Chapter 17
CliniPEARLS: A Technical Framework for Disseminating Clinical Practice Guidelines from Different Providers on PDA and Smartphone Devices Noreen Kamal, Tracy Thain, and Kendall Ho
Abstract Clinical practice guidelines (CPG) are becoming more readily available as aids to health professionals in clinical care decisions. CliniPEARLS is a technology framework that allows for the publication of CPGs from multiple providers on various PDA (personal digital assistant) and smartphone devices. The technical contributions for CliniPEARLS include (1) allowing for multiple organizations to publish guidelines on a single platform; (2) providing a flexible security and administration structure that allow users to subscribe to guidelines from multiple organizations; (3) allowing for a central place to enter the guideline content by either internal editors or external contributors with the appropriate permissions; (4) four client handheld applications that connect to the central framework for Palm, Windows Mobile, Blackberry, and iPhone; and (5) providing a mechanism to ensure the users obtain the latest guidelines and update their existing ones. The project revealed insights and lessons learned in developing a technical framework for an electronic dissemination mechanism for guideline updates and connection of multiple device types. One of the key findings from this study shows the importance for developers of CPG applications to be on the cutting edge of technological advancements in hardware and software.
N. Kamal, P Eng., Ph.D. (*) UBC Media and Graphics Interdisciplinary Centre (MAGIC), FSC 3640 - 2424 Main Mall, Vancouver, BC V6T 1Z4, Canada e-mail:
[email protected] T. Thain, B.Sc., BCS • K. Ho, M.D., FRCPC eHealth Strategy Office, University of British Columbia, 855 West 10th Ave, Vancouver, BC V5Z 1L7, Canada e-mail:
[email protected] K. Ho et al. (eds.), Technology Enabled Knowledge Translation for eHealth: Principles and Practice, Healthcare Delivery in the Information Age, DOI 10.1007/978-1-4614-3495-5_17, © Springer Science+Business Media, LLC 2012
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17.1
Introduction
Clinical practice guidelines (CPGs) have been described as “systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances” (Field and Lohr 1992, p. 2). CPGs are not intended to replace clinician knowledge; rather, they are meant as a decision-support tool for physicians and health-care practitioners. Policy makers and health administrators are also interested in the clinical use and uptake of CPGs as this decisionsupport tool could help harmonize the clinical practices of individual health professionals and improve the overall quality of care by reducing variability (Field and Lohr 1992).
17.1.1
Clinical Practice Guideline Adoption
Researchers investigating the impact of CPGs on physician’s behavior, practice, and overall quality of health care have found inconsistent findings. The adoption of CPGs in practice has faced obstacles because they are perceived as too didactic in nature rather than practice-based (Davis and Taylor-Vaisey 1997). Researchers have identified three key categories of barriers to physician adherence (Cabana et al. 1999). The first category is knowledge, as physicians are either unfamiliar with the large amount of information or there is a lack of awareness of the information that is available. The second category is physician’s attitudes, where there is a lack of agreement with specific guidelines or the concept of guidelines in general (i.e., “cookbook medicine”); additionally, physicians do not feel that the guidelines will lead to desired outcomes. A lack of self-efficacy and lack of motivation are additional attitudinal barriers. The third category is behavior, including both external (e.g., patient factors and guideline characteristics) and environmental (e.g., such as lack of time and organization constraints) barriers. Other researchers have examined ways that adherence can be improved such as through the creation of incentives (Lomas et al. 1989; Tan 2006).
