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How mobile devices are changing pharmacy practice Timothy Dy Aungst, Aimon C. Miranda, and Erini S. Serag-Bolos Am J Health-Syst Pharm. 2015; 72:494-500
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he first mobile devices to enter the market were the personal digital assistants (PDAs) of the late 1990s and early 2000s, and they ushered in the era of handheld computers. PDAs combined popular features of electronic tools (e.g., calculator) and computer apps applications (e.g., e-mail, calendar, planner) into a single handheld device and were identified as potential mobile resources in medical and pharmacy practice.1-7 Studies examining the patterns of PDA use among physicians and pharmacists revealed that these devices served as drug information references and facilitated medical calculations, supporting clinical activities.8-10 PDAs also helped to reduce adverse drug events, identify potentially dangerous drug interactions, document clinical activities, and increase productivity.11-20 However, these devices had notable limitations in their processing power,
memory storage, and capabilities and lacked a supportive electronic infrastructure with readily available cellular data services and wireless Internet. Mobile technology has undergone rapid advances in the past several years with the release of the modern smartphone and tablet computer. These devices have become a societal mainstay with which users can conduct everyday functions. The medical field has also seen an increased interest in the use of mobile devices in clinical care. Whereas 20–70% of physicians, medical residents, and medical students in the early 2000s had PDAs, recent data suggest that over 90% of these individuals have a smartphone.21-25 Many residents and students use their mobile devices during their didactic training and throughout their professional years.22-26 This shift in the use of mobile technology is due to the
Timothy Dy Aungst, Pharm.D., is Assistant Professor of Pharmacy Practice, MCPHS University, Worcester, MA, and Editor, iMedicalApps.com, Raleigh, NC. A imon C. Miranda, Pharm.D., BCPS, is Assistant Professor and Clinical Informatics Coordinator; and Erini S. Serag-Bolos, Pharm.D., is Assistant Professor and Coordinator of Interprofessional Education, Department of Pharmacotherapeutics and Clinical Research, College of Pharmacy, University of South Florida, Tampa. Address correspondence to Dr. Aungst ([email protected]). Paul Belliveau, Pharm.D., and Jennifer L. Donovan, Pharm.D., are acknowledged for
their assistance in the preparation of this article and for their insight and recommendations to improve upon it. Dr. Aungst is an editor for iMedicalApps. com, a website dedicated to providing news on the integration of mobile technology into medical care and reviewing medical apps for mobile devices. He does not consult or receive reimbursement from app developers or creators. The authors have declared no other potential conflicts of interest.
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amalgamation of different functions into a handheld tool that can be used for both clinical and societal applications. With advancements in mobile technology and increased uptake by the medical field, smartphones and tablet computers offer versatility in the clinical setting that was not possible a decade ago.27,28 This article describes the utility, possible opportunities, and limitations of mobile device use in pharmacy practice settings. Mobile medical apps for pharmacy practice. The iTunes and the Google Play stores currently contain over 20,000 medical apps.29,30 Although the apps tagged as “medical” are quite heterogeneous with regard to their purpose, audience, and function, some apps may help to support the clinical functions and daily workflow of pharmacy practitioners (Figure 1). Several published reports have identified apps suited for general pharmacy practice and specialty areas such as infectious diseases, emergency medicine, and pain management.31-37 While these reports may not be all-encompassing, they serve as a preliminary point for pharmacists seeking apps suited to their specific practice and interests. Clinical references. Medical smartphone apps are most commonly used for reference purposes, with drug information being the largest practical resource in pharmacy practice.22,25 The drug information references used as clinical decision support tools vary among individuals and institutions.38-40 Several popular drug reference suites (e.g., Micromedex [Truven Health Analytics, Ann Harbor, MI], Lexi-Comp [Lexi-Comp, Hudson, OH]) have migrated from personal computers to a mobile app format
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on smartphones and tablet computers.28,29 Many of these apps can be downloaded to the device and function offline, serving as a virtual drug information platform. These applications serve as resources for drug information, drug interactions, i.v. compatibility, and drug identification.31,32 With such functions, these apps can provide pharmacists with constant access to quality drug information. Clinical reference tools that have also found a niche on mobile devices include medical calculator apps.
These apps allow pharmacists to enter data needed for medical calculations, such as creatinine clearance estimations (e.g., Cockcroft–Gault equation to estimate renal function) and other calculations pertinent to specific medical disciplines (e.g., cardiology, neurology). Many textbooks and handbooks commonly found on pharmacy bookshelves or in white-coat pockets are being incorporated into electronic formats such as eBooks or fully integrative apps. The American Academy
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of Pediatrics’ Red Book and Nelsons Pediatric Antimicrobial Therapy are both available as apps.33 The Sanford Guide app (Antimicrobial Therapy, Sperryville, VA) incorporates information found in the traditional pocket-sized book but also integrates dose calculators pertinent to infectious diseases.35 Other apps have capitalized on the function of mobile devices to serve as portals that allow direct access to the medical literature, providing pharmacists with the most current
Figure 1. Integration of mobile devices into the pharmacy workflow.
