Smartphone Usage Patterns by Canadian Neurosurgery Residents: A National Cross-Sectional Survey

doi:10.1016/j.wneu.2017.12.089

World Neurosurgery

Volume 111, March 2018, Pages e465-e470

https://doi.org/10.1016/j.wneu.2017.12.089 Get rights and content

Background

Smartphones and their apps are used ubiquitously in medical practice. However, in some cases their use can be at odds with current patient data safety regulations such as Canada's Personal Health Information Protection Act of 2004. To assess current practices and inform mobile application development, we sought to better understand mobile device usage patterns among Canadian neurosurgery residents.

Methods

Through the Canadian Neurosurgery Research Collaborative, an online survey characterizing smartphone ownership and usage patterns was developed and sent to all Canadian neurosurgery resident in April of 2016. Questionnaires were collected and completed surveys analyzed.

Results

Of 146 eligible residents, 76 returned completed surveys (52% response rate). Of these 99% of respondents owned a smartphone, with 79% running on Apple's iOS. Four general mobile uses were identified: 1) communication between members of the medical team, 2) decision support, 3) medical reference, and 4) documentation through medical photography. Communication and photography were areas where the most obvious breaches in the Canadian Personal Health Information Protection Act were noted, with 89% of respondents taking pictures of patients' radiologic studies and 75% exchanging them with Short Message System. Hospital policies had no impact on user behaviors.

Conclusions

Smartphones are used daily by most neurosurgery residents. Identified usage patterns are associated with perceived gains in efficacy and challenges in privacy and data reliability. We believe creating and improving workflows that address these usage patterns has a greater potential to improve privacy than changing policies and enforcing regulations.

Introduction

The use of mobile devices is prevalent in medical practice, with 80%–96% of physicians having adopted smartphones in 2014.1, 2 Of the >2,200,000 available apps on the Apple iOS platform in 2017, >55,800 were categorized as medical apps, 159 of which were neurosurgery-specific.3, 4, 5 Examples of how these apps are used in practice include: enhancing communication with staff and colleagues,2, 6, 7 accessing patient information,⁸ review patient investigation results and radiology images,⁹ accessing clinical measurement tools10, 11 and medical references,⁹ resident education,12, 13 establishing and maintaining a social learning ecosystem,¹⁴ reporting clinically significant events,¹⁵ and as a resident performance/operative assessment tool.⁴

As convenient as mobile devices can be, their use can lead to breaches of privacy being at odds with current regulations such as the Canadian Personal Health Information Protection Act (PHIPA) of 2004.¹⁶ Although specific handling requirements of protected health information, including a patient's diagnosis, radiologic studies, and management plan are detailed in the Act, compliance in the clinical setting is lacking. In a single-center survey of surgical residents, Niehaus et al¹⁷ found that 98.7% owned a smartphone with most trainees stating that it was “very important” or “extremely important” for patient care. Text messaging was the primary method of communication in 57.8% of respondents and mostly involved discussion of patients. Taking, sending, receiving, and storing case photographs was also a common use.17, 18 Although the use of mobile devices was extremely high in surgical residents, the knowledge of university guidelines regarding the use of such devices was exceedingly low. Often app usage patterns were in direct opposition to what is permitted by these guidelines, yet residents believed that they could not provide timely and safe patient care without doing so.8, 18

To better understand the needs and challenges associated with mobile devices use across Canada, we performed a cross-sectional survey of Canadian neurosurgery residents. We sought to assess the current usage patterns of mobile technology in the resident's workflow, with a specific emphasis on where technology and convenience might be at odds with privacy and associated regulations. We then highlighted potential solutions to the complex issues raised by the identified usage patterns.

Section snippets

Ethics, Consent, and Permissions

This study was conducted through the Canadian Neurosurgery Research Collaborative (CNRC)¹⁹ and approved by the Research and Ethics Board of the Centre Hospitalier Universitaire de Sherbrooke. Consent to publish anonymized aggregated data was obtained as part of the general consent for study participation.

Survey Development and Administration

Survey development and administration has been described previously.²⁰ Briefly, the survey was developed by one of the authors (C.I.-M.), validated by the CNRC steering committee, and

Results

Seventy-six completed surveys were returned from 146 eligible residents yielding a 52% response rate. The demographics of survey respondents have been published previously.²⁰ Briefly, 76% were men and the median age was 29 years. Resident were equally distributed across residency levels (post-graduate year 1– post-graduate year 6) and provinces. Survey results related to mobile device ownership and usage patterns are presented in Table 1, Table 2, Table 3, Table 4.

