First off I should state that while I generally love Apple products and have owned many, I have no financial interest in the company so this is not a plug with a hidden objective. Rather I was tipped off by a friend who is co-founder of Kindoma (a brilliant piece of software I would add that I also previously wrote about here). She was watching the Apple Keynote address and texted me after she saw something that she knew might pique my interest. No it wasn’t a bigger or faster iPhone, an iPad or even the Watch itself but rather a new capability using an Watch that I believe will revolutionize how we physicians and other health care providers interact with each other.
The short 4 minute presentation was by the founders of a piece of software called Airstrip and thankfully I was able to isolate just that presentation
I like others work in a busy NICU that at any given time has multiple babies receiving myriad blood and radiological tests. In tandem there are babies in need of physical exams, discharges to prepare, lectures to hear and paperwork to sign. After testing is ordered there is no way to predict exactly when results will be ready but when they are, we rely on our memory or the assistance of the bedside nurses to remind us that we need to follow-up. In the case of testing that is slow to come back, such as those that are only batched on certain days or sent to an outside laboratory the potential for missed follow-up is high.
Do Physicians Actually Miss Tests?
This was in fact the subject of a systematic review The safety implications of missed test results for hospitalised patients: a systematic review. This study examined the results of 12 studies, each of which sought to determine how commonly results were missed by staff physicians. One of the studies included found that 28.8% of the time results that were considered urgent were never accessed by the physician. Interestingly 5.1% of the time they did attempt to see them via a login terminal but before the results were ready so in other words were either too early or too late (not at all before the patient left). When looking at only emergency room settings, seven studies quantified the extent of failure to followup in EDs This ranged from 1.0% to 75% of tests and 0% to 16.5% of patients treated in the ED. Test types included: radiology with failure to follow-up ranging from none to 5.6%; microbiology with failed follow-up ranging from 3.0% to 75% and urgent biochemistry with 44.7% not followed up. One can see the comparison between a busy NICU and an ED so to think that so many tests can be missed due to lack of follow-up is frightening. Another concerning finding from the above analysis was that whether the hospital used paper, paper/electronic charting or purely electronic did not affect the rate of missed results.
Another question though is how quickly do physicians respond to a critical result.
This was the question that Kuperman GJ and colleagues tried to answer in their paper from 1998. In the chart review of a 9 day period, 99 test results were identified as being critical (CLR). Among these 99 CLRs, the median time interval until an appropriate treatment was ordered was 2.5 hours. This interval was 1.8 hours when the CLR met the laboratory’s criteria and a phone call was made, and 2.8 hours when the CLR met more complex criteria not requiring a phone call (p = 0.07). Shockingly, for 27 (27%) of the CLRs, an appropriate treatment was ordered only after five or more hours. The use of a phone call system does not seem to truly improve the reaction time even for these critical results.
The following year the same group published their findings using an automated alerting system to notify health care providers of such abnormal results. The laboratory equipment is capable of identifying an abnormal result and then automatically generating a page to the responsible physician. In this study, the main goal was to see if their previous response times could be improved. After exclusions, 192 alerting situations (94 interventions, 98 controls) were analyzed. The intervention group had a 38 percent shorter median time interval (1.0 hours vs. 1.6 hours, P = 0.003; mean, 4.1 vs. 4.6 hours, P = 0.003) until an appropriate treatment was ordered. There was no significant difference between the two groups in the number of adverse events.
You might be surprised by the minimal increase in efficiency with such a paging system but I can’t say I am shocked. Having a system that still requires the provider to call back or check a computer is great if the person is free at the time but what if they are with a patient or being pulled in three different directions in the ED. Will they still remember to answer the page? In many cases I imagine they might forget and then recall afterwards.
How Will Airstrip Resolve These Issues?
It is unclear to me whether the data from an electronic patient record needs to be pushed by a nurse or whether it can be automated but if not now I am certain the future will have this capability. Information can be pushed to the Watch as soon as it is reported so the clinician need only glance down at their watch to see the results. Guessing as to whether the results are ready is eliminated as are wasted minutes each time they sit down at a terminal to check if they are done. Imagine as well ordering an x-ray and a message appearing on the watch to inform you it is processed and ready for viewing. Then there is the ripple effect to consider. At some point perhaps even now the bedside nurse or unit clerk need to waste time finding the doctor to remind them to check. They could focus on the patient which is something they would rather do I imagine anyway!
In terms of privacy issues the technology is able to recognize when the physician is wearing the watch and push the data to them as long as it is on their wrist. Once removed (if taken off in a washroom and forgotten) it is disabled and in addition is HIPPA compliant with hospital compliance requirements.
There is additional functionality with being able to communicate with the nurse or family of a patient via the linked patient, family, nurse and lab results to the physician. Imagine getting the results of a head ultrasound and while walking from viewing the images sending the family a note via secure text letting them know you are coming to the unit if they want to hear the results. Embedded within this technology is also the ability to send orders to the EPR via a touch interface on the iWatch. Get an abnormal set of electrolytes that you believe is dilutional? Simply tap the electrolytes order on the Watch and the EPR notifies the bedside nurse or lab to recollect. I could go on with the many potential improvements to workflow that this technology may bring but thus far as you can tell I am quite impressed.
The chief problems that we face as providers in a busy NICU are failing to follow-up on results, and acting on these results. Airstrip on the iWatch would certainly go a long way to helping with these issues. I imagine a study to prove such efficiency will soon follow and if the results are as I expect I look forward to seeing an Watch on all of our medical staff in the near future. Better care is always our goal and this could be one efficient way to achieve it.