Drug-related question occurs during rounds
Order placed for pharmacist verification
Pharmacist can use a mobile device to accomplish many functions throughout daily clinical responsibilities
Pharmacist needs to contact provider for intervention
Patient sends blood pressure data to pharmacist for monitoring
CLINICAL REFERENCE Pharmacist can look up drug information at the point of care
ORDER PROCESSING Pharmacist processes order as received while on the floor
COMMUNICATION Pharmacist contacts provider through texting, direct call, or e-mail
DOCUMENTATION Pharmacist documents all activities as he or she performs them
PATIENT ENGAGEMENT Pharmacist reviews patient data to make a therapeutic decision for management
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medical literature to support therapy decisions. Other apps provide point-of-care guidelines or pertinent medical recommendations, such as those found in Dynamed (EBSCO Information Services, Ipswich, MA), UpToDate (Wolters Kluwer, Alphen aan den Rijn, Netherlands), and the Johns Hopkins Point of Care guides (Unbound Medicine, Charlottesville, VA).32-34 Apps serving as portals to medical organization guidelines have also been created, such as the American Heart Association Joint Guidelines app (International Guidelines Center, Lake Mary, FL) and the National Comprehensive Cancer Network Guidelines app (TIP Medical Communications, Warren, NJ).35,36 Pharmacy workflow and productivity. Clinical decision support systems (CDSSs) are increasingly being made available as point-ofcare tools to help with patient care activities. The Internet access available with mobile devices allows for the easy transfer of data to desktop computers and retrieval of information for use at the patient’s bedside or examination room. Some CDSSs have built-in treatment algorithms to assist with prescribing and improve patient safety.41 CDSSs can also provide dosing recommendations, check for drug–drug interactions, and track follow-up interventions. The access provided by mobile devices reduces the need for a pharmacist to be dependent on a computer housed in a specific location, thus increasing the pharmacist’s mobility. In one recent study, pharmacists evaluated the use of iPads to process orders during medical patient care rounds in a hospital settting.42 Pharmacists became more productive in their order-entry functions, as the iPad decreased the time required to process immediate or urgent orders, and had the ability to access information to answer drugrelated questions during patient care rounds. 496
Mobile devices may also prove to be useful as tools to help prescribers and pharmacists improve patient safety. Boussadi and colleagues 43 investigated alert systems embedded within electronic health records (EHRs), such as those that addressed renal function and anticoagulation concerns, to complement pharmacist activities and improve safety benefits. Of the 5006 drug prescription lines analyzed, the alert system correctly analyzed 4863 (97.14%), whereas the pharmacists correctly analyzed 4745 (94.77%) of the same lines. Implementation of such alert systems through mobile devices can facilitate implementation of decision support tools for antimicrobial prescribing to help improve the efficiency of antimicrobial stewardship programs.44,45 Previously, documentation of direct patient care and clinical services was captured using PDAs.15-20 These activities can now be documented through EHRs or other surveillance software that integrates with EHRs. Since pharmacists can document the amount of time spent on various functions at the point of care using a mobile device, a pharmacist need not rely on recall when recording these activities. Such documentation has proven valuable in justifying pharmacist full-time equivalents, helping with time management, and documenting outcomes of cost-saving initiatives.15-20 Education. Mobile devices may increase healthcare professionals’ access to a variety of unique continuing-education (CE) platforms such as podcasts, visual interactive anatomy guides, and medical simulations.35 The literature describing the use of these education tools is mostly limited to physicians using apps to train providers in laparoscopic skills, rapid responses, or emergency situations.46,47 While few apps are related to pharmacy education, there are opportunities to expand this area (e.g., board-review programs or apps to
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train pharmacists and students in the areas of physical assessment). Such tools may also take the form of unique electronic platforms. Virtual reality programs are one such platform (e.g., Second Life [Linden Lab, San Francisco, CA]) that has been used for communication skills training of pharmacy students.48,49 Second Life has also been used to train surgical residents to complete patient interviews and physical examinations via interactions with patient avatars.50 An additional area of interest is the implementation of game mechanics into learning activities, called gamification, and has been recently explored as a mechanism to engage patients and students.51,52 Such an approach could be integrated into mobile apps and serve as a novel way to teach students and pharmacists about new topics or medical cases. Apps may also be used by pharmacists to collect required CE hours and to remain current on medical news and topics. The Pharmacist’s Letter app (Therapeutic Research, Stockton, CA) allows users to collect CE credits directly through the app. Future opportunities may include new ways of conducting CE programs for pharmacists that will capitalize on gamification and other interactive mechanisms available through mobile devices. Communication. Research evaluating the small-scale integration of smartphones as communication tools in the hospital has found improved communication and perceived faster productivity with use of such devices.53,54 Smartphones’ texting and e-mail abilities are leveraged with time-sensitive situations and institutional patient confidentiality policies but may allow increased data communication that would otherwise be communicated orally. In addition, “phone tag,” which may occur with pager communications, may be less of an issue when practitioners have direct access to each other via smartphones. In a study by
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Wilson and colleagues,55 the use of smartphones to communicate between pharmacists and providers did not result in a significant reduction in time to resolution of medicationrelated issues, but participants did report improved team communication efficiency. At the current time, there is no app designed specifically to enhance interdisciplinary communication among health professionals. However, with the rapid pace of app and device development and their ubiquitous availability in healthcare settings, future innovations in smartphone technology may make smartphone use for this purpose commonplace and compliant with the Health Insurance Portability and Accountability Act. Patient engagement. Mobile devices and their apps offer new ways for pharmacists to directly engage with patients. Portals, which allow patients to access their medical information, are becoming commonplace. Several large-scale medical institutions, such as the Mayo Clinic and Kaiser Permanente, have created apps designed for use by patients.56,57 Through these apps, patients can receive reminders for follow-up laboratory tests, reminders about upcoming appointments, and results of laboratory or diagnostic tests. Patient queries regarding medical concerns can be sent through these portals and addressed by healthcare providers at their convenience, thus avoiding disruption of workflow while providing reassurance to the patients that their questions are being addressed. One key area where mobile apps may play a notable role between pharmacy and patient care is medication adherence and education. Counseling for patients with human immunodeficiency virus infection and medication counseling education via such an app were shown to improve patients’ knowledge of disease and medications and increased medication adherence.58-60 Dayer and colleagues60 evaluated medication
adherence apps available on three main smartphone operating systems (Apple, Android, and Blackberry) and concluded that while these apps have not been tested in trial settings, pharmacists could consider their use for nonadherent patients. Such apps can be easily integrated into patient education activities since they are inexpensive, are accessible, and do not require separate devices. Mobile apps and associated peripheral devices also have applicability for future uses in telemedicine and mobile health.61 New devices approaching the market include those that can collect pertinent vital signs such as heart rate, blood pressure, blood glucose, electrocardiogram readings, physical activities, and weight. There are many health management apps for chronic diseases such as diabetes, hypertension, and obesity.62 Patients now have the capabilities to record their data and share it with providers through these tools. In addition, the built-in cameras of mobile devices expand on virtual communication, allowing digital, face-to-face communication. This may provide additional opportunities for outpatient management by pharmacists. One recent study by Margolis and colleagues63 investigated the home monitoring of blood pressure of hypertensive patients and their medication management by pharmacists. Using the data collected by patients and transmitted to the clinic, pharmacists were able to assess patients’ responses to treatment and enhance patient engagement through telemedicine practices to make therapeutic adjustments.63 Mobile devices and apps may help pharmacists engage patients with chronic diseases and those at high risk for adverse drug events and help with postdischarge monitoring of drug therapies. Current limitations. While mobile devices and their associated apps have much to offer pharmacists, there are
