Commentry

Handheld devices and Informatics in anesthesia

Prasanna Vadhanan,MD1, Adinarayanan S., DNB2

1Associate Professor, Department of Anaesthesiology, Vinayaka Missions Medical College & Hospital, Keezhakasakudimedu, Kottucherry Post, Karaikal, Puducherry 609609, (India)

2Associate Professor, Department of Anaesthesiology & Critical Care. The Jawaharlal Institute of Postgraduate Medical Education & Research, Dhanvantri Nagar, Gorimedu, Puducherry, 605006, (India)

Correspondence: Dr. Prasanna Vadhanan, MD, No. 6, P&T Nagar, Mayiladuthurai 609001 (India); Phone: +919486489690; E-mail:  Vadhanan.prasanna@gmail.com

ABSTRACT

Handheld devices like smartphones, once viewed as a diversion and interference in the operating room have become an integral part of healthcare. In the era of evidence based medicine, the need to remain up to date with current practices is felt more than ever before. Medical informatics helps us by analysing complex data in making clinical decisions and knowing recent advances at the point of patient care. Handheld devices help in delivering such information at the point of care; however, too much reliance upon technology might be hazardous especially in an emergency situation. With the recent approval of robots to administer anesthesia, the question of whether technology can replace anesthesiologists from the operating room looms ahead. The anesthesia and critical care related applications of handheld devices and informatics along with its possible drawbacks are discussed.

Key words: Informatics; Anesthesia informatics; Anesthesia; Critical care; Devices; Smart phones

Citation: Vadhanan P, Adinarayanan S. Handheld devices and Informatics in anesthesia. Anaesth Pain & Intensive Care 2016;20(2):201-208

Received: 02 April 2016; Reviewed: 2 May 2016; Corrected: 02 June 2016; Accepted: 10 June 2016

INTRODUCTION

The integration of technology into medicine has made the entire process of patient management more efficient, accurate and safer. Complex medical devices are becoming smaller and robust, and hand held devices have an increasing role to play in day to day patient management. Hand held devices like smartphones, personal digital assistants (PDA), informatic devices and handheld ultrasound are changing the ways in which anesthesia and critical care is practiced.

Information Overload

In this era of evidence based medicine litigation has become an everyday happening. Anesthesiologists therefore, need to stay up to date with recent advances and practice guidelines. Searching for evidence, appraising and grading the evidence and determining their practical applicability needs time and resources. Before internet, the only source of information was textbooks, few journals and personal opinion of experts (the least possible level of evidence), but today the sources of information are vast and are shown in Table 1.

Table 1: Sources of Information

Sources of anesthesia related information
1.  Peer reviewed journals

2.  Text books with new editions every few years

3.  Conferences and seminars

4.  Association guidelines (American Society of Anesthesiologists, Difficult Airway Society etc.)

5.  National and institutional protocols

6.  Pharmaceuticals monographs

7.  Expert opinions, best practice guidelines

8.  Web based resources (websites of societies like WFSA, NYSORA etc.)

According to Medline, since 2005 between 2000 to 4000 completed references are added each day .In 2013 this amounted to more than 700,000 articles.1 Even within a specific speciality, it is impossible to keep up with all the published medical reports.2 With the increasing number of medical publications, however narrow a speciality field may be, it is impossible to keep up to date to become an expert. As of 2014 in anesthesiology and pain medicine nearly 118 anesthetic and 81 journals critical care journals are being published.3 gThe total number of articles published in these journals amounts to approximately 12,000 in anesthesiology and 10,000 in critical care annually. This implies that even if a trainee manages to read and assimilate information from 40 articles per day for five days a week, he or she can only cover half the published articles that year and additional 22,000 articles would have assimilated by that time. Literally we are living in an era of information overload.

Information from Patients

Patient data can lead to information overload as well. As monitoring and laboratory parameters are increasing it becomes difficult for the human mind to process them and arrive at a clinically relevant diagnosis. Human mind can adequately process four variables only at one time. 4 A patient in an intensive care unit can generate up to 236 variables,5 hence it is possible to miss relevant data that can help in diagnosis and management. On the other hand, such excess of information can lead to diagnostic errors and neglect of relevant data. Therefore instead of just raw data in the form of investigation reports and clinical parameters, we need computers to process them with appropriate algorithms and provide us with clinically relevant hypothesis/diagnosis that best explains the raw data.6

Human Errors

Fatigue and mood of the physicians had been shown to influence his/her decision making in patient management. Emotion can play a role in decision making, and studies in both psychology and economics have demonstrated human fallibility in everyday decision making.7 A stressed physician is more likely to deviate from standard protocols with or without his knowledge. Physicians tend to talk less, prescribe and refer more when they are stressed and in a negative mood.8 Informatics can help in reducing such events by constantly alerting the physicians whenever a deviation from protocol is noted and thereby preventing litigations.9

Medical Informatics

Medical informatics can be defined as a complex science that integrates relevant theories, design methodologies, and knowledge of best practices drawn from various cognitive, computational, informational, organizational, and other expert knowledge domains.10 It involves synergistically collecting, storing, organizing, manipulating, using, and disseminating clinical-based and health-related information. Handheld devices can be used to utilize the numerous benefits of medical informatics at point-of-care.