17.1.2
CPGs and Technology
In an effort to overcome these identified barriers to adherence, the use of computers and other electronic tools have been studied. By using electronic tools, CPGs and other decision-support tools can be used at the point of care (Lomas et al. 1989; Garg et al. 2005). This provides a modality to overcome some of the external and environmental barriers described by Cabana (Cabana et al. 1999). The use of electronic tools integrates the use of CPGs into the care process (Holopainen et al. 2007; Lobach and Hammond 1997). To increase navigation and offer a forgiving, flexible
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interface, several favorable design features have been identified in the hope of increasing usability at the point of care (Gadd et al. 1998). In fact, an increase in the use of CPGs has been demonstrated when a wirelessly networked mobile computer is available at bedside; moreover, patients appeared to accept the use of information technology by health providers to assist in decision-making (Bullard et al. 2004). However, the variation in the types of electronic medical records, guideline modeling languages, guideline knowledge bases, and execution engines has been identified as a significant obstacle (Johnson et al. 2001). Fitting into the workflow of physicians is an important consideration in the development of computer-based decision support such as offered by CPGs (Edmonson et al. 2007; Sim et al. 2001). In fact, clinician workflow has been identified as one of the most significant independent predictors of improved clinical practice through effective clinical decision support (Bates et al. 2003; Kawamoto et al. 2005). For this reason, the use of a computing device such as a PDA (personal digital assistant) or smartphone allows access to CPGs at the point of care (Wilcox and La Tella 2001). Studies investigating the use of PDAs for point-of-care access to patient record and charting system have shown benefits to patient care (Carroll et al. 2002, 2004). It remains important that the PDA software be designed so as to ensure efficient access to relevant information at the point of care. This will both increase acceptance of PDAs and facilitate their use in clinical settings (Lu et al. 2005). Mobile technologies are evolving rapidly from PDA technologies to smartphone devices. The use of smartphones in clinical practice has been empirically investigated within the context of multiple device use (e.g., using smartphones in combination with pagers and PDAs) and the creation of a system for telemedicine (Burdette et al. 2008; Holopainen et al. 2007; Reponen et al. 2005). Despite the limited number of studies that have been conducted in the use of mobile devices for point-of-care access to CPGs, there have been several commercial products developed that are currently available and highly popular. UpToDate (2011) is a software solution that physicians use extensively as a medical reference. Although used mostly online, it is also available via mobile devices. Epocrates (2011) is another popular medication prescribing tool for physicians developed specifically for access through mobile devices. There are also a number of other applications available that provide CPGs for specific disease areas such as Braunwald’s Practice Guidelines for cardiac guidelines (2011) and Clinical Care Options for oncology (2011).
17.1.3
History of Mobile Devices and Their Major Manufacturers
Mobile technologies change very quickly, and developing software for them is complex and challenging. PDAs first came on the market by Palm Computing, a wing of US Robotics, who introduced the Pilot 1000 and Pilot 5000 in 1996 and the Palm Pilots (Palm V) in 1999 (Palm (PDA) from Wikipedia, 2011). The use of
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Palm Pilots is popular in medicine and health care as they provide physicians and other clinicians access to information at point of care. Microsoft introduced the Pocket PC in 2000 (Pocket PC from Wikipedia 2011), which was an operating systems (OS) that could run on mobile devices from a variety of manufacturers. Throughout its different generations, this distinct advantage has continued in the windows OS, and it is evident from Windows Mobile 2003SE (2003), to Windows Mobile 5 (2005), Windows Mobile 6 (2006), and to the present day Windows Phone 7, available on many smartphone devices such as HTC 7 Surround, LG Optimus 7, HTC HD7, Samsung Focus, and LG Optimus Quantum (Windows Phone 2011). Research in Motion (RIM) introduced the first smartphone device – the Blackberry – in 2002. RIM quickly became the leader in providing smartphones to employees of corporations and other organizations in part due to their Blackberry Enterprise Server (BES; Blackberry 2011) that combined convenience of use with the a secure network. Apple took a bite out of the smartphone market with its hugely popular iPhone, which was first released in 2007; the iPhone rapidly changed mobile computing with its multi-touch interface and new interaction paradigms that integrated intuitive human gestures. Currently, Apple has sold over 100 million iPhone 4 and iPhone 3 (3G) devices (iPhone 2011). The iPhone is quickly replacing Palm devices as the leader in providing medical and health applications. Google, who introduced their Android OS for smartphones, has taken up this new popular design paradigm for mobile computing. Google partnered with HTC in 2010 and released the Nexus One that ran on an Android OS. Android is quickly gaining market share with a large number of applications including medical and health applications (Android 2011). In summary, a variety of reasons make mobile devices ideal for physicians and health professionals to access clinical practice guidelines electronically and optimally utilize them. The rapid evolution of mobile devices and their OS is making these devices ubiquitous and potentially highly functional as a tool for medical decision support. Thus, a perfect window of opportunity now exists to introduce a CPG tool, with desirable design elements, to positively influence physicians’ behavior through electronic CPGs accessible on mobile devices. The rest of this chapter describes our journey in the design of such a tool and its eventual adoption as a provincial standard in British Columbia for use by clinicians. Our experiences, lessons learned, and ongoing development directions will be discussed.