Choice of Platform

With nearly 80% of respondents owning an iPhone, Apple's iOS operating system was the clear choice of neurosurgical residents. Interestingly, 62% reported their choice of platform not to have been influenced by their profession. This contrasts with the general public, where Android is known to have a higher penetration rate.²¹ Our results suggest that, at least for the near future, iOS-specific apps can reach most neurosurgery residents with combined iOS and Android apps reaching virtually all

Conclusion

Smartphones are used daily by mostneurosurgery residents. Usage patterns include communication between members of the medical team, clinical decision support, as a medical reference, and for case documentation through medical photography. Each pattern is associated with perceived gains in efficacy and challenges in privacy and data reliability. We suggest that creating and improving workflows addressing these usage patterns will be more effective at improving privacy than changing policies and

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Digital photography in the evaluation and management of female patients with congenital adrenal hyperplasia: A standardized protocol for quality improvement
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Smartphones were previously the least preferred method for obtaining photographs [12,13,27] and patient privacy and data security have been concerns related to smartphone use [4,6,14,21,28,29]. Prior to the introduction of integrated smartphone applications, digital images captured on smartphones were stored on smartphones, computers, or unencrypted flash drives and transferred via text message, encrypted email, non-encrypted email, or hard copy [4,14,21,28,29]. Common photograph sharing and storage methods were not HIPAA-compliant and prone to data theft [29].
Digital photography can be securely stored in the medical record and enhance documentation of physical exam findings and monitor wound healing. A standardized protocol that respects the dignity of the patient and maintains the fidelity of objective documentation is needed for patients with differences in sexual development (DSD) and congenital adrenal hyperplasia (CAH).
The purpose of this study was to evaluate the feasibility, acceptability, and applications of a HIPAA-compliant digital photography protocol in the care of female patients with CAH.
A protocol for standardized digital imaging including consent, permission, data capture, and storage in the electronic medical record (EMR) was implemented. Patients undergoing physical examination during multidisciplinary CAH clinic visits, preoperative evaluation, and postoperative follow-up from October 2020 through May 2021 were included. Male patients with CAH, patients with clitoromegaly or urogenital sinus not from CAH, and patients seen through telehealth were excluded. Consent was obtained from caregivers and permission from patients. Images of the exam were taken during clinic visits or at the time of surgery with no identifying features included. Images were directly uploaded into the patient's chart in the HIPAA-protected EMR separate from other clinical documentation and not stored on personal devices.
There were 17 patients with CAH seen with median age 6 years (range 2 weeks–18 years). There was a median of 3 photos per patient during the study period with cooperation from both the patient and their caregiver. Amongst the patients seen, 6 patients underwent reconstruction with a median of 10 photos per patient. Images were available and used for preoperative planning and counseling. Patients with previous images did not require repeat examinations and were subjected to fewer genital examinations. Fewer providers were present during exams. Images taken by providers and caregivers during the postoperative period were used to monitor wound healing and surgical outcomes.
Protocol implementation improved patient care by reducing the number of exams and number of providers present, enhancing clinical documentation, and providing a means of tracking the physical exam over time. This was in concordance with guidelines for limiting exams for patients with DSD and CAH. Implementation of best practices for medical photography was important in respecting patient dignity and confidentiality.
Implementation of standardized digital photography was feasible and acceptable to patients and caregivers. Digital images reduced the need for repeat physical examination and provided a visual means of enhancing clinical documentation.
BYOD usage and security behaviour of hospital clinical staff: An Australian survey
2022, International Journal of Medical Informatics
Citation Excerpt :
Such research mostly centres on either general mobile device use in hospitals, or information security practices and behaviour among clinicians, with minimal reference to BYOD use. Kameda-Smith et al. conducted a cross-sectional survey to understand smartphone usage patterns among Canadian neurosurgeons, especially in terms of hospital policy and its impact on their usage behaviour [23]. Nerminathan et al. and Mobasheri et al. also described mobile device usage patterns among clinicians, while briefly referring to the problems of mobile device use in hospitals, highlighting the need for a guideline for the safe use of personal mobile devices to protects patient privacy [7,24].
Healthcare professionals are known to use their personal devices extensively for work purposes (Bring-Your-Own-Device). However, it is also a source of major concern for healthcare organisations, given the heavy reliance of patient data privacy on clinician’s usage behaviour and higher risk of data breaches. Previous research into hospital BYOD security has been scarce and fragmented. Therefore, the aim of this paper is to understand the preferences, behaviour, and knowledge of Australian hospital clinical staff with respect to BYOD security through a survey.
An online survey was conducted among clinicians working in Australian hospitals, asking them about their BYOD related user behaviour, knowledge of best practices, and support received from their hospitals. Descriptive statistical analysis and cross tabulation were carried out on the survey data.
Majority of the surveyed clinicians used BYOD (87%). Some of the good behavioural practices found included use of passcode: (91.95%), never disclosing password (67.82%); strong passwords (63.22%) and no storage of patient data (59.77%) on BYOD devices. However, several risky practices were also found, particularly when usability or clinical workflow mattered to clinicians including use of personal/social apps for clinical communication (e.g. SMS: 57.47%, WhatsApp: 39.08%); connecting BYOD devices containing patient data to public hotspots (40.23%) and use of a common data backup platform for personal and patient data (79.93%). A large proportion of surveyed clinicians were either unaware or didn’t receive BYOD related security training (74.71%) or policy (39.08%), but those who did were more confident across all aspects of BYOD security asked in the survey, indicating their importance.
By taking a wholistic and socio-technical view, this study helps us to better understand BYOD related security behaviour of hospital-based clinicians and its consequential implications. It can therefore provide important insights for both technical and clinical stakeholders of BYOD within hospitals.
Radiological Imaging Transmission via Smartphones by Neurosurgery Residents in the United States
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Neurosurgery requires the communication of radiological imaging. Smartphones are increasingly used for this purpose because of the efficiency and convenience of integrated cameras and native Multimedia Messaging Service (MMS) functionality. There is inconsistency among hospitals regarding policies addressing this use as it relates to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Some hospitals offer a HIPAA-compliant secure messaging application (SMA) as a substitute. The authors hypothesized that the use of smartphones for sharing radiological imaging would be commonplace among residents. We sought to characterize usage patterns, resident awareness of policies and HIPPA, and the effectiveness of SMAs as a means of avoiding HIPAA violations.
An electronic dynamic questionnaire was sent to all 116 Accreditation Council for Graduate Medical Education–accredited US neurosurgery residency program directors and coordinators to be forwarded to their residents.
A total of 100 responses were received, representing 49 residency programs. Ninety-two (92%) residents reported using MMS to transmit radiological imaging. Twenty-six (26%) reported doing so with patient identifiers. Roughly half (48%) of residents were unaware of policies regarding imaging transmission via MMS at their institutions. Among the 17 (35%) programs providing SMAs, only 3 of 27 (11%) residents in these programs did not use MMS for image transmission.
The data suggest that there is widespread resident use of MMS for image transmission, regardless of policy and the availability of alternative HIPAA-compliant applications. Knowledge of local institutional policies and HIPAA privacy rules is poor. Alternative strategies are needed to prevent HIPAA-noncompliant transmission of imaging by residents.
How to Take a Good Neurosurgical Photograph with a Mobile Phone Camera
2020, World Neurosurgery
Citation Excerpt :
The exact terminology of these laws varies among countries and judicial systems, but the concepts remain the same. As mobile phones become vital to daily life as a doctor,3 it has become increasingly difficult for governing bodies and employers to closely monitor information storage. Thus, the responsibility is passed down to the photographer, which is you, the surgeon, in the case of mobile phones.
Using a Smartphone as an Exoscope Where an Operating Microscope is not Available
2019, World Neurosurgery
Citation Excerpt :
In a recent visit to a West African Neurosurgical Unit, we adapted our smartphone as a valid alternative to a microscope. Smartphones are currently used in neurosurgery as portable social media,1,2 and some applications (“apps”) are considered useful and instructional daily tools.3-6 In some case smartphones can also be considered as an integration of instruments routinely used in the surgical room.7,8
Neurosurgical operating rooms are equipped with microscopes in order to provide a good standard of care. Nevertheless, in developing countries, microscopes are not always available. During a short period in a western Africa hospital, we adapted our smartphones as a valid alternative to the microscope.
Using a shaped tin can, a smartphone cover, and a rod fixed to the bed, we could make a support for a smartphone creating a simple “homemade” exoscope, which allowed us to have magnification and light in the surgical field.
Among others, we performed 5 surgical interventions of both spinal and brain surgery using our smartphone as a magnifier. This allowed us to overcome the absence of a better magnification system.
This simple “smartphone-based exoscope” allows surgeons to get an adequate magnification during surgery when microscopes or magnification goggles are not available. It can be a useful solution in developing countries where often nothing better is available.
In Reply to the Letter to the Editor Regarding: “Other Apps Beyond WhatsApp”
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: Conflict of interest statement: CI-M is a stakeholder in Hyperexis, a mobile application development company who developed the free TBI Prognosis Calculator for iOS and Android. No funding nor financial support from Hyperexis for work on this project. Furthermore, CI-M holds no stakes in any other application mentioned in this study.