There are three major areas where informatics is used in anesthesia and critical care.

  1. As a tool for electronic record keeping and retrieval.
  2. In making decisions based on patients’ clinical parameters and as a database of best practices from reliable sources. This is called HDSS or Health Decision Support Systems. Intelligent medical informatics should be able to mimic the thought process of an expert physician.10
  1. In Telemedicine.Telemedicine is the ability to diagnose and treat diseases remotely. This is the basis of tele-ICU and tele surgery.

Anesthesia related informatics systems are known as Anesthesia information management system or AIMS. Most of the features of the AIMS can be accessed by hand held devices. Companies like McKesson, Stanford Anesthesia informatics provide integration of the informatics systems with hand held devices. Some of the practical uses of AIMS are shown in Table 2.

Table 2. Use of informatics in Anesthesia

Practical uses of AIMS
·         Storing patient data, automatic recording of intra operative vitals and events

·         Calculating drug dosages and infusion rates

·         Predicting possible drug interactions based on patient’s medications

·         Diagnosing light anesthesia and unstable blood pressures

·         Reminders for drugs (e.g. insulin, DVT prophylaxis, antibiotics)

·         Scheduling surgeries and reserving post-operative beds

·         Decision support involving multiple patient factors.

Handheld Devices and Internet

Another major application of handheld devices is accessing internet for information. Most AIMS devices provide integrated internet access.

E Learning is a concept where computers and networks are used to provide online educational materials and communication. Modules rich in multimedia teaching files and discussions and feedback create a virtual classroom. It is also referred to by other terms: online learning, computer-assisted-learning, or Web-based learning. E Learners have demonstrated increased retention rates and better utilization of content.11 Other advantages are that the learner can control the pace, timeliness of content and sequence of learning. Interactive learning enables users to manipulate variables and observe outcomes, for example drug kinetics. Several societies and associations offer eLearning modules on various topics, which can be accessed from handheld computers as well. In a randomized trial, residents scored high on post module knowledge assessment after a regional anesthesia E Learning module and all participants reported a preference for web based learning.12

For the practicing anesthesiologist, the need to stay up to date in current concepts and guidelines is being felt more and more. The need to retrieve reliable and clinically relevant data rapidly at the point of care has made few institutions to employ perioperative librarians dedicated solely to this purpose.

While accessing information from the internet, the pitfalls should be borne in mind. The source, reliability, and time of publishing should be noted. Most patients and even some health care professionals believe that any information from the World Wide Web is reliable. For example, the quality of drug information from Wikipedia continues to be inconsistent, and clinicians may inappropriately rely upon it. 13 Like all other medical literature, information from Web sites should be evaluated and compared to prior knowledge, new studies, and current recommendations.14

To avoid pitfalls, appropriate databases (PubMed, Embase, CINAHL, Scopus, Cochrane database, DARE etc.) should be used for searching with appropriate key words, filters and Boolean operators. A step by step guide for searching evidence on internet was published by Stillwell et al, in 2010. 15

Handheld Devices

As technology advances, we have smaller devices capable of doing more and more. Remote monitoring via a hand held devices in real time is possible. The hand held device communicates with the server wirelessly via Bluetooth (range- 10 -20m), WLAN (70-100m), Internet, or newer protocols like Zigbee.

Ultrasound devices have become hand held, enabling greater mobility and ease of use. Most require the image to be transferred to a computer for proper processing and reporting. At least three manufacturers are currently marketing handheld USG devices. Vscan by General Electricals, Mobisante US and Signostics.

Smartphone as a Medical Device

Apart from accessing internet and AIMS, the smartphone has found several uses in our day to day practice. Since 2010, smartphones have virtually replaced personal digital assistants or PDAs.

Today, a smartphone has the ability that a personal computer had few years back. The huge storage capacity, fast processing speed and memory enables them to store entire textbooks or rather libraries. Most journal articles can be accessed anytime and social media sites like face book are providing a platform where case discussions can be carried out with peers. Videos of procedures can be watched, and calculation of drug dosages and infusion rates can be done. Podcasts where digital media files can be downloaded and watched later helps in understanding complex concepts with ease. Podcasting uses RSS (Rich site summary) format to broadcast audio or video files from Web sites to portable players, allowing physicians to access educational materials at point of care. In a survey among anesthesia residents 60% used podcasts mainly for procedural videos.16 AIMS manufacturers like McKesson and Metavision provide applications meant for smartphones connectivity.

