Mobile technology

Major challenges with mobile healthcare applications

Ganesh Bhutkar ⁱ , Jalindar Baban Karande ⁱⁱ , Manikrao Dhore ⁱⁱⁱ
Vishwakarma Institute of Technology, Pune, India. Contacts

Introduction

There are a variety of computerized medical applications available in the market such as electronic health records (EHR) systems, decision support Systems (DSS) and picture archiving and communication systems (PACS). It is expected that practically, every physician should use some of them. These computerised applications have limitations as many of them are standalone and may not be used over larger networks; especially mobile networks. Thus, the use of computerized medical applications by physicians is restricted over smaller areas.

Many errors occur in patient care due to lack of required information at the point of decision-making and breakdown in communication for coordinating patient care team members [Mendonca et al 2004]. About a hundred thousand patients die every year as a result of broken healthcare processes just in American healthcare [Grossman 2007]. This scenario projects a need for research in mobile Healthcare (m-Healthcare), which is an important extension of electronic healthcare (e-healthcare).

The m-Healthcare applications can be used for patient records, disease monitoring, communication, workflow management, medical surveys, documentation, alarms and help (Alasaarela et al. 2006). Advantages of m-Healthcare applications for accessing and processing medical data include less time spent searching data, more relevant information available when making decisions and less time spent in documentation [Afrin et al. 2001].

For physicians, having timely access to critical information can make the difference between life and death. A m-Healthcare system also enables the patient care team to have an ever-present and continuous access to patient’s EHR along with co-ordination among different team members. It also facilitates physicians with the latest medical knowledge at any time through connection to standard medical databases. It allows patients with chronic conditions to remain under constant observation without a need of being physically present at the hospital.

Though m-Healthcare systems provide solutions to several problems in the medical domain, there are many significant challenges in their implementation [Shieh et al. 2008]. These challenges are categorized as issues with usability, mobile networks, ethics and application management. This categorization of challenges is depicted in Figure 1 below.

Figure 1: Categorization of challenges with m-Healthcare applications

Issues with usability of the systems

Following are the issues with usability of the m-Healthcare systems:

1. Mobile screen:

The screens of mobile devices are smaller than desktop versions, thus limiting the type of medical information that is sensible to view. Most users may feel happy with larger screens, but it should not be at the expense of the overall size of the device (Nielsen 2009).

Many physicians are more comfortable with horizontally-oriented screens compared to vertically-oriented screens. For many users, resolution of the screen is also important consideration (320 x 320 or 640 x 320 pixels), especially for medical images.

2. Data entry

The input systems are miniaturized keyboards, keypads or pen-based handwriting systems, none of which is suitable for inputting medical information (Nielsen 2009) such as EHRs. Data entry containing special signs as well as symbols is tedious. Use of the keyboard with hand gloves or in cold conditions by medical staff appears to be difficult and time-consuming.

Data entry in the dark is nearly impossible unless the screen is angled towards the keyboard or a self-illuminated keyboard is provided. A healthcare-specific speech-recognition tool for faster data input and better accuracy is not yet available.

3. Battery life

The battery life is a major concern for remote field operations, especially when battery-charging facilities are not available. For outdoor operations in a chilly climate, the battery runs out very fast. A recurrent problem in the field operations is that the work pace can be very hectic, which means that the medical staff can forget to charge the battery.

Normal use of a device will require 3-5 days before need for recharge. Most devices such as PDA have a battery life of 2.5 to 4 hours of continuous use [Horne 2004]. Thus, battery life can add to the difficulties with m-Healthcare applications.

4. Contents

Medical users find searching for specific content difficult. They would like to see some headers as the shortcuts to information they need in few important databases (Pharmaca or doctor’s handbook). Because websites are typically optimized for desktop usability, they don't follow the guidelines necessary for usable mobile access (Nielsen 2009).

Tables and pictures may not be transformed properly to mobile devices; thus failing to provide required information. Also, many things such as radiology and pathology reports, progress notes and encounter histories [Afrin et al. 2001] are difficult to display on mobile devices. Such information displayed may appear to be too much condensed. Also, these m-Healthcare applications should be programmed to be context-aware with consideration of contexts such as location, time, identity and activity eg emergency medicine and services.

Issues with mobile networks

Following are the issues related with mobile networks supporting m-Healthcare applications:

1. Bandwidth

The speed of the m-Healthcare applications appears to be slower, especially when facing emergencies. Many times, mobile devices take a longer time to access patient’s EHR due to congestion in the network. Research on distributed mobile computing may help to deal with this problem, which will allow physicians to monitor patient's health information in real-time [Han et al 2006]. Also, bandwidth required for transmitting medical images and other diagnostic test results is not enough on mobile networks [Nversel 2009].

2. Coverage

The coverage of mobile networks is expanding very fast all across the globe. But still there are remote areas where coverage is missing. Actually, these are areas, where healthcare facilities are not enough and telemedicine can provide a viable solution. The coverage gaps underutilize mobile networks. Older mobile infrastructure suffers from signal loss on lower floors and in basements while new mobile technology may suffer from deflected cellular signals from steel-encased buildings with glazed windows [Nversel 2009].

3. Integration

There are many services provided by existing e-Healthcare systems, which have been used for more than a decade. These legacy systems were developed at different times and with diversified technologies; especially networking technologies. Now, there is a lack of integration between existing e-Healthcare services and upcoming mobile services [Istepanian et al 2004], which creates difficulty in operations of m-Healthcare applications. Also, there are interoperability issues with 2G/3G mobile network technologies as well as network protocols, which affect speed as well as operational cost.