17.2
Project Description
CliniPEARLS is a project that provides CPGs on mobile devices. Its purpose is to allow access to guidelines at the point of care so that guideline searches can be easily integrated into physicians’ workflow. CliniPEARLS is a technology framework that allows for the publication of CPGs from multiple providers on various PDAs and smartphone devices. By building a system that allows multiple providers to publish their guidelines, physicians can easily access guidelines through a single application.
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Further, the server–client technical architecture (see list of key terms for definition) allows for the user to easily access guidelines through a variety of devices. CliniPEARLS provided guidelines derived from British Columbia’s Guidelines and Protocol Advisory Committee (GPAC) and distributed a condensed version of full guidelines via PDAs and smartphones. A secondary guideline provider was the BC Cancer Agency. The technical contributions for CliniPEARLS include the following: 1. Allowing for multiple organizations to publish guidelines on a single platform 2. Providing flexible security and administration structure that allows users to subscribe to guidelines from multiple organizations 3. Allowing for a central place to enter guideline content by either internal editors or external contributors with the appropriate permissions 4. Four client handheld software systems that connect to the central framework for the following devices: Palm, Windows Mobile, Blackberry, and iPhone 5. Providing a mechanism to ensure the users obtain the latest guidelines and update their existing ones
17.2.1
Technical Framework
The technical framework for CliniPEARLS is shown in Fig. 17.1. The technical framework has three main components: (1) the central server, (2) the administration, and (3) the mobile devices. The central server stores all the guideline content as well as administrative information about the providers and users. This administrative information includes the following: security information about the users that informs the system if a user can read the guidelines from each provider; security information about administrators, such as who can add new content and edit existing content; and user profile information such as e-mail address, password, and profession (i.e., general practitioner, specialist, registered nurse, nurse practitioner, etc.). The administration component enables the addition of new guidelines and the editing of existing guideline content for any provider based on security permissions. The mobile devices contain the client software that is downloaded along with the existing guidelines and enables the device to get updates when guideline content has changed or when new guidelines are available. A web version is also available so users can access the guidelines from a computer as well.