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several limitations that may prevent easy assimilation into clinical practice. One of the foremost concerns with mobile medical apps is quality, which has been noted to be lacking in the majority of available apps. With over 20,000 apps offered by iTunes and the Google Play stores, this may come as no surprise, especially considering that Apple and Google are not directly responsible for reviewing the information found within those apps.29,30 Research has shown that the number of apps that are poorly developed, are inadequately researched, or have other areas of concern may be higher than expected. In several studies, authors noted that clinical information is often not cited, medical dose calculators (e.g., for opioid conversion) are inconsistent, and authors and conflicts of interest are rarely disclosed.37,64-67 While there has been debate as to whether the Food and Drug Administration (FDA) should regulate mobile medical apps, FDA has recently released guidelines to address concerns about their impact on patients and clinical care. 68,69 However, in its current iteration, the guidelines only address apps that (1) “are intended to be used as an accessory to a regulated medical device” or (2) “transform a mobile platform into a regulated medical device.”69 As many of these medical apps do not fall into this realm and will most likely not be reviewed by FDA, recommendations abound for professional organizations to evaluate these apps.70-73 This has led to the creation of app certification programs and curated app programs by institutions.74,75 Integration of mobile devices into clinical practice faces many technological obstacles due to the rapid pace of mobile device and app development and limitations of available institution infrastructure. Because of the rapid pace of technological development, institutions may invest time and resources in the selection of
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technology, which will be supplanted by newer emerging options. In addition, device selection will likely remain a concern. Currently, the two largest stakeholders in the market are Apple (iOS) and Google (Android), and both have several devices that support their operating systems.76 With multiple variants of operating systems and devices available, there is a high possibility of fragmentation in the system, which may require monitoring and regulation by information technology departments and necessitating the integration of increased clinical information systems. 76 Furthermore, the rapid development of mobile technology may also pose a barrier in terms of how to incorporate unique wearable technologies coming to the market. These include Google Glass, smart watches, and other wearable devices that may function as adjunctive tools to current smartphones and tablet computers. Some of these devices may find a niche in the practice of pharmacy, such as the utilization of Google Glass in the hospital to aid in the medication dispensing process or documentation of activities.77 Further research is needed to determine the role of such devices into pharmacy practice as well as demonstrate their practical utilization. Other barriers to device adoption in the workplace include education of personnel, perceptions that adoption requires extra effort and time, fear of new technology, cost of app subscriptions, and the planning required for effective technology integration into workflow.78 The smaller screens and keyboards on mobile devices and wireless Internet connection consistency throughout an institution also may slow adoption.42,79 Summary. Mobile devices and their accompanying applications pose several benefits over currently utilized technology infrastructures. These devices afford healthcare providers with easy access to pertinent 498
and detailed clinical references and tools for patient care. These devices may aid in clinical decision-making, allow mobile access to the EHR and hospital workflow systems, and provide a platform for remote patient engagement. The substantial storage capacity of these devices allows apps to be downloaded and used without reliance on an internet connection to function, allowing them to serve as mobile workstations. Future research with mobile devices and apps should focus on outcomes documentation. Such research is vital to assess the effectiveness of mobile health devices in improving the quality of interprofessional care, medication adherence, and patient outcomes. In particular, investigations are needed to assess in which settings mobile devices would be of most benefit as well as which apps would be of most use in specific healthcare environments. References 1. Baumgart DC. Personal digital assistants in health care: experienced clinicians in the palm of your hand? Lancet. 2005; 366:1210-22. 2. Honeybourne C, Sutton S, Ward L. Knowledge in the palm of your hands: PDAs in the clinical setting. Health Info Libr J. 2006; 23:51-9. 3. Kostka-Rokosz MD, Mccloskey WW. Survey of pharmacy preceptors’ use of hand-held electronic devices. J Am Pharm Assoc. 2009; 49:69-72. 4. Felkey B, Fox BI. Emerging technology at the point of care. J Am Pharm Assoc. 2003; 43(suppl 1):S50-1. 5. Dasgupta A, Sansgiry SS, Sherer JT et al. Pharmacists’ utilization and interest in usage of personal digital assistants in their professional responsibilities. Health Info Libr J. 2010; 27:37-45. 6. Yu F, Houston TK, Ray MN et al. Patterns of use of handheld clinical decision support tools in the clinical setting. Med Decis Making. 2007; 27:744-53. 7. Knollmann BC, Smyth BJ, Garnett CE et al. Personal digital assistant-based drug reference software as tools to improve rational prescribing: benchmark criteria and performance. Clin Pharmacol Ther. 2005; 78:7-18. 8. Rothschild JM, Lee TH, Bae T et al. Clinician use of a palmtop drug reference guide. J Am Med Inform Assoc. 2002; 9:223-9. 9. McCreadie SR, Stevenson JG, Sweet BV et al. Using personal digital assistants to access drug information. Am J Health-Syst Pharm. 2002; 59:1340-3.
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10. Enders SJ, Enders JM, Holstad SG. Druginformation software for Palm operating system personal digital assistants: breadth, clinical dependability, and ease of use. Pharmacotherapy. 2002; 22:1036-40. 11. Clauson KA, Seamon MJ, Clauson AS et al. Evaluation of drug information databases for personal digital assistants. Am J Health-Syst Pharm. 2004; 61:1015-24. 12. Galt KA, Rule AM, Houghton B et al. Personal digital assistant-based drug information sources: potential to improve medication safety. J Med Libr Assoc. 2005; 93:229-36. 13. Barrons R. Evaluation of personal digital assistant software for drug interactions. Am J Health-Syst Pharm. 2004; 61:380-5. 14. Dallenbach MF, Bovier PA, Desmeules J. Detecting drug interactions using personal digital assistants in an out-patient clinic. QJM. 2007; 100:691-7. 15. Fox BI, Felkey BG, Berger BA et al. Use of personal digital assistants for documentation of pharmacists’ interventions: a literature review. Am J Health-Syst Pharm. 2007; 64:1516-25. 16. Patel RJ, Lyman AE, Clark DR et al. Personal digital assistants for documenting primary care clinical pharmacy services in a health maintenance organization. Am J Health-Syst Pharm. 2006; 63:258-61. 17. Collins MF. Measuring performance indicators in clinical pharmacy services with a personal digital assistant. Am J HealthSyst Pharm. 2004; 61:498-501. 18. Ford S, Illich S, Smith L et al. Implementing personal digital assistant documentation of pharmacist interventions in a military treatment facility. J Am Pharm Assoc. 2006; 46:589-93. 19. Raybardhan S, Balen RM, Partovi N et al. Documenting drug-related problems with personal digital assistants in a multisite health system. Am J Health-Syst Pharm. 2005; 62:1782-7. 20. Lynx DH, Brockmiller HR, Connelly RT, Crawford SY. Use of a PDA-based pharmacist intervention system. Am J HealthSyst Pharm. 2003; 60:2341-4. 21. Gillespie G. PDAs are willing, but will they be able? Health Data Manag. 2002; 10:20-2,26-8. 22. Boruff JT, Storie D. Mobile devices in medicine: a survey of how medical students, residents, and faculty use smartphones and other mobile devices to find information. J Med Libr Assoc. 2014; 102:22-30. 23. Kho A, Henderson LE, Dressler DD et al. Use of handheld computers in medical education. A systematic review. J Gen Intern Med. 2006; 21:531-7. 24. Franko OI, Tirrell TF. Smartphone app use among medical providers in ACGME training programs. J Med Syst. 2012; 36:3135-9. 25. Payne KB, Wharrad H, Watts K. Smartphone and medical related app use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Decis Mak. 2012; 12:121.