Other out of the box usages of smartphones has been reported. Age appropriate videos shown to children before induction has been shown to allay anxiety, a technique nicknamed iphone induction.17 The high definition cameras of iPod touch have been used as a low cost remote monitor.18 The accelerometer (the hardware that senses orientation and motion of the device) has been used to accurately measure 15 degree tilt during Cesarean sections 19 and as a monitor for neuromuscular junction,20 where the fade can be demonstrated accurately as a graph.

Smartphone Medical Applications (Apps)

A lot of anesthesia related applications are available for smartphones. Ready reckoner for calculating drug doses, endotracheal tube sizes, normal laboratory values are available. Pharmacokinetic models like procalculator are some of the apps worth mentioning. The accuracy of data of these applications cannot be guaranteed and should not be relied upon to replace our knowledge. Several drug databases are also available. A review of the smartphone apps for paediatric anesthesia was published in 2012.21

FDA encourages development of mobile medical apps to enable health care professional’s access relevant information. It is estimated that more than 500 million smartphone users will be using a medical application by 2015, and by 2018, 50% of all smartphone and tablet users (3.4 billion) will be using a medical related application.22 Epocrates, a leading software for health professionals is being used by more than half of US doctors for accessing information on drug dosing, interactions and insurance information,. On 2015, FDA released guidance for implementing regulations for certain devices and applications.22 Soon we will have FDA approved medical apps, subjected to regulations.

Hazards of Handheld Devices

  1. Distraction: Handheld devices especially smartphones can distract health care providers especially when used in operation theatres and critical care units. Slagle and Weinger 23 note that with the introduction of electronic patient care information, the opportunities and allure of electronic non-patient care activities, e.g., web surfing, are increasing. A ‘no personal internet use policy’ and restricted use by personnel can be the only solution. Most anesthesiologists view their mobile phone as a life saving device rather than a life threatening one.
  2. Interference: Can handheld devices cause electromagnetic or radiofrequency interference with sensitive medical equipment like ventilators and pace makers? Most of the anecdotal reports were seen with cardiac monitors24 and pacemakers. Initially a one-meter rule was proposed by Irnich et al25, which suggested restriction of mobile phone use to greater than 1 meter from equipment, and it still holds good. However, such interferences are not seen with modern mobile devices with low electromagnetic interference, and medical equipment by FDA regulations, should be immune from interference in fields of up to 7 V/m within the frequency range of 450–1000 MHz. 26
  3. Infection: Mobile devices have been shown to harbour numerous pathogens, including MRSA, coagulase negative staphylococcus aureus and kleibsella. After the use of mobile phones, 38 out of 40 anesthetists had bacterial contamination on their hands, some were human pathogens.27 Frequent wiping of mobile surfaces with antiseptics and using antiseptic covers has been recommended. Avoidance in sensitive areas like ICU, transplant theatres etc seems to be prudent.

FUTURE

As technology improves, devices will get small, robust and versatile. Remote anesthesia is now a possibility. A remote intubation system, Keplar Intubation system has been developed by Thomas Hemmerling, McGill University(2011).28 Similarly a remote anesthesia maintenance system McSleepy 29,(developed by Intelligent Technologies in Anesthesia) can maintain anesthesia by automatically adjusting the infusion rates of drugs bases on three patient parameters(Depth of hypnosis via EEG, Analgascore for pain, and muscle relaxation with phonomyography).

Sedasys, a computer assisted personalized sedation device got FDA 30 approval in 2013 to administer sedation and titrating propofol based on the clinical parameters for endoscopy and colonoscopy , “where an anesthesia professional is immediately available”. This implied anesthesiologist need not be present all the time during the procedure. FDA issued a recall of the device on 2015 and the manufacturers discontinued it.

The future of handheld devices holds much promise, and judicious usage helps us in early and accurate diagnoses, evidence based management of patients and accessing reliable information from our finger tips. Like all technology, the ultimate result lies in the way it is used.

However, caution should be exercised in relying solely upon these devices and software and hardware malfunction can prove life threatening, as exemplified by the Therac-25 incident where lethal doses of radiation was administered accidentally due to an error in the software. Any advance in technology should be properly used with caution and should not be used to replace the basic motto of anesthesiology – eternal vigilance.

Conflict of interest: None declared by the authors

Authors’ Contribution: PV – Concept, Literature search; AS – Manuscript preparation, Proof reading.

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