: Drs. Michelle Masayo Kameda-Smith and Christian Iorio-Morin are both co-first authors of this manuscript.

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Original ArticleSmartphone Usage Patterns by Canadian Neurosurgery Residents: A National Cross-Sectional Survey

Background

Methods

Results

Conclusions

Introduction

Section snippets

Ethics, Consent, and Permissions

Survey Development and Administration

Results

Choice of Platform

Conclusion

J Surg Educ

PM R

PM R

Study: Hospital IT paying lip service to address physician mobile requirements, says Spyglass Consulting Group

Text messaging and protected health information: what is permitted?

JAMA

App store metrics: current active application count by category

Smartphones, smart feedback: using mobile devices to collect in-the-moment feedback

Acad Psychiatry

Neurosurgery apps: novel knowledge boosters

Turk Neurosurg

Image transfer by mobile phones in neurosurgery

Zentralbl Neurochir

Pilot study of iPad incorporation into graduate medical education

J Grad Med Educ

Spectrum of tablet computer use by medical students and residents at an academic medical center

Peer J

Comparison of PACS and Bone Ninja mobile application for assessment of lower extremity limb length discrepancy and alignment

J Child Orthop

Original Article
Smartphone Usage Patterns by Canadian Neurosurgery Residents: A National Cross-Sectional Survey