Issues with ethics

Following are the ethical issues with m-Healthcare applications:

1. Privacy

A massive amount of health and lifestyle information about patients is gathered by healthcare systems to generate EHRs. In many of these systems, not enough attention is provided to aspects like what is gathered, who has access to it and where/ how that information is stored [Brown et al 2007]. The right to information privacy must be interpreted with due attention to a duty of care owed to patients, particularly those vulnerable to significant negative consequences with information sharing. So, a balance must be struck between preserving the autonomy of individuals, and preserving their life and good health. So, access to information should be under the control of the patient or appointed guardian or surrogates if the patient is deemed legally incompetent to make such decision.

2. Trust

In m-Healthcare, there can be a decision about medication or therapy, which is taken without face-to-face (f2f) communication with patients or relatives of patient. Sometimes, this decision may lead to a mistrust or disagreement in patient care [Mendonca et al 2004]. As m-Healthcare systems are becoming more complex, there is a need to define an 'informed consent' in such mobile environment where f2f communication may not be possible.

3. Equity

The health gap between rich and poor (and the associated life expectancy gap) is already significant in many developed countries. The life expectancy between rich and poor differs by at least 5% of lifespan [Brown et al 2007]. More advanced healthcare is already available if one has the money. The ageing population is rapidly increasing all across the globe. The m-Healthcare applications can help taking healthcare applications to masses with lesser costs just like other mobile services and avoiding the kind of inequities in healthcare systems to certain extent.

4. Responsibility for errors

The history of healthcare information systems is plagued with examples of medical errors producing serious harm to the patients. Medical error is a leading cause of death along with motor vehicle accidents, breast cancer and AIDS [Zhang et al 2003]. Some errors can be fatal, causing bigger emotional as well as economical loss to the family of patients. If anything goes wrong in m-Healthcare systems and harms patient, a clear medical policy and guidelines should be defined. These guidelines may include regulations about who is to blame and how will be resulting costs covered [Brown et al 2007].

Issues with management of applications

Following are the issues associated to management of m-Healthcare applications:

1. Data protection

The hardware limitations of mobile devices prevent usage of strong encryption algorithms [Ahmad 2003], which are necessary for better level of security for commercial transactions in healthcare. Modern operating systems used in mobile devices are not designed for carrying out secure transactions like transfer of EHR or payment of bills.

With the convergence of mobile and computer technologies, high throughput and low bandwidth cryptographic algorithms [Crounse 2009] need to be developed to exchange information across various devices, applications and networks. Patient data stored on mobile devices could mean the difference between life and death and thus must be protected from accidental loss. One solution is to fit a freefall detector on the device, which shuts down the system if it falls to the floor.

2. Authentication & authorization

In m-Healthcare applications, many users like physicians, medical staff, patients, administrators etc. are involved. If their access to EHRs as well as other medical data with m-healthcare applications is not controlled or restricted appropriately, it can be a real threat to the security of the system.

Though public records can be accessed by all users, vital medical data should be accessed only by related authenticated users. Thus, there should an authentication process for confirming the identity of users. These identified users should be authorized to access related functionalities as well as data as per requirements, eg only the physicians and no other users are authorized to update a critical medical data in EHR. With m-Healthcare systems, an authorized physician should be confident that he/she can access the EHR and communicate with a hospital or patient, if needed [Crounse 2009].

3. Return on investment

In healthcare applications, return on investment (ROI) consideration is vital [Archer 2009]. In calculating ROI for m-Healthcare applications, the cost considerations include software, hardware, installation, ongoing maintenance, and further upgrading. Savings include medical staff time and flexibility, patient timesavings and safety.

Virtual healthcare operations and extended field operations tend to have a higher ROI. Health services require a convincing case for the adoption of m-Healthcare applications, since there are so many other competing demands on resources. In addition, since there are typically a number of stakeholders like physicians, nursing / medical staff, patients, administrators, institutions — hospitals, government, telecom service providers etc — should each receive a perceived benefit in order to encourage use of m-Healthcare applications.

Conclusion

There are various challenges with m-Healthcare applications, categorized into issues with usability, networks, ethics and management as listed in Figure 2 (below). The observations about various challenges show that there is a wider scope to study the m-Healthcare domain and its evolving behaviour along with impact on healthcare services.

Figure 2. Challenges with m-Healthcare applications.

There is, therefore, a need for developing more secure and usable applications on expanding mobile networks. Now, with smaller, lighter, and smarter mobile devices supported by greater battery life, it is no longer a matter of whether a physician will use mobile technology.

It's a question of how far the m-Healthcare domain can go forward improving patient care and decreasing healthcare costs using powerful information technologies supported by mobile solutions. Also, the physicians, medical staff and patients should develop sound ethical practices for efficient and responsible use of m-Healthcare applications. If these challenges are overcome with courage and wisdom, then only m-Healthcare applications will become trustworthy and will be used on a wider scale by medical users like physicians and patients.

Authors

i. Ganesh Bhutkar, Assistant Professor, Vishwakarma Institute of Technology, Pune, India.
His areas of expertise are medical usability and the human-computer interface. Email:

ii. Jalindar Baban Karande, Lecturer, Vishwakarma Institute of Technology, Pune, India.
His areas of expertise are web technologies and mobile computing. Email: 

iii. Manikrao Dhore, Associate Professor, Vishwakarma Institute of Technology, Pune, India.
His areas of expertise are mobile computing and computer networks. Email: 

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