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26. George P, Dumenco L, Dollase R et al. Introducing technology into medical education: two pilot studies. Patient Educ Couns. 2013; 93:522-4. 27. Ozdalga E, Ozdalga A, Ahuja N. The smartphone in medicine: a review of current and potential use among physicians and students. J Med Internet Res. 2012; 14:e128. 28. Mosa AS, Yoo I, Sheets L. A systematic review of healthcare applications for smartphones. BMC Med Inform Decis Mak. 2012; 12:67. 29. PocketGamer.biz. Application category distribution. www.pocketgamer.biz/ metrics/app-store/ (accessed 2014 Oct 13). 30. AppBrain. AppBrain stats: number of Android applications. www.appbrain.com/ stats/number-of-android-apps (accessed 2014 Jun 8). 31. Aungst TD. Medical applications for pharmacists using mobile devices. Ann Pharmacother. 2013; 47:1088-95. 32. Haffey F, Brady RR, Maxwell S. Smartphone apps to support hospital prescribing and pharmacology education: a review of current provision. Br J Clin Pharmacol. 2014; 77:31-8. 33. Moodley A, Mangino JE, Goff DA. Review of infectious disease applications for iPhone/iPad and Android: from pocket to patient. Clin Inf Dis. 2013; 57:1145-54. 34. Burdette SD, Trotman R, Cmar J. Mobile infectious disease references: from the bedside to the beach. Clin Infect Dis. 2012; 55:114-25. 35. Goff DA. iPhones, iPads, and medical applications for antimicrobial stewardship. Pharmacotherapy. 2012; 32:657-61. 36. Lin M, Rezaie S, Husain I. Top 10 mobile apps in emergency medicine. Emerg Med J. 2014; 31:432-3. 37. Rosser BA, Eccleston C. Smartphone applications for pain management. J Telemed Telecare. 2011; 17:308-12. 38. Clauson KA, Marsh WA, Polen H et al. Clinical decision support tools: analysis of online drug information databases. BMC Inform Decis Mak. 2007; 7:7-14. 39. Polen HH, Zapantis A, Clauson KA et al. Ability of online drug databases to assist in clinical decision-making with infectious disease therapies. BMC Infect Dis. 2008; 8:153-63. 40. Polen HH, Clauson KA, Thomson W et al. Evaluation of nursing-specific drug information PDA databases used as clinical decision support tools. Int J Med Inform. 2009; 78:679-87. 41. Berner ES, Houston TK, Ray MN et al. Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial. J Am Med Inform Assoc. 2006; 13:171-9. 42. Ray SM, Clark S, Jeter JW et al. Assessing the impact of mobile technology on order verification during pharmacist participation in patient rounds. Am J Health-Syst Pharm. 2013; 70:633-6. 43. Boussadi A, Caruba T, Karras A et al. Validity of a clinical decision rule-based alert system for drug dose adjustment
in patients with renal failure intended to improve pharmacists’ analysis of medication orders in hospitals. Int J Med Inform. 2013; 82:964-72. 44. Kullar R, Goff DA. Transformation of antimicrobial stewardship programs through technology and informatics. Infect Dis Clin North Am. 2014; 28:291-300. 45. Charani E, Kyratsis Y, Lawson W et al. An analysis of the development and implementation of a smartphone application for the delivery of antimicrobial prescribing policy: lessons learnt. J Antimicrob Chemother. 2013; 68:960-7. 46. Bahsoun AN, Malik MM, Ahmed K et al. Tablet based simulation provides a new solution to accessing laparoscopic skills training. J Surg Educ. 2013; 70:161-3. 47. EM Gladiators LLC. Resuscitation! app. https://itunes.apple.com/us/app/ re s u s c i t a t i o n ! / i d 5 5 3 8 8 7 7 3 6 ? m t = 8 (accessed 2014 Feb 8). 48. Hussainy SY, Styles K, Duncan G. A virtual practice environment to develop communication skills in pharmacy students. Am J Pharm Educ. 2012; 76:article 202. 49. Veronin MA, Daniels L, Demps E. Pharmacy cases in Second Life: an elective course. Adv Med Educ Pract. 2012; 3:10512. 50. Flowers MG, Aggrawal R. Second Life: a novel simulation platform for the training of surgical residents. Expert Rev Med Devices. 2014; 11:101-3. 51. Gabarron E, Schopf T, Serrano JA et al. Gamification strategy on prevention of STDs for youth. Stud Health Technol Inform. 2013; 192:1066. 52. Cafazzo JA, Casselman M, Hamming N et al. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res. 2012; 14:e70. 53. Wu R, Rossos P, Quan S et al. An evaluation of the use of smartphones to communicate between clinicians: a mixedmethods study. J Med Internet Res. 2011; 13:e59. 54. Wu RC, Morra D, Quan S et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med. 2010; 5:553-9. 55. Wilson C, Wu R, Lo V et al. Effects of smartphones on pharmacist-physician clinical communication. J Pharm Technol. 2012; 28:234-42. 56. Mayo Clinic. Patient app. https:// i t u n e s . a pp l e . com / u s / a pp / p a t i en t / id523220194?mt=8 (accessed 2014 Feb 8). 57. Kaiser Permanente. Kaiser Permanente app. https://itunes.apple.com/us/app/ kaiser-permanente/id493390354?mt=8 (accessed 2014 Feb 8). 58. Brock TP, Smith SR. Using digital videos displayed on personal digital assistants (PDAs) to enhance patient education in clinical settings. Int J Med Inform. 2007; 76:829-35. 59. Smith SR, Brock TP, Howarth SM. Use of personal digital assistants to deliver education about adherence to antiretroviral
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medications. J Am Pharm Assoc. 2005; 45:625-8. 60. Dayer L, Heldenbrand S, Anderson P et al. Smartphone medication adherence apps: potential benefits to patients and providers. J Am Pharm Assoc. 2013; 53:172-81. 61. Clauson KA, Elrod S, Fox BI et al. Opportunities for pharmacists in mobile health. Am J Health-Syst Pharm. 2013; 70:1348-52. 62. Boulos MN, Wheeler S, Tavares C, Jones R. How smartphones are changing the face of mobile and participatory healthcare: an overview, with example from eCAALYX. Biomed Eng Online. 2011; 10:24. 63. Margolis KL, Asche SE, Bergdall AR et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013; 310:46-56. 64. Carter T, O’Neill S, Johns N et al. Contemporary vascular smartphone medical applications. Ann Vasc Surg. 2013; 27:804-9. 65. Pandey A, Hasan S, Dubey D et al. Smartphone apps as a source of cancer information: changing trends in health information-seeking behavior. J Cancer Educ. 2013; 28:138-42. 66. Haffey F, Brady RR, Maxwell S. A comparison of the reliability of smartphone apps for opioid conversion. Drug Saf. 2013; 36:111-7. 67. Cantudo-Cuenca MR, Robustillo-Cortés MA, Cantudo-Cuenca MD et al. A better regulation is required in viral hepatitis smartphone applications. Farm Hosp. 2014; 38:112-7. 68. Thompson BM, Brodsky I. Should the FDA regulate mobile medical apps? BMJ. 2013; 347:f5211. 69. Food and Drug Administration. Mobile medical applications—guidance for industry and Food and Drug Administration staff. www.fda.gov/downloads/ MedicalDe v ices/De v iceRegulation andGuidance/GuidanceDocuments/ UCM263366.pdf (accessed 2014 Jun 8). 70. Mccarthy M. FDA will not regulate most mobile medical apps. BMJ. 2013; 347:f5841. 71. Van Velsen L, Beaujean DJ, van GemertPijnen JE. Why mobile health app overload drives us crazy, and how to restore the sanity. BMC Med Inform Decis Mak. 2013; 13:23. 72. Misra S, Lewis TL, Aungst TD. Medical application use and the need for further research and assessment for clinical practice: creation and integration of standards for best practice to alleviate poor application design. JAMA Dermatol. 2013; 149:661-2. 73. Lewis TL. A systematic self-certification model for mobile medical apps. J Med Internet Res. 2013; 15:e89. 74. Happtique. Happtique homepage. www. happtique.com (accessed 2014 Jun 8). 75. NHS Choices Health Apps Library. Ab o u t . h t t p : / / a p p s . n h s . u k / a b o u t (accessed 2014 Jun 5).
