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The Use of Smartphones in Hand Surgery
IN BRIEF
The Use of Smartphones in Hand Surgery Cameron Barr, MD, Jeffrey Yao, MD an ever more common tool for the physician. Its role in patient care continues to evolve as the technology improves. Most surgeons recognize the prevalence of the smartphone in the hospital, and this article aims to elucidate its uses, capabilities, and regulations as it applies to hand surgery.
T
HE SMARTPHONE IS BECOMING
In Brief
BACKGROUND A smartphone is a mobile device with advanced computing ability and connectivity, combining the functions of a personal digital assistant and a cellular phone. Although the technology existed as early as 1992 (IBM Simon), wireless Web browsing and information sharing became commercially available with the development of the Palm and Blackberry in 2001 and 2002, respectively.1 With Apple’s release of the iPhone in 2007 and its capability of installing and running additional native applications, the popularity of smartphones accelerated.2 As of January 2011, the top 3 smartphone platforms (in US market shares) were those for the Android (31%), Blackberry (30%), and iPhone (25%).3 Although no studies focus specifically on hand surgeons, a national survey of close to 500 orthopedic surgeons found that 84% have a smartphone and that most of them (55%) have an iPhone.4 COMMUNICATION The primary function of any smartphone is mobile telecommunication. With a smartphone providing voice, text, multimedia message, and e-mail options, there are more methods with which members of a surgical team can communicate. Because of the convenience and speed of response with smartphones, surFrom the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. Received for publication August 16, 2011; accepted in revised form October 17, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. The authors do not advocate any particular smartphone or platform use. Corresponding author: Jeffrey Yao, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/12/37A01-0035$36.00/0 doi:10.1016/j.jhsa.2011.10.036
168 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
geons are free to travel between sites of patient care while being readily accessible. The variety of communication options also allows the degree of urgency and detail of the message to be better conveyed. Hand surgeons frequently need to provide medical opinion away from the bedside, such as in the case of outside referrals, emergency room and inpatient consults, transfer requests, or assistance to residents and fellows. The smartphone enables clinical photos to be sent quickly, aiding in obtaining an expert opinion. Electronic transmission of clinical images for remote consultation has been successfully implemented in dermatology, pathology, and radiology.5– 8 A number of international studies have found smartphone cameras and multimedia messaging sufficient in providing management decisions for musculoskeletal limb injuries and burns.9 –11 Tsai et al12 evaluated 60 cases of extremity wound management through smartphone communication and found acceptable levels of sensitivity and specificity for diagnosing gangrene (85% and 93%, respectively), necrosis (72% and 87%, respectively), erythema (61% and 76%, respectively), and cellulitis or infection (71% and 91%, respectively). A study of smartphone use for evaluation of replantation potential of amputated fingers found a sensitivity of 90% and specificity of 83%.13 The mean time from image acquisition to reception was 3 to 4 minutes. APPLICATIONS An application (“app”) is native software developed specifically for a smartphone. Of the current popular smartphone operating systems, each has a respective online “app store” to browse and download applications (ie, BlackBerry App World, Android Market, iPhone App Store/iTunes). Apple alone has over 425,000 applications available through its online app store.14 Applications can also be found on commercial Web sites (ie, Amazon.com) and independent developer Web sites. Key words or titles are entered into search functions to identify applications of interest. The cost of downloading such applications varies, but many are free. In a review of smartphone apps for orthopedic surgeons, a database search revealed that iPhone and Android platforms had 61 and 13 apps, respectively, spe-
169
cifically created for orthopedic surgery.4 The average cost for all apps was $12.85 (range, free to $99.99). Few, however, were highly ranked or deemed desirable by surgeon respondents. The 4 most requested categories of apps were textbook/reference, technique/guides, board review, and billing/coding. A review of smartphone applications for the plastic surgery trainee concluded that there are few noncosmetic applications.15 We found no study that specifically evaluated smartphone applications for the hand surgeon.
tracking service, and (5) encrypt device backups. Medical centers and private security services may allow physicians to download a single application that automates all such security measures directly to the smartphone. As the use of smartphones in hand surgery and medicine in general becomes more ubiquitous, it is important for practitioners to familiarize themselves with their uses, capabilities, and, most important, regulations when used in daily medical care.
OTHER MEDIA A smartphone may also serve as a portable media player. Podcasts are a series of audio or video files that are released episodically and may be downloaded onto a smartphone. Several surgical journals, such as the Journal of Bone and Joint Surgery, now offer podcasts that provide physicians with audio recordings of recently published abstracts or videos of surgical techniques. Various academic centers also provide podcasts with expert discussions and surgical demonstrations. The University of Washington and the Hospital for Special Surgery are 2 institutions that have hand surgery topics available through iTunes.
