For Ashley Davis, BS, RN, using her smartphone as an ICU nurse provides quick and easy access not only to medical information, but also to a critical care physician.

“I don’t use one specific mobile app,” says Davis. “Typically, I will enter a topic or medication into Google and read from several of the results to get a well-rounded answer to my question. If I am looking for journal articles, my preferred site is Medscape. As a registered member of their site, I also receive regular e-mails from them regarding top medical news, trends, and educational opportunities.”

As helpful as the information Davis finds can be, it does have limits: “I do not rely on an app or website to dictate patient care,” says Davis, who uses a smartphone at work even though her hospital bans such use. “Rather, it is an additional tool to broaden my knowledge base. Any treatment should be administered with sound nursing judgment and under the direction of a physician.”

That Davis feels the need to use her own smartphone to access mobile health apps to improve her efficiency with patient care despite hospital policy illustrates the growing need for nurses to not only join the mHealth movement, but also become leaders in it, according to nursing experts.

Power of Nurses

“Nurses play an important role in mHealth transformation,” says Jing Wang, PhD, MPH, RN, an assistant professor of nursing systems at the University of Texas Health Science Center at Houston School of Nursing. “There are many apps that are tailor-made for nurses to better manage their patients. However, few nurses take a leading role in designing and developing apps for patients to better take care of themselves. There’s much more [that] can be done,” says Wang, a diabetes researcher.

One critical step is to integrate the apps in clinical information systems, devices, and nurse call systems, Wang says. “Nurses are at the forefront of health care. There is a huge need to connect mobile apps that nurses use to clinical information systems, so that nurses can better communicate with other health care providers. And there is also a huge need to connect patient-using apps to electronic health record systems that nurses and other providers use, so that nurses can better provide patient-centered care, in collaboration with other health care providers.”

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Nurses must be taken into consideration as apps increasingly play a role in health care, says Lori O’Connor, RN, chief nursing and quality officer for Care at Hand, Inc. “Sometimes, when doctors are at the forefront, things are done a certain way, and the realistic part of nursing… doesn’t truly represent itself. I think any app that includes any type of nursing intervention, or has nurses using it, is better off for it.”

A survey done in early June 2015 by InCrowd, an on-demand market intelligence provider to the life sciences, found that despite HIPAA-/security-driven restrictions and mobile device use policies, 95% of nurses own a smartphone and 88% of them use smartphone apps at work. At 88%, nurses’ use of smartphone apps is greater than the 67% figure recorded in a February 2014 Wolters Kluwer survey, and on par or above other reports of smartphone usage by 67% of medical residents and 80% of physicians, the report found.

Most nurses, like Davis, use apps to check drug interaction or symptom and disease details. By doing so, they often find no need to consult before providing care. Apps replaced the nurse asking information of a nursing colleague (52%) or a physician (32%) to save time, according to the survey. The high smartphone app use among nurses happened even though most facilities do not provide or reimburse for smartphones or ban their use during nurses’ shifts.

Over 10,000 apps exist on IOS and Android devices, a number that has more than doubled in 30 months, according to the mHealth App Developer Economics 2014 report. Fitness, medical reference, and wellness apps make up the largest categories.

Highlighting the must-have apps is difficult since nurses work in diverse health care settings, experts say. There is no single app that every nurse would find useful, says Wang. “Nurses in clinical settings may find apps that can look up drug information helpful. Nurses working with chronically ill patients may want to invest time in learning a few popular health and fitness apps that patients use to better understand patients’ behaviors and provide individualized care.”

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Apps that are popular with nurses are easy to install and use and can help with patient documentation, says Birgit Koellmer, RN, BSN, a nurse informaticist at Saint Mary’s Hospital in Waterbury, Connecticut. At Saint Mary’s, mobile apps and technologies are improving care coordination, clinical communication, patient safety, and patient engagement, says Koellmer.

To secure text messaging and other clinical communication, Saint Mary’s has adopted Imprivata Cortext, which gives its care providers a fast, secure means of communicating and coordinating right from their smartphone, iPad, or computer.  Communication is more efficient between physicians and nurses, who started using the app a year ago, although all hospital staff now uses it. The app “is good for any hospital,” says Koellmer.

Patient Engagement

Saint Mary’s has seen great improvement since implementing Imprivata Cortext, but one of the more interesting angles is how they are using it to improve patient engagement. HIPAA requirements make it difficult to have meaningful e-mail, phone, or text message communications with patients and their families because health information must be protected; native SMS texting, for example, does not meet HIPAA compliance. Imprivata Cortext allows providers to send a text to a patient, even if they don’t have Cortext, to a secure link that is encrypted. For example, after day-surgery, health care providers can send a patient’s family text messages about the status of their loved one, whether they are in a waiting room or at home unsure about what’s happening. Appointment reminders can also be sent to alert patients about appointment times or instructions.