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76. OpenSignal. Android fragmentation visualized. http://opensignal.com/reports/ fragmentation-2013 (accessed 2014 Jun 4). 77. Fox BI, Felkey BG. Potential uses of Google Glass in the pharmacy. Hosp Pharm. 2013; 48:783-4. 78. Lu YC, Xiao Y, Sears A et al. A review and framework of handheld computer adoption in healthcare. Int J Med Inform. 2005; 74:409-22. 79. Krogh PR, Rough S, Thomley S. Comparison of two personal-computer-based mobile devices to support pharmacists’ clinical documentation. Am J Health-Syst Pharm. 2008; 65:154-7.
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How mobile devices are changing pharmacy practice Timothy Dy Aungst, Aimon C. Miranda, and Erini S. Serag-Bolos Am J Health-Syst Pharm. 2015; 72:494-500
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he first mobile devices to enter the market were the personal digital assistants (PDAs) of the late 1990s and early 2000s, and they ushered in the era of handheld computers. PDAs combined popular features of electronic tools (e.g., calculator) and computer apps applications (e.g., e-mail, calendar, planner) into a single handheld device and were identified as potential mobile resources in medical and pharmacy practice.1-7 Studies examining the patterns of PDA use among physicians and pharmacists revealed that these devices served as drug information references and facilitated medical calculations, supporting clinical activities.8-10 PDAs also helped to reduce adverse drug events, identify potentially dangerous drug interactions, document clinical activities, and increase productivity.11-20 However, these devices had notable limitations in their processing power,
memory storage, and capabilities and lacked a supportive electronic infrastructure with readily available cellular data services and wireless Internet. Mobile technology has undergone rapid advances in the past several years with the release of the modern smartphone and tablet computer. These devices have become a societal mainstay with which users can conduct everyday functions. The medical field has also seen an increased interest in the use of mobile devices in clinical care. Whereas 20–70% of physicians, medical residents, and medical students in the early 2000s had PDAs, recent data suggest that over 90% of these individuals have a smartphone.21-25 Many residents and students use their mobile devices during their didactic training and throughout their professional years.22-26 This shift in the use of mobile technology is due to the
Timothy Dy Aungst, Pharm.D., is Assistant Professor of Pharmacy Practice, MCPHS University, Worcester, MA, and Editor, iMedicalApps.com, Raleigh, NC. A imon C. Miranda, Pharm.D., BCPS, is Assistant Professor and Clinical Informatics Coordinator; and Erini S. Serag-Bolos, Pharm.D., is Assistant Professor and Coordinator of Interprofessional Education, Department of Pharmacotherapeutics and Clinical Research, College of Pharmacy, University of South Florida, Tampa. Address correspondence to Dr. Aungst ([email protected]). Paul Belliveau, Pharm.D., and Jennifer L. Donovan, Pharm.D., are acknowledged for
their assistance in the preparation of this article and for their insight and recommendations to improve upon it. Dr. Aungst is an editor for iMedicalApps. com, a website dedicated to providing news on the integration of mobile technology into medical care and reviewing medical apps for mobile devices. He does not consult or receive reimbursement from app developers or creators. The authors have declared no other potential conflicts of interest.
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Copyright © 2015, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/15/0302-0494. DOI 10.2146/ajhp140139
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amalgamation of different functions into a handheld tool that can be used for both clinical and societal applications. With advancements in mobile technology and increased uptake by the medical field, smartphones and tablet computers offer versatility in the clinical setting that was not possible a decade ago.27,28 This article describes the utility, possible opportunities, and limitations of mobile device use in pharmacy practice settings. Mobile medical apps for pharmacy practice. The iTunes and the Google Play stores currently contain over 20,000 medical apps.29,30 Although the apps tagged as “medical” are quite heterogeneous with regard to their purpose, audience, and function, some apps may help to support the clinical functions and daily workflow of pharmacy practitioners (Figure 1). Several published reports have identified apps suited for general pharmacy practice and specialty areas such as infectious diseases, emergency medicine, and pain management.31-37 While these reports may not be all-encompassing, they serve as a preliminary point for pharmacists seeking apps suited to their specific practice and interests. Clinical references. Medical smartphone apps are most commonly used for reference purposes, with drug information being the largest practical resource in pharmacy practice.22,25 The drug information references used as clinical decision support tools vary among individuals and institutions.38-40 Several popular drug reference suites (e.g., Micromedex [Truven Health Analytics, Ann Harbor, MI], Lexi-Comp [Lexi-Comp, Hudson, OH]) have migrated from personal computers to a mobile app format
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on smartphones and tablet computers.28,29 Many of these apps can be downloaded to the device and function offline, serving as a virtual drug information platform. These applications serve as resources for drug information, drug interactions, i.v. compatibility, and drug identification.31,32 With such functions, these apps can provide pharmacists with constant access to quality drug information. Clinical reference tools that have also found a niche on mobile devices include medical calculator apps.