REFERENCES
REGULATIONS With increasing utility and value of the smartphone in medicine, hand surgeons should also be aware of the rules and regulations accompanying the technology. The United States Congress first enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996 with the goal of properly protecting individuals’ health information.16 Recent news has highlighted HIPAA violations surrounding mobile devices.17 Many experts now consider smartphones a greater HIPAA security risk than other electronic devices.18 Much of this is because smartphones are treated more casually with less emphasis on security. In 2006 the Department of Health and Human Services stressed that providers be “extremely cautious” while using portable devices and to only do so after “great rigor” has been taken to ensure policies and workforce training are in place.19 Patient information stored in or transmitted over a smartphone falls under the same HIPAA security regulations as any other mode of storage. For that reason, if a smartphone is stolen or lost and no information protection measures have been taken, the owner is liable for the lost patient data. It is recommended that a physician’s smartphone (1) have a passcode at least 8 characters long, (2) be set to auto-lock after 1 minute of nonuse, (3) link with an e-mail account that allows remote wipe-out if necessary, (4) connect with a remote
1. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis 2010;50:1268 –1274. 2. Markoff J. Apple, hoping for another iPod, introduces innovative cellphone. New York Times. January 10, 2007;A1. 3. comScore. January 2011 U.S. Mobile Subscriber Market Share. 2011. Available: http://www.comscore.com/Press_Events/Press_ Releases/2011/3/comScore_Reports_January_2011_U.S._Mobile_ Subscriber_Market_Share. Accessed: August 6, 2011. 4. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res 2011;469:2042–2048. 5. Strode SW, Gustke S, Allen A. Technical and clinical progress in telemedicine. JAMA 1999;281:1066 –1068. 6. Menn ER, Kvedar JC. Teledermatology in a changing health care environment. Telemed J 1995;1:303–308. 7. Kvedar JC, Edwards RA, Menn ER, Mofid M, Gonzalez E, Dover J, et al. The substitution of digital images for dermatologic physical examination. Arch Dermatol 1997;133:161–167. 8. Kirkpatrick AW, Brenneman FD, McCallum A, Breeck K, Boulanger BR. Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals. J Trauma 1999;46: 1017–1023. 9. Archbold HA, Guha AR, Shyamsundar S, McBride SJ, Charlwood P, Wray R. The use of multi-media messaging in the referral of musculoskeletal limb injuries to a tertiary trauma unit using: a 1-month evaluation. Injury 2005;36:560 –566. 10. Elkaim M, Rogier A, Langlois J, Thevenin-Lemoine C, AbelinGenevois K, Vialle R. Teleconsultation using multimedia messaging service for management plan in pediatric orthopaedics: a pilot study. J Pediatr Orthop 2010;30:296 –300. 11. Shokrollahi K, Sayed M, Dickson W, Potokar T. Mobile phones for the assessment of burns: we have the technology. Emerg Med J 2007;24:753–755. 12. Tsai HH, Pong YP, Liang CC, Lin PY, Hsieh CH. Teleconsultation by using the mobile camera phone for remote management of the extremity wound: a pilot study. Ann Plast Surg 2004;53:584 – 587. 13. Hsieh CH, Jeng SF, Chen CY, Yin JW, Yang JC, Tsai HH, et al. Teleconsultation with the mobile camera-phone in remote evaluation of replantation potential. J Trauma 2005;58:1208 –1212. 14. Apple. iPhone App Store. 2011. Available: http://www.apple.com/ iphone/apps-for-iphone/. Accessed: August 6, 2011. 15. Amin K. Smartphone applications for the plastic surgery trainee. J Plast Reconstr Aesthet Surg 2011;64:1255–1257. 16. The U.S. Department of Health and Human Services. The Health Insurance Portability and Accountability Act. 1996. Available: http://www.hhs.gov/ocr/privacy/. Accessed: August 6, 2011. 17. Anderson, J. Portable electronic may be source of HIPAA violatoins, penalties. Internal Medicine News Digital Network. Available: http://www.internalmedicinenews.com/single-view/portable-electronics-
JHS 䉬 Vol A, January
In Brief
SMARTPHONES IN HAND SURGERY
170
SMARTPHONES IN HAND SURGERY
may-be-source-of-hipaa-violations-penalties/af89bd4ce5.html. Accessed: September 25, 2011. 18. Experts say smart phones at equal or greater risk for security breaches; users fail to safeguard data. Guide to Medical Privacy and HIPAA Newsletter. March 2011;10:1–2.
19. U.S. Department of Health and Human Services. HIPAA security guidance for remote use of and access to electronic protected health information. 2006. Available: http://www.hhs.gov/ocr/privacy/ hipaa/administrative/securityrule/remoteuse.pdf. Accessed: August 6, 2011.