17.2.2
CliniPEARLS Client Software Application
The CliniPEARLS client software application downloads onto the mobile devices through either a web link or through synchronization software on a computer that connects to the mobile device. This depends on the specifications of the device. This client software application is how the users access the guidelines and interact with the software. Screenshots of the iPhone application for the CliniPEARLS software
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Fig. 17.1 Technical framework for CliniPEARLS
is shown in Figs. 17.2 and 17.3. The main homepage (see Fig. 17.2 left) displays a full list of the guidelines available and provides an option to access the guideline by topic. For example, the topic Cardiovascular includes guidelines pertaining to the cardiovascular system such as Hypertension and Congestive Heart Failure. Each guideline’s content is composed of a series of linked pages that are accessible through its table of contents. Much like with a website, clicking links within pages will open another page with more detailed content on the subject selected. The content can contain figures, tables (e.g., Fig. 17.2 center), or text (e.g., Fig. 17.2 right). The user can also quickly go back to the guideline’s table of contents, bookmark the page, or go back to the previously viewed page. The application also provides search functionality (see Fig. 17.3 left). Users can search all the guidelines or a particular guideline for one or more keywords. Pages that have been bookmarked by the user can be quickly accessed at anytime through the bookmark page (e.g., Fig. 17.3 right). The client application also provides other functionality. The user has the ability to hide guidelines that he/she is less likely to access, allowing easy navigation of the home page. Furthermore, the user has full control to synchronize the software. This functionality is central to keeping the guidelines up to date by obtaining any new guidelines that may become available. Since CliniPEARL’s technical framework is available across multiple mobile devices including PDAs and smartphones, there is
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Fig. 17.2 Screen captures of iPhone version for the CliniPEARLS software for GPAC’s BC guideline. The screenshot on the left shows the home screen where users can see all guidelines in alphabetical order or view the guidelines by topic. The center and right screens show content pages within the guidelines
Fig. 17.3 Screenshots of iPhone version for the CliniPEARLS software for GPAC’s BC guideline. The screenshot on the left shows an example of the search functionality; the screenshot on the right shows the bookmark page
no push functionality. In other words, there is no alert when new guidelines become available as many PDAs do not have any ability to stay connected to the server. In order to compensate for this, a reminder system prompts the user to synchronize his/ her guidelines in order to receive updates and new guidelines. The time between reminders can be set by the provider.
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Fig. 17.4 Security infrastructure for the CliniPEARLS technical framework
17.2.3
Security Infrastructure
The technical framework allows for a flexible security infrastructure (illustrated in Fig. 17.4). Users can access guidelines from multiple providers based on the clinician’s expertise and practice domains. In Fig. 17.4, users that are in the middle group are accessing guidelines from provider 1, and users in the bottom group are accessing guidelines from provider 2. Users can belong to multiple groups, allowing them to access guidelines from multiple providers (as shown in Fig. 17.4 by the user that sits in both middle and bottom groups). The CliniPEARLS technical framework manages this through a unique identifier for each user, who can then be assigned to various groups who have permission to view guidelines from specific providers. Further, users can gain access to guidelines from another provider at anytime by simply subscribing to them. This subscription process is the basis for the security infrastructure for CliniPEARL’s technical framework. The security framework also provides permission for administrators to edit existing guidelines, create new guidelines, and delete existing guidelines. Administrators can be assigned these write privileges to any of the providers. This security infrastructure decouples the entry of the guidelines from the software maintenance and means that organizations such as the guideline providers can have their own administrators that enter the guidelines. As shown in Fig. 17.4, one administrator, represented by the users in the top area, has access to edit guidelines from both providers 1 and 2; however, the second administrator, who also belongs to the middle group, only has access to edit guidelines from provider 1.
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Insights/Results CliniPEARLS Rollout: A 3-Year Journey