These apps allow pharmacists to enter data needed for medical calculations, such as creatinine clearance estimations (e.g., Cockcroft–Gault equation to estimate renal function) and other calculations pertinent to specific medical disciplines (e.g., cardiology, neurology). Many textbooks and handbooks commonly found on pharmacy bookshelves or in white-coat pockets are being incorporated into electronic formats such as eBooks or fully integrative apps. The American Academy
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of Pediatrics’ Red Book and Nelsons Pediatric Antimicrobial Therapy are both available as apps.33 The Sanford Guide app (Antimicrobial Therapy, Sperryville, VA) incorporates information found in the traditional pocket-sized book but also integrates dose calculators pertinent to infectious diseases.35 Other apps have capitalized on the function of mobile devices to serve as portals that allow direct access to the medical literature, providing pharmacists with the most current
Figure 1. Integration of mobile devices into the pharmacy workflow.
Drug-related question occurs during rounds
Order placed for pharmacist verification
Pharmacist can use a mobile device to accomplish many functions throughout daily clinical responsibilities
Pharmacist needs to contact provider for intervention
Patient sends blood pressure data to pharmacist for monitoring
CLINICAL REFERENCE Pharmacist can look up drug information at the point of care
ORDER PROCESSING Pharmacist processes order as received while on the floor
COMMUNICATION Pharmacist contacts provider through texting, direct call, or e-mail
DOCUMENTATION Pharmacist documents all activities as he or she performs them
PATIENT ENGAGEMENT Pharmacist reviews patient data to make a therapeutic decision for management
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medical literature to support therapy decisions. Other apps provide point-of-care guidelines or pertinent medical recommendations, such as those found in Dynamed (EBSCO Information Services, Ipswich, MA), UpToDate (Wolters Kluwer, Alphen aan den Rijn, Netherlands), and the Johns Hopkins Point of Care guides (Unbound Medicine, Charlottesville, VA).32-34 Apps serving as portals to medical organization guidelines have also been created, such as the American Heart Association Joint Guidelines app (International Guidelines Center, Lake Mary, FL) and the National Comprehensive Cancer Network Guidelines app (TIP Medical Communications, Warren, NJ).35,36 Pharmacy workflow and productivity. Clinical decision support systems (CDSSs) are increasingly being made available as point-ofcare tools to help with patient care activities. The Internet access available with mobile devices allows for the easy transfer of data to desktop computers and retrieval of information for use at the patient’s bedside or examination room. Some CDSSs have built-in treatment algorithms to assist with prescribing and improve patient safety.41 CDSSs can also provide dosing recommendations, check for drug–drug interactions, and track follow-up interventions. The access provided by mobile devices reduces the need for a pharmacist to be dependent on a computer housed in a specific location, thus increasing the pharmacist’s mobility. In one recent study, pharmacists evaluated the use of iPads to process orders during medical patient care rounds in a hospital settting.42 Pharmacists became more productive in their order-entry functions, as the iPad decreased the time required to process immediate or urgent orders, and had the ability to access information to answer drugrelated questions during patient care rounds. 496
Mobile devices may also prove to be useful as tools to help prescribers and pharmacists improve patient safety. Boussadi and colleagues 43 investigated alert systems embedded within electronic health records (EHRs), such as those that addressed renal function and anticoagulation concerns, to complement pharmacist activities and improve safety benefits. Of the 5006 drug prescription lines analyzed, the alert system correctly analyzed 4863 (97.14%), whereas the pharmacists correctly analyzed 4745 (94.77%) of the same lines. Implementation of such alert systems through mobile devices can facilitate implementation of decision support tools for antimicrobial prescribing to help improve the efficiency of antimicrobial stewardship programs.44,45 Previously, documentation of direct patient care and clinical services was captured using PDAs.15-20 These activities can now be documented through EHRs or other surveillance software that integrates with EHRs. Since pharmacists can document the amount of time spent on various functions at the point of care using a mobile device, a pharmacist need not rely on recall when recording these activities. Such documentation has proven valuable in justifying pharmacist full-time equivalents, helping with time management, and documenting outcomes of cost-saving initiatives.15-20 Education. Mobile devices may increase healthcare professionals’ access to a variety of unique continuing-education (CE) platforms such as podcasts, visual interactive anatomy guides, and medical simulations.35 The literature describing the use of these education tools is mostly limited to physicians using apps to train providers in laparoscopic skills, rapid responses, or emergency situations.46,47 While few apps are related to pharmacy education, there are opportunities to expand this area (e.g., board-review programs or apps to
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train pharmacists and students in the areas of physical assessment). Such tools may also take the form of unique electronic platforms. Virtual reality programs are one such platform (e.g., Second Life [Linden Lab, San Francisco, CA]) that has been used for communication skills training of pharmacy students.48,49 Second Life has also been used to train surgical residents to complete patient interviews and physical examinations via interactions with patient avatars.50 An additional area of interest is the implementation of game mechanics into learning activities, called gamification, and has been recently explored as a mechanism to engage patients and students.51,52 Such an approach could be integrated into mobile apps and serve as a novel way to teach students and pharmacists about new topics or medical cases. Apps may also be used by pharmacists to collect required CE hours and to remain current on medical news and topics. The Pharmacist’s Letter app (Therapeutic Research, Stockton, CA) allows users to collect CE credits directly through the app. Future opportunities may include new ways of conducting CE programs for pharmacists that will capitalize on gamification and other interactive mechanisms available through mobile devices. Communication. Research evaluating the small-scale integration of smartphones as communication tools in the hospital has found improved communication and perceived faster productivity with use of such devices.53,54 Smartphones’ texting and e-mail abilities are leveraged with time-sensitive situations and institutional patient confidentiality policies but may allow increased data communication that would otherwise be communicated orally. In addition, “phone tag,” which may occur with pager communications, may be less of an issue when practitioners have direct access to each other via smartphones. In a study by
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Wilson and colleagues,55 the use of smartphones to communicate between pharmacists and providers did not result in a significant reduction in time to resolution of medicationrelated issues, but participants did report improved team communication efficiency. At the current time, there is no app designed specifically to enhance interdisciplinary communication among health professionals. However, with the rapid pace of app and device development and their ubiquitous availability in healthcare settings, future innovations in smartphone technology may make smartphone use for this purpose commonplace and compliant with the Health Insurance Portability and Accountability Act. Patient engagement. Mobile devices and their apps offer new ways for pharmacists to directly engage with patients. Portals, which allow patients to access their medical information, are becoming commonplace. Several large-scale medical institutions, such as the Mayo Clinic and Kaiser Permanente, have created apps designed for use by patients.56,57 Through these apps, patients can receive reminders for follow-up laboratory tests, reminders about upcoming appointments, and results of laboratory or diagnostic tests. Patient queries regarding medical concerns can be sent through these portals and addressed by healthcare providers at their convenience, thus avoiding disruption of workflow while providing reassurance to the patients that their questions are being addressed. One key area where mobile apps may play a notable role between pharmacy and patient care is medication adherence and education. Counseling for patients with human immunodeficiency virus infection and medication counseling education via such an app were shown to improve patients’ knowledge of disease and medications and increased medication adherence.58-60 Dayer and colleagues60 evaluated medication