In Brief JHS 䉬 Vol A, January
The Use of Smartphones in Hand Surgery Cameron Barr, MD, Jeffrey Yao, MD an ever more common tool for the physician. Its role in patient care continues to evolve as the technology improves. Most surgeons recognize the prevalence of the smartphone in the hospital, and this article aims to elucidate its uses, capabilities, and regulations as it applies to hand surgery.
T
HE SMARTPHONE IS BECOMING
In Brief
BACKGROUND A smartphone is a mobile device with advanced computing ability and connectivity, combining the functions of a personal digital assistant and a cellular phone. Although the technology existed as early as 1992 (IBM Simon), wireless Web browsing and information sharing became commercially available with the development of the Palm and Blackberry in 2001 and 2002, respectively.1 With Apple’s release of the iPhone in 2007 and its capability of installing and running additional native applications, the popularity of smartphones accelerated.2 As of January 2011, the top 3 smartphone platforms (in US market shares) were those for the Android (31%), Blackberry (30%), and iPhone (25%).3 Although no studies focus specifically on hand surgeons, a national survey of close to 500 orthopedic surgeons found that 84% have a smartphone and that most of them (55%) have an iPhone.4 COMMUNICATION The primary function of any smartphone is mobile telecommunication. With a smartphone providing voice, text, multimedia message, and e-mail options, there are more methods with which members of a surgical team can communicate. Because of the convenience and speed of response with smartphones, surFrom the Department of Orthopaedic Surgery, Stanford University, Redwood City, CA. Received for publication August 16, 2011; accepted in revised form October 17, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. The authors do not advocate any particular smartphone or platform use. Corresponding author: Jeffrey Yao, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, Pavilion C, Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/12/37A01-0035$36.00/0 doi:10.1016/j.jhsa.2011.10.036
168 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
geons are free to travel between sites of patient care while being readily accessible. The variety of communication options also allows the degree of urgency and detail of the message to be better conveyed. Hand surgeons frequently need to provide medical opinion away from the bedside, such as in the case of outside referrals, emergency room and inpatient consults, transfer requests, or assistance to residents and fellows. The smartphone enables clinical photos to be sent quickly, aiding in obtaining an expert opinion. Electronic transmission of clinical images for remote consultation has been successfully implemented in dermatology, pathology, and radiology.5– 8 A number of international studies have found smartphone cameras and multimedia messaging sufficient in providing management decisions for musculoskeletal limb injuries and burns.9 –11 Tsai et al12 evaluated 60 cases of extremity wound management through smartphone communication and found acceptable levels of sensitivity and specificity for diagnosing gangrene (85% and 93%, respectively), necrosis (72% and 87%, respectively), erythema (61% and 76%, respectively), and cellulitis or infection (71% and 91%, respectively). A study of smartphone use for evaluation of replantation potential of amputated fingers found a sensitivity of 90% and specificity of 83%.13 The mean time from image acquisition to reception was 3 to 4 minutes. APPLICATIONS An application (“app”) is native software developed specifically for a smartphone. Of the current popular smartphone operating systems, each has a respective online “app store” to browse and download applications (ie, BlackBerry App World, Android Market, iPhone App Store/iTunes). Apple alone has over 425,000 applications available through its online app store.14 Applications can also be found on commercial Web sites (ie, Amazon.com) and independent developer Web sites. Key words or titles are entered into search functions to identify applications of interest. The cost of downloading such applications varies, but many are free. In a review of smartphone apps for orthopedic surgeons, a database search revealed that iPhone and Android platforms had 61 and 13 apps, respectively, spe-
169
cifically created for orthopedic surgery.4 The average cost for all apps was $12.85 (range, free to $99.99). Few, however, were highly ranked or deemed desirable by surgeon respondents. The 4 most requested categories of apps were textbook/reference, technique/guides, board review, and billing/coding. A review of smartphone applications for the plastic surgery trainee concluded that there are few noncosmetic applications.15 We found no study that specifically evaluated smartphone applications for the hand surgeon.
tracking service, and (5) encrypt device backups. Medical centers and private security services may allow physicians to download a single application that automates all such security measures directly to the smartphone. As the use of smartphones in hand surgery and medicine in general becomes more ubiquitous, it is important for practitioners to familiarize themselves with their uses, capabilities, and, most important, regulations when used in daily medical care.
OTHER MEDIA A smartphone may also serve as a portable media player. Podcasts are a series of audio or video files that are released episodically and may be downloaded onto a smartphone. Several surgical journals, such as the Journal of Bone and Joint Surgery, now offer podcasts that provide physicians with audio recordings of recently published abstracts or videos of surgical techniques. Various academic centers also provide podcasts with expert discussions and surgical demonstrations. The University of Washington and the Hospital for Special Surgery are 2 institutions that have hand surgery topics available through iTunes.