The technical infrastructure as described above was rolled out in a phased implementation in British Columbia (BC), Canada. There were two main providers that were engaged to publish guidelines on the CliniPEARLS technical framework. The first provider was BC’s Guidelines and Protocols Advisory Committee (GPAC), who, to date, has published over 50 guidelines for BC physicians that are available through their website in both PDF and html format. They have also mailed full sets of their guidelines to all family physicians in BC. We worked closely with GPAC to disseminate their guidelines in a mobile format. This involved first condensing their full guidelines through the support of a medical writer. Condensing the guidelines involved consideration of the following: the smaller screen available on mobile devices, easy access to required content at point of care, and assuring accuracy and completeness in an abbreviated format. The second provider was the BC Cancer Agency (BCCA), who provided cancer care guidelines for primary care physicians. The CliniPEARLS technical framework with BCCA was prototyped with a few of their guidelines. The ability to allow users to access guidelines for either or both providers was tested and confirmed. The implementation of GPAC guidelines on mobile devices was a 3-year journey, starting in fall of 2007 with client software versions for Palm OS and Pocket PC. The users were intended to be physicians, residents, medical students, and nurse practitioners throughout BC. The client software for Palm and Pocket PC devices was downloadable from the CliniPEARLS website (www.CliniPEARLS.ca), and users were able to synchronize new guideline content through the “sync” software for their device. As Windows Mobile OS became available, the Pocket PC software was updated for the new Windows Mobile versions. In 2009, the mobile market share was changing considerably, and Blackberry and iPhone devices were being used more than Palm and Windows Mobile devices. New client software for these two devices was created and released in the late fall of 2009 for Blackberry and in early 2010 for iPhone. Since iPod Touch devices have the same OS as the iPhone, the software was also available on iPod touch devices. Similar to the Palm and Pocket PC devices, the Blackberry software could be downloaded from the CliniPEARLS website. The iPhone and iPod Touch software was available through iTunes’ App Store, making downloading of the software seamless and matched the process for all other applications for these devices. Based on the needs of GPAC, new guidelines were continually added to the system, and currently (2011) there are 38 GPAC guidelines available on mobile devices (see Table 17.1). Soliciting physicians’ feedback proved to be an informative aspect that guided the development of CliniPEARLS. From feedback obtained 1 year after the launch, physician users of CliniPEARLS found that the layout of the information in the guidelines was not optimal. The guideline content was initially formatted so that each page could be viewed with little scrolling required. This resulted in a large
298 Table 17.1 GPAC guidelines available on mobile devices Ankle injury ESR Asthma Febrile seizures B12 & Folate deficiency Frailty in the elderly Bone density measurement Gallstones in women Cardiovascular disease GERD Cataract Heart failure care Chest pain Hepatitis B Chronic kidney disease Hepatitis C Cognitive impairment Hypertension COPD Infectious diarrhea Depression Iron deficiency Diabetes Iron overload Dyspepsia Liver chemistry abnormalities
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Mammography Methadone maintenance Oral rehydration therapy in children Osteoarthritis Otitis media Rheumatoid arthritis Stroke & TIA Thyroid function testing Viral hepatitis testing Vitamin D testing protocol Warfarin therapy management Warfarin therapy – PeriOp
number of pages per guideline and consequently a large number of links to these pages. Users found it cumbersome to have so many pages and links, and their preference was to have more content on each page and fewer links so that relevant content could be reached within only a few clicks/pages. Based on these new recommendations, the condensed GPAC guidelines were reformatted to have fewer pages and links and more content on each page. This was also influenced by the new form factors that modern devices now display. Their increased screen size, higher resolution, and focus on making scrolling easier all supported the new formatting that saw more content per page. This 3-year journey guided our decision to also evolve the development of our software into a single programming platform so as to reduce the burden of developing new client software for each type of mobile device OS. This platform allowed us to develop software for Palm, Windows Mobile, and Blackberry with the bulk of the programming code being the same for all three. This allowed us to develop these software applications using a Java programming language; however, many workarounds were required to allow for specific functions to work on each device. This common programming language could not be used for the iPhone since users would be required to jailbreak1 their device. Therefore, the iPhone application was written in Objective-C 2.0, which is the primary programming language to develop applications for Mac and iPhones. Although, there were difficulties in having to learn a new language for this portion of the projects, the benefits of using a language native to the mobile device were realized in the end project. This is discussed in more detail in the Recommendations section of this chapter.
1 Jailbreaking is a term used to describe a process that is used to open the operating system of iPhone and iPod devices to allow users to install software applications (apps) that have not been approved by Apple.
