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Medicine adapts to new era of connectivity

One of the most significant societal shifts of the past decade has been the rise of mobile computing technology, smartphones in particular. As physicians and patients use new tools and applications, dermatologists, along with their colleagues throughout medicine, are participating in a rare bit of futurism as they consider how these technologies will impact physician-patient relationships.

Smartphones and medicine

The ability to not only communicate but access almost any conceivable information using a device that fits in a pocket has resonated strongly with the American public a 2012 Nielsen survey placed smartphone adoption rates among all U.S. adults at 50.4 percent. Among physicians, the numbers are far less studied, but seem to surpass the general median. A 2010 study by Manhattan Research found that 72 percent of doctors reported that they used smartphones, and the firm predicted an increase to 81 percent in 2012. Among the next generation of physicians, the trend is even more pronounced. An October 2012 study in the Journal of Medical Systems (36(5):3135-9) found that among those in ACGME training programs, 85 percent reported smartphone use.

Among patients, use is similarly robust. The Pew Internet and American Life Project reported that 85 percent of U.S. adults own a cell phone, and 45 percent of adults own a smartphone. Rates of use are especially high in the urban and suburban areas where dermatologists most often practice. [pagebreak]

Stanford University internist Errol Ozdalga, MD, who wrote on the use of smartphones among students and physicians for the Journal of Medical Internet Research (2012;14(5):e128) said that many of today’s physicians and physicians-in-training are comfortable integrating smartphones into both their personal and professional lives, and that the growth in smartphone utilization among doctors is largely an outgrowth of a younger generation’s entry into the medical workforce.

As a medical student, Dr. Ozdalga said, he was given the use of a slightly older generation of technology — a personal digital assistant manufactured by defunct hardware brand Palm. Having received that accompaniment to his training (he graduated in 2008), he said, he was conditioned to embrace evolving technology as part of the practice of medicine.

“I can’t emphasize how important it was for me to have that Palm Pilot with me during medical school and have something that would tell me exactly what the physical exam findings should be, and what the questions to ask were,” Dr. Ozdalga said. “Technology made me a better student, a better resident, and today it’s making me a better physician every day I use it. A greater number of physicians are using their phones like this, and I think that number still needs to grow.” [pagebreak]


The smartphone, according to dermatologist Jeffrey Benabio, MD, director of physician innovation at Kaiser Permanente, and a frequent speaker on technology and social media, has applications in multiple areas of a dermatologist’s professional life — from interacting with colleagues to educating patients about their conditions to keeping one’s public profile relevant.

“When I have spare time, I’m able to use the New England Journal of Medicine app and a few others for reading the materials that are recommended to me,” Dr. Benabio said. “When I’m with a patient, there’s point-of-care software available to offer patients additional information. And when I want to have discussions with my colleagues, I can use email informally to discuss medical issues, or a physician networking app like Sermo or Doximity to begin a conversation with dermatologists from all over the country.”

As an internal medicine physician admitting patients from the emergency room, Dr. Ozdalga said, he’s able to update himself on an incoming patient’s condition in the time it takes him to walk across the hospital.

“There’s so much to know these days, and to have that much information in your phone is powerful. When I’m walking down the hallway toward the ER, maybe a three-minute walk, questions come up to my head depending on what the staff has told me about the patient,” Dr. Ozdalga said. “The patient may have certain cardiovascular disease, and I can literally look [information about it] up on my phone. I can answer almost every condition-specific question I have within 60 seconds or less. It’s immensely powerful, and it really has made me a better physician.” [pagebreak]

Even for dermatology, which has seen slower EHR adoption than some specialties due to its higher percentage of smaller practices, Dr. Benabio said, smartphone applications offer value to practices through patient-directed safety and prescription programs.

“I don’t use a lot of point-of-care apps, but I like that I have the e-prescribing ones available to me. Drug interactions directly impact patient care, and I like that I can quickly enter, say, minocycline and isotretinoin’ into an app and trip the alarm that tells me that the drugs are contra-indicated,” he said.