While mobile health apps enable individuals to learn more about their own health, some of the resources they seek can be misleading, nurses say.

“I feel patients can be more informed with mobile health apps as long as they are trusted sites,” says Davis. “I have had patients in the past who have researched an illness or procedure and have been severely misinformed. Being misinformed can add undue stress to an ill patient and/or family members. This in turn can lead to mistrust of the information provided by the medical team as well as delayed treatment.”

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As far as mobile apps affecting patient care directly, Davis says that won’t happen “unless they are encompassed into each facility’s EMR. I do, however, believe that they can serve as a great resource for nurses and physicians. Having additional resources will always be valuable when addressing the needs of patients.”

One app that has attracted attention for benefiting patients and health centers is the Care at Hand app, a mobile care coordination technology to help prevent hospital readmissions by using nurses as well as nonclinical support, such as home care individuals, to flag emerging issues before hospitalization is required. The app tracks a person’s health in real time on a consistent basis and has lowered hospitalizations and readmissions, says O’Connor. “The community health workers are the ones asking the questions, and all that information is transmitted to me. I can go into the app and see from my staff or the patient level, who is costing us the most money? Who is the sickest? Of the sickest patients, did we do the right intervention? Are my nurses doing what they are supposed to do to prevent those readmissions, and are the community health workers doing what they are supposed to be doing?”

The app is also popular with some homebound individuals, O’Connor says. The elderly especially like the app as it also opens up a whole new world to them. “It’s popular among people who may be alone or who don’t have family in the area. It gives them that interaction with somebody, so that’s a huge benefit,” in addition to the medical implications.

Named a 2013 Robert Wood Johnson Foundation Nurse Faculty Scholar, Wang agrees that apps can empower patients to become more informed and engaged in their health care. Her current project is evaluating the effect of mobile applications on the care of diabetic patients.

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Mobile health apps for diabetes patients include one that can track blood sugar levels or automatically transmit blood sugar data from glucose meter to smartphone apps. Others set behavioral goals and track progress, such as the AADE Goal Tracker app. Popular fitness and weight-loss apps that will help diabetes patients keep track of their weight, diet, and activity levels include MyFitnessPal, Lose It!, and the Fitbit and Jawbone wristbands that can automatically track your steps and sleep.

“These self-monitoring apps can help patients with diabetes become more informed and aware of their own behaviors in relation to blood sugar control. These apps also help patients become more engaged in their own care,” says Wang.

It is important to have rigorously designed research studies to measure the efficacy of mobile health apps. Such studies are mostly lacking today, says Wang. “Nurses can take a leading role in studying the efficacy of these apps in relation to health outcomes, as we are the best patient advocates.”

Workflow Matters

As the number of mobile health apps rises, workflow integration is essential, says Ron Razmi, MD, MBA, founder and CEO of Acupera, a health care technology company that provides a population health and care coordination platform for medical centers.

“Unlocking the untapped potential of mHealth will require that all applications and data, and nurses and care teams using those apps, plug back into a population health ‘command center,’ where interoperability and workflow integration can fuel comprehensive care coordination both inside and outside the hospital’s four walls,” says Razmi.

The cardiologist and entrepreneur says that “this is an increasingly important trend with the rise of value-based care, which requires a more integrated, comprehensive, and long-term vision for patients than ever before. While nurses and remote care teams are beginning to tap into these new mHealth solutions, often through mobile devices, they will assuredly fail if the data and workflows they rely on are kept siloed, and the data being collected isn’t collected with deliberate workflow use in mind.

“While these devices can produce valuable data, that data can end up in a ‘data landfill’ without a sophisticated integration model in place, and if the insights aren’t manipulated to create real-time workflows. Doctors and care teams don’t have the time or resources to filter, process, and implement that data on their own and often are overwhelmed by the idea of unnecessary new mounds of data flooding their care delivery strategy,” says Razmi.

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Mobile health apps are predicted to gain momentum and become an integral part of health care management.

Mobile health apps will give patients more autonomy and control of their own health and care, and better connect patients with providers as a way to facilitate communication between patients and providers, says Wang. “My currently funded Robert Wood Johnson Foundation Nurse Faculty Scholar Program project will provide better evidence on connecting mobile health apps with provider-facing clinical information system to bridge the gap. mHealth will definitely play a significant role in creating a culture of health.”

Koellmer predicts health providers will be able to take care of larger patient populations without compromising quality of care. Identifying outbreaks earlier will be another development, she says.

O’Connor says the future role of patients will shift. “I think you will see patients turn into consumers because mobile applications allow care to be delivered when it needs to be and where the patient is. It doesn’t require the patient to leave the house or for a patient in a rural area to drive three hours to an appointment. The technology reaches more people, and I think that it’s only going to get better from this point. I think when you have an interactive application…something like that is even more enhanced.”

Robin Farmer
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