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Fig. 17.5 Cumulative number of unique CliniPEARLS users over time
Fig. 17.6 Percent of users for each mobile platform
17.3.2
CliniPEARLS Usage
The results of the CliniPEARLS technical framework and the release of the client applications provided insight into the uptake of CPGs. As of February, 2011, the total number of unique CliniPEARLS users was 5,840. Figure 17.5 shows the number of unique users since the initial release of the Palm and Pocket PC versions to February, 2011. This figure illustrates a slow and steady increase in the number of users until the iPhone version was released in March, 2010, when the number of unique users dramatically climbed. This could be for many reasons such as the large market share among physicians in the usage of iPhone, the easy 1-step download and install from iTunes to obtain client’ software, and the increase in the visibility of the product due to it being available on the iTunes app store. We can further confirm if the release of the iPhone version is the reason for the surge in the number of users by looking at the distribution of usage for each device (i.e., Palm, Windows Mobile, Blackberry, and iPhone). Currently, almost 71% of CliniPEARLS users use iPhone (or iPod Touch) devices (see Fig. 17.6). This confirms
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Province
Number of users
British columbia Ontario Quebec Alberta Manitoba Nova Scotia Saskatchewan New Brunswick Newfoundland and Labrador P.E.I. Yukon Nunavut Northwest Territories
2,966 425 199 177 56 52 48 29 20 10 6 5 3
that the surge in usage in 2010 came as a result of the release of the iPhone version of the client software. This shows the importance of understanding current usage patterns when deploying electronic systems for CPG lookup and automated decision-support systems. Figure 17.6 also shows that 15% of CliniPEARLS users were on Palm devices, suggesting that many clinicians were reluctant to change their technology usage, and there was a need to continue to support legacy software. Eight percent of users were on Windows Mobile devices, and 4% on Blackberry devices. Figure 17.6 also shows that 2% of users were using “no device,” which are likely those users that accessed the guidelines using the Internet, as this functionality was also made possible. Although the GPAC guidelines were developed for physicians in BC, there was uptake of the guidelines from other countries as well. While 69% of users were Canadian, there were also users in over 30 other countries including the United States (10%), Brazil (3%), and the United Kingdom (1.5%). Four percent of registered users did not specify their location. BC users comprised the largest majority of Canadian users (see Table 17.2); however, there was representation from all Canadian provinces and territories. In an examination of the distribution of professions of registered CliniPEARLS users, it was revealed that 1,722 users were general practitioners. The next generation of physicians (medical students and residents) represented a large proportion of users. The full distribution of professions is shown in Fig. 17.7, with the other category including pharmacists, health administrators, nurses, paramedics, and physician assistants. These results show good promise for the use of smartphones for increased access to CPGs. The results reveal the importance of disseminating guidelines on a mobile platform that match the technology usage of the users, which in our case includes physicians, medical students, and residents. Our ability to overcome the challenges of releasing a software application for the iPhone resulted in a surge in users. Further, the high number of trainees that used the system shows future promise for the uptake of CPGs disseminated through mobile devices.
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Fig. 17.7 Profession of users
17.4
Recommendations
This project provided many rich and diverse insights and lessons learned, from technological issues to clinical adoption and future expansion.
17.4.1
Technological Considerations
By building a technical framework that allowed for easy dissemination of and updates to guidelines, a long-term strategy can be developed for publishing guidelines from multiple providers. One of the largest drawbacks to this technical framework was the individual branding of each provider. Our experience in disseminating the GPAC CPGs for mobile devices revealed a strong desire on the part of the provider to brand the application as their own. This involved ensuring that the access point to the CliniPEARLS client application be uniquely branded; therefore, every provider would then need their own access to their set of guidelines. This would invoke the need to have separate applications for each provider. Thought needs to be put into expanding the technical framework so that providers can have their brand associated with their guidelines. This includes the icon on the device to access the software and also the display; when the user is viewing each guideline, the “owner” of the guideline must be visible. These user interface issues need to be incorporated into the technical framework. Ease of access from a user perspective will also need to be further investigated and considered when investigating this