While physicians are making greater use of mobile applications, most patients are as well, with general smartphone use among the population taking a similarly sharp uptick over the last five years. With the sheer number of applications available to patients, it’s also vital to communicate to them that a piece of smartphone software is in no way a substitute for medical expertise or regular visits. Some of the medical software available to the public makes impressive claims for what remains a non-medical consumer technology device.

“A lot of applications marketed to patients are really just games, so to speak. For example, there’s an app that uses red and blue light to treat’ acne. Another one says that you can take a picture of a mole and it will tell you the risk level. It can’t deliver on that promise with the level of technology available,” Dr. Benabio said. “Those kind of apps explicitly say only for entertainment purposes,’ and you should direct your patients to more educational resources.”

For more of Dr. Benabio’s thoughts on how he believes smartphones and other mobile computing solutions will change the future of medicine, his TEDx PennQuarter presentation provides further detail. [pagebreak]

Follow up and patient communication

The idea of the smartphone as a physician tool and traditional communication tool may make some physicians uncomfortable. The separation of career and personal life, Dr. Ozdalga said, is always a concern, and communicating with patients via email on one’s phone can seem uncomfortably like giving them a line to one’s personal time. Yet with the services available, he said, he’s been able to effectively partition patient communication while improving patient satisfaction scores.

“I don’t give my patients my number, but I have an account set up where they can dial a number and leave a message that’s emailed to my phone,” he said. “I can check my emails and call them back when I’m available, and it doesn’t disrupt my day. My patients love it — it’s worked really well, and I’ve never had a single complaint. Thanks to that, there’s not a full disconnection with patients once they leave the hospital.”

In addition, Dr. Ozdalga said, he can encourage patients with interesting cases to call often and keep him apprised of changes. In practice, he said, the setup has proven not only convenient, but more intellectually stimulating than the old model of office calls (he’s often away from his desk) and more frequent follow-ups. In addition, he said, he’s able to make more time available to new patient appointments, acute care patients, or other professional pursuits. [pagebreak]

Cardiologist Ariel Soffer, MD, who runs a number of phlebology practices in the south Florida area, worked with developers at AppWorx to create an application specifically for his patients to monitor the appearance of their veins with the iPhone camera and text him updates and inquiries through the app between visits. Rather than taking away reimbursement by eliminating a number of routine follow-ups, Dr. Soffer has seen his patient satisfaction scores (the practice runs its own regular surveys) improve dramatically, leading to more visits.

“When my patients could see on their iPhones the difference in appearance with a HIPAA-compliant photo between sessions of a multi-session treatment, the compliance increase was so dramatic that it increased my practice volume by 38 percent year over year,” he said. “A picture’s worth a thousand words.”

New patient participation metrics will be part of stages 2 and 3 of EHR meaningful use requirements, meaning physicians will be expected to have online interaction with more of their patients through a secure portal. (See sidebar.) Dr. Benabio said that, in addition to helping them meet those requirements, smartphones offer physicians the opportunity to better educate their patients and get them more involved in the tracking of their care. [pagebreak]

“Under your direction, a patient could take a picture of a mole and load it into a mole map to see if there are changes or violations of criteria. Directing your patients to make good educational use of apps and learn more about their condition is far more constructive than a patient trying to diagnose themselves with a phone. You can engage and provide that direction,” he said. “There are also great apps that you can use [during the patient visit] to talk to the patient about different types of surgeries. You can actually use graphics on a smartphone to talk them through a procedure and demonstrate what you’re going to be doing. It can then be sent to the patient’s email so that they can follow up later and educate themselves.”