adherence apps available on three main smartphone operating systems (Apple, Android, and Blackberry) and concluded that while these apps have not been tested in trial settings, pharmacists could consider their use for nonadherent patients. Such apps can be easily integrated into patient education activities since they are inexpensive, are accessible, and do not require separate devices. Mobile apps and associated peripheral devices also have applicability for future uses in telemedicine and mobile health.61 New devices approaching the market include those that can collect pertinent vital signs such as heart rate, blood pressure, blood glucose, electrocardiogram readings, physical activities, and weight. There are many health management apps for chronic diseases such as diabetes, hypertension, and obesity.62 Patients now have the capabilities to record their data and share it with providers through these tools. In addition, the built-in cameras of mobile devices expand on virtual communication, allowing digital, face-to-face communication. This may provide additional opportunities for outpatient management by pharmacists. One recent study by Margolis and colleagues63 investigated the home monitoring of blood pressure of hypertensive patients and their medication management by pharmacists. Using the data collected by patients and transmitted to the clinic, pharmacists were able to assess patients’ responses to treatment and enhance patient engagement through telemedicine practices to make therapeutic adjustments.63 Mobile devices and apps may help pharmacists engage patients with chronic diseases and those at high risk for adverse drug events and help with postdischarge monitoring of drug therapies. Current limitations. While mobile devices and their associated apps have much to offer pharmacists, there are
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several limitations that may prevent easy assimilation into clinical practice. One of the foremost concerns with mobile medical apps is quality, which has been noted to be lacking in the majority of available apps. With over 20,000 apps offered by iTunes and the Google Play stores, this may come as no surprise, especially considering that Apple and Google are not directly responsible for reviewing the information found within those apps.29,30 Research has shown that the number of apps that are poorly developed, are inadequately researched, or have other areas of concern may be higher than expected. In several studies, authors noted that clinical information is often not cited, medical dose calculators (e.g., for opioid conversion) are inconsistent, and authors and conflicts of interest are rarely disclosed.37,64-67 While there has been debate as to whether the Food and Drug Administration (FDA) should regulate mobile medical apps, FDA has recently released guidelines to address concerns about their impact on patients and clinical care. 68,69 However, in its current iteration, the guidelines only address apps that (1) “are intended to be used as an accessory to a regulated medical device” or (2) “transform a mobile platform into a regulated medical device.”69 As many of these medical apps do not fall into this realm and will most likely not be reviewed by FDA, recommendations abound for professional organizations to evaluate these apps.70-73 This has led to the creation of app certification programs and curated app programs by institutions.74,75 Integration of mobile devices into clinical practice faces many technological obstacles due to the rapid pace of mobile device and app development and limitations of available institution infrastructure. Because of the rapid pace of technological development, institutions may invest time and resources in the selection of
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technology, which will be supplanted by newer emerging options. In addition, device selection will likely remain a concern. Currently, the two largest stakeholders in the market are Apple (iOS) and Google (Android), and both have several devices that support their operating systems.76 With multiple variants of operating systems and devices available, there is a high possibility of fragmentation in the system, which may require monitoring and regulation by information technology departments and necessitating the integration of increased clinical information systems. 76 Furthermore, the rapid development of mobile technology may also pose a barrier in terms of how to incorporate unique wearable technologies coming to the market. These include Google Glass, smart watches, and other wearable devices that may function as adjunctive tools to current smartphones and tablet computers. Some of these devices may find a niche in the practice of pharmacy, such as the utilization of Google Glass in the hospital to aid in the medication dispensing process or documentation of activities.77 Further research is needed to determine the role of such devices into pharmacy practice as well as demonstrate their practical utilization. Other barriers to device adoption in the workplace include education of personnel, perceptions that adoption requires extra effort and time, fear of new technology, cost of app subscriptions, and the planning required for effective technology integration into workflow.78 The smaller screens and keyboards on mobile devices and wireless Internet connection consistency throughout an institution also may slow adoption.42,79 Summary. Mobile devices and their accompanying applications pose several benefits over currently utilized technology infrastructures. These devices afford healthcare providers with easy access to pertinent 498
and detailed clinical references and tools for patient care. These devices may aid in clinical decision-making, allow mobile access to the EHR and hospital workflow systems, and provide a platform for remote patient engagement. The substantial storage capacity of these devices allows apps to be downloaded and used without reliance on an internet connection to function, allowing them to serve as mobile workstations. Future research with mobile devices and apps should focus on outcomes documentation. Such research is vital to assess the effectiveness of mobile health devices in improving the quality of interprofessional care, medication adherence, and patient outcomes. In particular, investigations are needed to assess in which settings mobile devices would be of most benefit as well as which apps would be of most use in specific healthcare environments. References 1. Baumgart DC. Personal digital assistants in health care: experienced clinicians in the palm of your hand? Lancet. 2005; 366:1210-22. 2. Honeybourne C, Sutton S, Ward L. Knowledge in the palm of your hands: PDAs in the clinical setting. Health Info Libr J. 2006; 23:51-9. 3. Kostka-Rokosz MD, Mccloskey WW. Survey of pharmacy preceptors’ use of hand-held electronic devices. J Am Pharm Assoc. 2009; 49:69-72. 4. Felkey B, Fox BI. Emerging technology at the point of care. J Am Pharm Assoc. 2003; 43(suppl 1):S50-1. 5. Dasgupta A, Sansgiry SS, Sherer JT et al. Pharmacists’ utilization and interest in usage of personal digital assistants in their professional responsibilities. Health Info Libr J. 2010; 27:37-45. 6. Yu F, Houston TK, Ray MN et al. Patterns of use of handheld clinical decision support tools in the clinical setting. Med Decis Making. 2007; 27:744-53. 7. Knollmann BC, Smyth BJ, Garnett CE et al. Personal digital assistant-based drug reference software as tools to improve rational prescribing: benchmark criteria and performance. Clin Pharmacol Ther. 2005; 78:7-18. 8. Rothschild JM, Lee TH, Bae T et al. Clinician use of a palmtop drug reference guide. J Am Med Inform Assoc. 2002; 9:223-9. 9. McCreadie SR, Stevenson JG, Sweet BV et al. Using personal digital assistants to access drug information. Am J Health-Syst Pharm. 2002; 59:1340-3.