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problem. Certainly, there is a need to ensure that users can access guidelines from various providers without having to exit one application and start another, all the while still maintaining the unique branding needs of the guideline providers. Compiling guidelines from various providers does present the challenge of presenting information that may have conflicting content depending upon the context. Considering that physicians possess substantial experiential subject matter knowledge and training, they can assess guideline information if they have enough background information about the source of the guidelines. Therefore, it is once again important to ensure that the provider of the guideline is always visible to the user. The recommendation is to incorporate visibility of the guideline provider into the CliniPEARLS technical framework. The current technical framework, as it has been presented, shows much of the infrastructure around the movement of data and security. The technical framework should also consider the user interface as it pertains to multiple providers as a logical next step prior to bringing more providers into the CliniPEARLS system. The current CliniPEARLS system provided client applications to four unique mobile operating systems: Palm, Windows Mobile, Blackberry, and iPhone. Challenges existed in keeping up with the latest devices, which are further compounded by the constant release of new devices (e.g., Android was expanding its market share). There are two ways of addressing this challenge: 1. To use a programming platform that allows for cross-platform support (used for windows mobile, Palm, and Blackberry) 2. Create new software for each platform (used for iPhone) Each one of these options has benefits and drawbacks. The first option was employed for rapid release of the Palm, Windows Mobile, and Blackberry application. It allowed programmers to focus on the functional requirements of the software without having to learn a new programming language. This option also had advantages to the user as all three applications had a very similar user interface. Thus, users could easily upgrade their mobile device (e.g., from a Palm to a Blackberry) and still be able to use the CliniPEARLS application with little need to learn new menu functions. However, option 1 also had many drawbacks. First, since it required the use of a multi-OS platform, the users had to download three separate applications onto their device in order for the CliniPEARLS application to function. This leads to a need to support users through the downloading and installation processes. Secondly, the user interface did not translate very well to different devices. For example, the size of buttons and menus might function perfectly on a Palm type of device that used a stylus but translate to poor usability on a device that used a trackball (e.g., Blackberry). Finally, despite the benefits mentioned earlier, there were drawbacks from a programming perspective. These drawbacks were mostly associated with the number of workarounds that were required in order to get the program to function on each particular device. The second option, of developing a unique software application in its native programming language for each device, was employed for the iPhone. This tactic had the benefit of realizing the interactions (in this case touch screen), screen size of the iPhone, and rich programming features that are unique to the iPhone. We were able to utilize the esthetics and design human interface
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principles that were embedded into the iPhone development that included consistency across all iPhone applications (e.g., the spinning picker wheel to make choices as shown in Fig. 17.3). It also allowed for an easier download and install process for the user by having a one-step installation of the application onto the device, resulting in the use of the application by non-technologically skilled users who may have abandoned the attempt if the installation had not gone smoothly. The main drawbacks of this option were that a new programming language and integrated development environment had to be learned before development of the software could begin and the need to maintain completely separate source code. Based on our experience, the key recommendation for mobile device development is to program each client application software in its native programming language, as the advantages and outcomes of this option outweigh the disadvantage of learning a new language. Regardless of which option is chosen, it is evident that the decision to develop new client applications for new devices is important. This recommendation will continue to have merit as new device types are becoming available such as Android. It is important to allow users to access the software regardless of the device that they have (as shown by the strong uptake of the iPhone version). New mobile modalities are another area that merits discussion, especially the surge in tablet devices such as Apple’s iPad. Tablets have long been used in the medical and health sector because their size allows the ability to view more information while remaining very mobile. With the surging popularity of iPads in the consumer marketplace, there are many applications for these devices in medical clinics. This includes applications for the dissemination of CPGs. The current CliniPEARLS technical framework can be easily expanded to include iPads; however, there are a number of features that can be added to the existing feature set that would take advantage of the larger form factor. These new features could include annotations to allow users to leave notes and reminders in the margins, connection to their electronic medical records, and allowance for collaboration between peers.
17.4.2
Clinical Insights
Based on the increase in downloading of CPGs over time and the surge of downloading when the iPhone application was launched, the interest level of clinicians in CliniPEARLS is rising. The challenge remains to empirically establish if the increase in downloads translates to an increase in actual usage of, and adherence to, the guidelines by users. Currently underway is a study examining medical residents’ use of PDA-based electronic guidelines and whether use of these guidelines impacts behavior (as compared to peers who do use electronic guidelines). The results of this experiment will illuminate whether, how, and under what conditions the electronic guidelines influence clinician’s behavior. Should a link be established between the use of electronic guidelines and adherence, the next step would be to work with health policy makers and health administrators to examine the effect on health-care delivery and cost-effectiveness.