Social marketing

In addition to the higher-level functions of smartphones, Dr. Benabio said, the popular social networking capabilities of smartphones allow one to produce original content and maintain patient and public connections throughout the day, and even while traveling. In addition, he said, it can also serve to humanize a physician and forge a deeper connection with engaged patients. [pagebreak]

“Your smartphone has a video camera that makes it extremely easy to produce and publish patient education content for your patients. In the context of social networking and creating content for one’s practice as part of building a platform, the smartphone is the best tool we’ve seen,” he said. “I use Twitter mostly to engage in discussions about health care and dermatology, but I also use it to talk about going to Voodoo Donuts in Portland. To some extent, that makes it more effective, because it makes me a real person. People learn more about me, which is part of marketing your practice and engaging with your community.”

Future applications

In the near future, both Dr. Benabio and Dr. Ozdalga said, the capabilities of smartphones in medical situations will take another impressive leap. According to Dr. Ozdalga, technology that is currently in development will allow physicians to attach a simple ultrasound device to a commercial smartphone and allow the physician to do bedside ultrasound exams.

“The idea of bedside ultrasounds was never even dreamed of with the technology we had just a couple of years ago,” Dr. Ozdalga said. “Developers and physicians will continue to come up with more ways to use the smartphone in ways we haven’t thought of.”

Dermatologist and application developer Manabu Inuzuka, MD, who created the photo database application tkDerm, said that the future of medicine lies in physicians having flexibility to manage their patient interactions and data in a way that allows for maximum efficiency. [pagebreak]

“Dermatologists, and doctors in general, are going to look for more flexibility in device choice and storage options that maximize their ability to interact with data in multiple formats,” Dr. Inuzuka said. “We’re already seeing this with the automatic backup and syncing of photos over the cloud across multiple devices. Compared to technologies of even the recent past, it’s like magic.” 

(To read more about how tkDerm and other photo storage systems work, visit an online-only sidebar about it.)

The FDA, according to Dr. Benabio, has been cautiously optimistic on the use of technology to augment physicians’ expertise and efficiency. While dermatology hasn’t seen any specialty-specific applications approved by the FDA for medical use, the agency has approved software that addresses other areas of medicine. A company named Asthmapolis received approval in July for an asthma sensor system and complimentary mobile. Earlier in 2012, the FDA cleared a device that allowed patients to take and send electrocardiographical signals to their physicians. An Andon Health subsidiary received clearance to sell a wrist-worn blood pressure cuff that interacts with iOS devices over Bluetooth technology. What used to be considered science fiction, he said, is coming ever closer to reality. Dermatology, he said, isn’t far behind. [pagebreak]

“Outside the world of dermatology, there are FDA-approved apps that can be appropriately used in a medical setting. They’re coming, and I think that dermatology would see a primary value in evaluating skin lesions for malignancy,” Dr. Benabio said. “There’s nothing now that fulfills that function that I’m aware of, but in the next five to 10 years, that’s something you’re likely to see.” 


At the Summer Academy Meeting 2012, University of North Carolina dermatologist Craig Burkhart, MD, presented a number of dermatology-related applications for smartphones and tablets. They cover a wide variety of both physician and patient medical issues. For one application, MelApp, Dr. Burkhart fed 100 pictures of classic melanomas taken under clinical conditions. The app diagnosed 11 of the melanomas as “high risk,” recommended monitoring 88, and classified one as “low risk.” The results he said, demonstrated that while the application has potential as a tool for teaching, it’s not yet ready to accurately detect melanomas especially in photos taken by untrained patients.

Overall, he said, the number of mobile applications related to health and dermatology published by Apple on the iOS platform has grown at an exponential rate. He presented the data below.

Meaningful use and patient communication

Some of the most significant changes to come with stage 2 of meaningful use deal with patient access to their health information and communication between physicians and patients. The strong emphasis on online engagement with patients marks the beginning of a new era in electronic health records (EHR). Provisions for meaningful use stage 2 include the following:

  • Secure electronic messaging (i.e. secure email) to communicate health information to patients. This could include lab results or a list of current medications.
  • Provide patients the means the view, download, and transmit their health information within four days of the information’s availability through a secure online portal. Half of all patients must be given access; 5 percent must take some sort of action, by viewing or downloading information or electronically transmitting questions or information.



Meaningful use and patient communication