burns and NeoMate apps.4 17 The planned Food and Drug Administration ‘precertification’ programme for medical apps is another way to address this issue.18–20 The focus here is mainly on the previous track record and the ability of the developer and manufacturer to monitor the app and respond quickly to any glitches rather than the individual product.

Not all apps used in healthcare will fall in the medical app category and therefore may not need MHRA or similar approval. An example would be WhatsApp. Since the release of this survey, the National Trauma Network has approved WhatsApp as an official communication app in line with NHS Digital guidance (Moran C. WhatsApp, Communication National Trauma Network UK, Personal Communication. 2018.). This ‘seal of approval’ by a group of experts is a good example of national leadership and may be the way forward for multiple other apps and mobile device functions that may be used in healthcare.

Mobile devices especially with in-built camera and video functions open up huge telemedicine capabilities for near-patient care and remote consultation. In our network, the use of an institutional camera is still the leading way to share images, whereas instant messaging and specialist encrypted medical communication apps are currently not widespread. To allow this to happen, the personal device or the app needs to be encrypted at a high enough level to ensure confidentiality if using direct patient identifiable information for example, images or paperless notes as already discussed with respect to WhatsApp.

This also raises the questions when this content should be deleted when it is no longer required. The National Trauma network did not provide any guidance on this with regards to WhatsApp.

A good example of medical app development is embraced at one site, where they organise regular hackathons to develop medical apps. The majority of sites that have developed apps did so with the input from either internal or external IT departments. Having access to clinicians who are trained in app develop and who are able to support this process is key to future development of this IT revolution. The absence of good IT support was raised as a concern at number of sites. Access to clinicians who are trained in app development may be one way to address this. Interestingly, none of the resuscitation medical apps were developed by PERUKI emergency departments, but the Intensivist as, for example, in the case of the Paediatric Emergencies or the NeoMate apps.3 17 The next generation of clinicians will need to have some IT training and basic understanding of this technology to guide this digital revolution.21 This is not a choice but a necessity with the increasing digitalisation of healthcare and our everyday living environment, with healthcare professionals and patients not just being consumers of this advance in technology but also protagonists in its development and application. The question is what skills and training does the next generation of clinicians need.

One site reported significant hurdles in app development with regards to IP rights, security IT issues and content control. These hurdles will also have to be addressed either on a local or national level to progress this digital revolution.

While the majority of the medical apps listed in this survey do not need an active internet connection to work on a day-to-day basis except for the occasional update (eg, BNF/BNFc, MicroGuide, RxGuidelines or any of the resuscitation apps) in this survey, poor internet and Wi-Fi connection was perceived as the main barrier to their use. Funding was another obstacle to the adaption of this technology.

Good internet or Wi-Fi connection, the institution and the provision of free medical apps were reported as key enablers of medical app use. These enablers are reflected in the NHS Digital strategy of the universal Wi-Fi provision and institutional policy.6 7

Interestingly, patients were equally seen as an obstacle and enabler to medical app use. There has been a lack of patient involvement in the development of a digital strategy at a national and local level and this needs to be addressed urgently.

Given the current drive within the NHS and other healthcare systems to bring about a digital revolution in healthcare,8 13 urgent infrastructure development (including investment in Wi-Fi, devices, apps and guidance) at an institutional level is essential. Further work needs to explore how clincians and patients will engage and interact with the wealth of available information in a safe manner.

Limitations

This survey was conducted at PERUKI sites in the UK and Ireland only and does not include all emergency departments that treat children or adults in these two countries, however over half of these departments treat adults. The sites that did not participate may not use mobile devices or medical apps, thereby skewing the results in favour of the centres that have embraced this technology. This survey does provide information on current practices across a wide range of hospital types, and the range of responses has clearly illuminated some of the key issues that are likely to be faced at sites not yet engaged with devices or apps.

Conclusions

There were no safety concerns raised in this point prevalence survey of clinician’s use of mobile devices and medical apps in paediatric emergency care. However, the breadth of app use was relatively low, there was variability in guidance on app use and challenges in Wi-Fi accessibility and device provision. Local guidance and implementation lags significantly behind the aspirations of national digital health strategies. This priority area should focus initially on creating equity of access to devices, apps and Wi-Fi, must include patient and public input, and work toward identifying the approaches of greatest benefit while monitoring for any harm.