REFERENCES
REGULATIONS With increasing utility and value of the smartphone in medicine, hand surgeons should also be aware of the rules and regulations accompanying the technology. The United States Congress first enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996 with the goal of properly protecting individuals’ health information.16 Recent news has highlighted HIPAA violations surrounding mobile devices.17 Many experts now consider smartphones a greater HIPAA security risk than other electronic devices.18 Much of this is because smartphones are treated more casually with less emphasis on security. In 2006 the Department of Health and Human Services stressed that providers be “extremely cautious” while using portable devices and to only do so after “great rigor” has been taken to ensure policies and workforce training are in place.19 Patient information stored in or transmitted over a smartphone falls under the same HIPAA security regulations as any other mode of storage. For that reason, if a smartphone is stolen or lost and no information protection measures have been taken, the owner is liable for the lost patient data. It is recommended that a physician’s smartphone (1) have a passcode at least 8 characters long, (2) be set to auto-lock after 1 minute of nonuse, (3) link with an e-mail account that allows remote wipe-out if necessary, (4) connect with a remote
1. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis 2010;50:1268 –1274. 2. Markoff J. Apple, hoping for another iPod, introduces innovative cellphone. New York Times. January 10, 2007;A1. 3. comScore. January 2011 U.S. Mobile Subscriber Market Share. 2011. Available: http://www.comscore.com/Press_Events/Press_ Releases/2011/3/comScore_Reports_January_2011_U.S._Mobile_ Subscriber_Market_Share. Accessed: August 6, 2011. 4. Franko OI. Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res 2011;469:2042–2048. 5. Strode SW, Gustke S, Allen A. Technical and clinical progress in telemedicine. JAMA 1999;281:1066 –1068. 6. Menn ER, Kvedar JC. Teledermatology in a changing health care environment. Telemed J 1995;1:303–308. 7. Kvedar JC, Edwards RA, Menn ER, Mofid M, Gonzalez E, Dover J, et al. The substitution of digital images for dermatologic physical examination. Arch Dermatol 1997;133:161–167. 8. Kirkpatrick AW, Brenneman FD, McCallum A, Breeck K, Boulanger BR. Prospective evaluation of the potential role of teleradiology in acute interhospital trauma referrals. J Trauma 1999;46: 1017–1023. 9. Archbold HA, Guha AR, Shyamsundar S, McBride SJ, Charlwood P, Wray R. The use of multi-media messaging in the referral of musculoskeletal limb injuries to a tertiary trauma unit using: a 1-month evaluation. Injury 2005;36:560 –566. 10. Elkaim M, Rogier A, Langlois J, Thevenin-Lemoine C, AbelinGenevois K, Vialle R. Teleconsultation using multimedia messaging service for management plan in pediatric orthopaedics: a pilot study. J Pediatr Orthop 2010;30:296 –300. 11. Shokrollahi K, Sayed M, Dickson W, Potokar T. Mobile phones for the assessment of burns: we have the technology. Emerg Med J 2007;24:753–755. 12. Tsai HH, Pong YP, Liang CC, Lin PY, Hsieh CH. Teleconsultation by using the mobile camera phone for remote management of the extremity wound: a pilot study. Ann Plast Surg 2004;53:584 – 587. 13. Hsieh CH, Jeng SF, Chen CY, Yin JW, Yang JC, Tsai HH, et al. Teleconsultation with the mobile camera-phone in remote evaluation of replantation potential. J Trauma 2005;58:1208 –1212. 14. Apple. iPhone App Store. 2011. Available: http://www.apple.com/ iphone/apps-for-iphone/. Accessed: August 6, 2011. 15. Amin K. Smartphone applications for the plastic surgery trainee. J Plast Reconstr Aesthet Surg 2011;64:1255–1257. 16. The U.S. Department of Health and Human Services. The Health Insurance Portability and Accountability Act. 1996. Available: http://www.hhs.gov/ocr/privacy/. Accessed: August 6, 2011. 17. Anderson, J. Portable electronic may be source of HIPAA violatoins, penalties. Internal Medicine News Digital Network. Available: http://www.internalmedicinenews.com/single-view/portable-electronics-
JHS 䉬 Vol A, January
In Brief
SMARTPHONES IN HAND SURGERY
170
SMARTPHONES IN HAND SURGERY
may-be-source-of-hipaa-violations-penalties/af89bd4ce5.html. Accessed: September 25, 2011. 18. Experts say smart phones at equal or greater risk for security breaches; users fail to safeguard data. Guide to Medical Privacy and HIPAA Newsletter. March 2011;10:1–2.
19. U.S. Department of Health and Human Services. HIPAA security guidance for remote use of and access to electronic protected health information. 2006. Available: http://www.hhs.gov/ocr/privacy/ hipaa/administrative/securityrule/remoteuse.pdf. Accessed: August 6, 2011.
In Brief JHS 䉬 Vol A, January