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Having multiple providers offer content through the same CliniPEARLS interface renders the use of CPGs convenient for clinicians who do not have to learn new interfaces for each new content. This was the intent of having both GPAC and BC Cancer Agency content on the same platform. It would be ideal to increase the number of content providers over time and see how clinicians respond to this increasing content library made available to them. Another area that merits investigation is how clinicians integrate electronic access to technologies and information in health-care delivery, including electronic medical records (EMR), electronic health records (EHR), or personal health records (PHR). Increasingly, the clinicians’ practice milieu is enriched by electronic strategies, data, and tools. CliniPEARLS not only needs to be seamless in its usage within clinicians’ workflow, but also within their electronic environment of practice. This would present both an important design challenge and also a thoughtful analysis and understanding of the evolving nature of EMR, EHR, and PHR over time.
17.5
Conclusions
CliniPEARLS is a project that built a technical framework to allow for the dissemination of CPGs from multiple providers on four mobile devices: Palm, Windows Mobile, Blackberry, and iPhone. CliniPEARLS provided a sophisticated security infrastructure that allowed users to belong to multiple groups, where rights ranged from reading guidelines from one or many providers to editing or adding guidelines to any provider. The results revealed that releasing the application on an iPhone resulted in a surge in usage. This highlights the need for technology developers to conform to the technology requirements of the users rather than expect that users will conform to the technology made available to them. In other words, technology developers need to be leading the wave of technology adoption by their user base, as we cannot expect users to maintain and adopt older technology for the sake of the perfect application. Further, adapting applications to accommodate and take advantage of the unique features of the devices they will be used on is essential to the application’s success. Having an application behave similarly in different environments allows users to easily move from one version to another, but it can be detrimental to the ease of use of the application. There must be a balance found between the similarity of use and look between different versions while still allowing for adaption to the interface modalities of specific devices. The next step in this work is to study the use of the system by physicians. This would include conducting surveys to get a broad understanding of physicians’ and other health-care professional’s thoughts of the application and their use of it. Certainly, one possibility would be to interview and observe physicians in clinical settings while making use of CPGs (i.e., observation studies) to better understand how the use of CPGs, as accessed via mobile devices, fits into their day-to-day practice. The results of this study could be used to iterate the design to ensure that technology is optimally designed to promote CPG usage.
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List of Key Terms Client software
CPG
OS
PDA
Provider Server
Server–client architecture
Smartphone
This is the application that accesses a remote service on another computer system (server) through a network such as the Internet Clinical practice guidelines are systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical circumstances (Field and Lohr 1992) An operating system is the software that manages the connection between the hardware and a computer’s applications (e.g., OS on computers include Windows 7 or Mac (Snow Leopard)) Personal digital assistants are mobile devices that function as personal information managers; they typically are stand-alone devices that historically are not connected to the Internet An organization that has an interest in creating and disseminating clinical practice guidelines A physical computer dedicated to running one or more such services (such as data access) to serve the needs of programs running on other computers (clients) A distributed application structure that partitions tasks or workloads between providers, server computer, and requestors, client computer, or device A mobile phone that is capable of running advanced functions such as e-mail, Internet browsing, calendar, and other applications
Key Messages • CliniPEARLS is a technical framework to allow for the dissemination of CPGs from multiple providers on four mobile devices: Palm, Windows Mobile, Blackberry, and iPhone. • Releasing the application on an iPhone resulted in a surge in usage which highlights the need for technology developers to conform to the technology requirements of the users rather than expect that users will conform to the technology made available to them. • Technology developers need to be leading the wave of technology adoption by their user base as we cannot expect users to maintain and adopt older technology for the sake of an application. • Adapting applications to accommodate and take advantage of the unique features of the devices they will be used on is essential to the application’s success. • There must be a balance found between the similarity of use and look between different versions while still allowing for adaption to the interface modalities of specific devices.
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