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in patients with renal failure intended to improve pharmacists’ analysis of medication orders in hospitals. Int J Med Inform. 2013; 82:964-72. 44. Kullar R, Goff DA. Transformation of antimicrobial stewardship programs through technology and informatics. Infect Dis Clin North Am. 2014; 28:291-300. 45. Charani E, Kyratsis Y, Lawson W et al. An analysis of the development and implementation of a smartphone application for the delivery of antimicrobial prescribing policy: lessons learnt. J Antimicrob Chemother. 2013; 68:960-7. 46. Bahsoun AN, Malik MM, Ahmed K et al. Tablet based simulation provides a new solution to accessing laparoscopic skills training. J Surg Educ. 2013; 70:161-3. 47. EM Gladiators LLC. Resuscitation! app. https://itunes.apple.com/us/app/ re s u s c i t a t i o n ! / i d 5 5 3 8 8 7 7 3 6 ? m t = 8 (accessed 2014 Feb 8). 48. Hussainy SY, Styles K, Duncan G. A virtual practice environment to develop communication skills in pharmacy students. Am J Pharm Educ. 2012; 76:article 202. 49. Veronin MA, Daniels L, Demps E. Pharmacy cases in Second Life: an elective course. Adv Med Educ Pract. 2012; 3:10512. 50. Flowers MG, Aggrawal R. Second Life: a novel simulation platform for the training of surgical residents. Expert Rev Med Devices. 2014; 11:101-3. 51. Gabarron E, Schopf T, Serrano JA et al. Gamification strategy on prevention of STDs for youth. Stud Health Technol Inform. 2013; 192:1066. 52. Cafazzo JA, Casselman M, Hamming N et al. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res. 2012; 14:e70. 53. Wu R, Rossos P, Quan S et al. An evaluation of the use of smartphones to communicate between clinicians: a mixedmethods study. J Med Internet Res. 2011; 13:e59. 54. Wu RC, Morra D, Quan S et al. The use of smartphones for clinical communication on internal medicine wards. J Hosp Med. 2010; 5:553-9. 55. Wilson C, Wu R, Lo V et al. Effects of smartphones on pharmacist-physician clinical communication. J Pharm Technol. 2012; 28:234-42. 56. Mayo Clinic. Patient app. https:// i t u n e s . a pp l e . com / u s / a pp / p a t i en t / id523220194?mt=8 (accessed 2014 Feb 8). 57. Kaiser Permanente. Kaiser Permanente app. https://itunes.apple.com/us/app/ kaiser-permanente/id493390354?mt=8 (accessed 2014 Feb 8). 58. Brock TP, Smith SR. Using digital videos displayed on personal digital assistants (PDAs) to enhance patient education in clinical settings. Int J Med Inform. 2007; 76:829-35. 59. Smith SR, Brock TP, Howarth SM. Use of personal digital assistants to deliver education about adherence to antiretroviral
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medications. J Am Pharm Assoc. 2005; 45:625-8. 60. Dayer L, Heldenbrand S, Anderson P et al. Smartphone medication adherence apps: potential benefits to patients and providers. J Am Pharm Assoc. 2013; 53:172-81. 61. Clauson KA, Elrod S, Fox BI et al. Opportunities for pharmacists in mobile health. Am J Health-Syst Pharm. 2013; 70:1348-52. 62. Boulos MN, Wheeler S, Tavares C, Jones R. How smartphones are changing the face of mobile and participatory healthcare: an overview, with example from eCAALYX. Biomed Eng Online. 2011; 10:24. 63. Margolis KL, Asche SE, Bergdall AR et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA. 2013; 310:46-56. 64. Carter T, O’Neill S, Johns N et al. Contemporary vascular smartphone medical applications. Ann Vasc Surg. 2013; 27:804-9. 65. Pandey A, Hasan S, Dubey D et al. Smartphone apps as a source of cancer information: changing trends in health information-seeking behavior. J Cancer Educ. 2013; 28:138-42. 66. Haffey F, Brady RR, Maxwell S. A comparison of the reliability of smartphone apps for opioid conversion. Drug Saf. 2013; 36:111-7. 67. Cantudo-Cuenca MR, Robustillo-Cortés MA, Cantudo-Cuenca MD et al. A better regulation is required in viral hepatitis smartphone applications. Farm Hosp. 2014; 38:112-7. 68. Thompson BM, Brodsky I. Should the FDA regulate mobile medical apps? BMJ. 2013; 347:f5211. 69. Food and Drug Administration. Mobile medical applications—guidance for industry and Food and Drug Administration staff. www.fda.gov/downloads/ MedicalDe v ices/De v iceRegulation andGuidance/GuidanceDocuments/ UCM263366.pdf (accessed 2014 Jun 8). 70. Mccarthy M. FDA will not regulate most mobile medical apps. BMJ. 2013; 347:f5841. 71. Van Velsen L, Beaujean DJ, van GemertPijnen JE. Why mobile health app overload drives us crazy, and how to restore the sanity. BMC Med Inform Decis Mak. 2013; 13:23. 72. Misra S, Lewis TL, Aungst TD. Medical application use and the need for further research and assessment for clinical practice: creation and integration of standards for best practice to alleviate poor application design. JAMA Dermatol. 2013; 149:661-2. 73. Lewis TL. A systematic self-certification model for mobile medical apps. J Med Internet Res. 2013; 15:e89. 74. Happtique. Happtique homepage. www. happtique.com (accessed 2014 Jun 8). 75. NHS Choices Health Apps Library. Ab o u t . h t t p : / / a p p s . n h s . u k / a b o u t (accessed 2014 Jun 5).
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76. OpenSignal. Android fragmentation visualized. http://opensignal.com/reports/ fragmentation-2013 (accessed 2014 Jun 4). 77. Fox BI, Felkey BG. Potential uses of Google Glass in the pharmacy. Hosp Pharm. 2013; 48:783-4. 78. Lu YC, Xiao Y, Sears A et al. A review and framework of handheld computer adoption in healthcare. Int J Med Inform. 2005; 74:409-22. 79. Krogh PR, Rough S, Thomley S. Comparison of two personal-computer-based mobile devices to support pharmacists’ clinical documentation. Am J Health-Syst Pharm. 2008; 65:154-7.
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