Emergency. 2017; 5 (1): e14 OR I G I N A L RE S E A RC H Smartphones and Medical Applications in the Emergency Department Daily Practice Amirhosein Jahanshir1, Ehsan Karimialavijeh1∗, Hojjat Sheikh Motahar Vahedi1, Mehdi Momeni1 1. Department of Emergency Medicine, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Received: April 2016; Accepted: June 2016; Published online: 9 January 2017 Abstract: Introduction: Medical applications help physicians to make more rapid and evidence based decisions that may provide better patient care. This study aimed to determine the extent to which smart phones and medical ap- plications are integrated in the emergency department daily practice. Methods: In a cross sectional study, a modified standard questionnaire (Payne et al.) consisting of demographic data and information regarding qual- ity and quantity of smartphone and medical app utilization was sent to emergency-medicine residents and in- terns twice (two weeks apart), in January 2015. The questionnaire was put online using open access "Web-form Module" and the address of the web page was e-mailed along with a cover letter explaining the survey. Finally, responses were analyzed using descriptive statistics and SPSS 22 software. Results: 65 cases participated (re- sponse rate 86%). The mean age of interns and residents were 25.03 ± 1.13 and 30.27 ± 4.68 years, respectively (p < 0.001). There was no significant difference between interns and residents in owning a smartphone (p = 0.5). Android was more popular than IOS (67.7% against 25.8%) and the most popular medical apps were Med- scape and UpToDate, respectively. 38 (61.3%) of the respondents were using their apps more than once a day and mostly for drug information. English (83.9%), Persian (12.9%), and other languages (3.2%) were preferred languages for designing a medical software among the participants, respectively. Conclusion: The findings of present study showed that smartphones are very popular among Iranian interns and residents in emergency department and a substantial number of them own a smartphone and are using medical apps regularly in their clinical practice. Keywords: Smartphone; mobile applications; emergency service, hospital; evidence-based practice © Copyright (2017) Shahid Beheshti University of Medical Sciences Cite this article as: Jahanshir A, Karimialavijeh E, Sheikh Motahar Vahedi H, Momeni M. Smartphones and Medical Applications in the Emer- gency Department Daily Practice. Emergency. 2017; 5 (1): e14. 1. Introduction Today smartphones and tablets are universal, well known, and popular devices that are integrated into daily life of many people (1). By installing appropriate mobile applications on a smartphone or tablet, they will be capable of performing different tasks. App is short for application, and a mobile app is a software that has been designed to run on smartphones or tablets. Apps can be downloaded from application distri- bution platforms (ADP) such as Google Play, App Store, Win- dows Phone Store, and BlackBerry App World. International sanctions on Iran led to development of local Iranian app stores like Bazaar and Myket, which serve as sources of mo- ∗Corresponding Author: Ehsan Karimialavijeh; Emergency Department, Dr. Shariati Hospital, Kargar Avenue, Tehran, Iran P.O Box: 14117-13137 ; Tel: +982161192240; Fax: +982166904848 ; Email: drkarimi86@gmail.com bile apps. For healthcare professionals, this novel technol- ogy provides an opportunity to promote patient care and de- crease medical errors through rapid access to the latest evi- dence based medical information (2, 3). Physicians use med- ical apps for different purposes such as: learning, education, decision making, medical calculation, and better interpre- tation of paraclinical tests (4-11). Medical students are also very familiar with these handheld devices (12, 13). Despite all benefits, several problems exist in this context. Smartphones may have hardware limitations such as narrow screen, con- nectivity issues and so on. The reliability of medical apps is also under debate (14). The problem of app overload is an- other factor that may also confuse users in finding appro- priate applications (15). Based on the above mentioned, the present study aimed to investigate the extent of smartphone ownership and utilization of medical applications among in- terns and residents in an emergency department. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Jahanshir et al. 2 2. Methods 2.1. Study design and setting This cross sectional study was performed in a teaching hospi- tal of Tehran University of Medical Sciences (TUMS) in Iran, during January 2015. Who met the inclusion criteria were contacted via 2 separate emails (two weeks apart). Inclu- sion criteria consisted of 1. Participation in TUMS emer- gency medicine training program; 2. Registration of email address into the database of office of the vice chancellor for student affairs; 3. Consent for use of mail address in corre- spondence with TUMS. The local ethical committee of TUMS approved the conduct of the study and researchers adhered to all Helsinki recommendations and confidentiality of par- ticipants information. 2.2. Data gathering Initially, a modified version of Payne et al. questionnaire of smartphones and medical apps use among medical stu- dents was developed (1). The questionnaire was translated into Persian by the authors separately, and then the best translation for each item was chosen. Statements about pre- ferred apps and their user interface language were added, and one statement about current hospital of employment was deleted. Medical apps were mentioned in the ques- tionnaire, according to the researchers personal experience about their possible popularity. In order to establish face va- lidity of the survey, an expert panel of emergency medicine professors, who were familiar with new technologies and medical applications, reviewed the final questionnaire and compared it with the original one. They suggested 2 mi- nor revisions in translation and approved its content validity. 30 interns, who were in the emergency department rotation, were asked to fill the questionnaire as a pilot study. Princi- ple components analysis (PCA) was performed and the Cron- bach’s alpha coefficient was calculated to evaluate the inter- nal consistency of the survey. Values higher than 0.6, were considered acceptable. The questionnaire was put online us- ing open access "Web-form Module" in a website that was designed with "Drupal Platform", and the address of the web page as well as a cover letter explaining the survey were sent to 75 emergency department residents and interns by email and they were asked to fill it. Responses were IP-sensitive and stored on a password-protected server. If any of the partici- pants wanted to fill the questionnaire in an offline format, printed questionnaires were available. 2.3. Data collection We collected data from patients electronic medical records and a regional ICU database. For each patient with clinically and Doppler proven DVT, key demographic and clinical char- acteristics including age, sex, diagnosis on admission, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, VTE prophylaxis regimen, duration of mechanical ven- tilation, length of ICU stay and patient’s outcome (discharge or death) were collected. To provide a uniform and unbi- ased assessment of Doppler proven DVT, one research asso- ciate, who was a vascular surgeon, performed the Doppler examination for all patients potentially having DVT and was blinded to the patients history and clinical status. All clinical decisions were made at the discretion of the ICU team. Po- tentially having DVT was defined as International ClassiFica- tion of Diseases, 9th Revision, Clinical ModiFication (ICD-9- CM) codes (453.40, 453.41, 453.42, 453.80, and 453.90). 2.4. Measured items 1. The number of smartphone owners among emergency medicine residents and interns. 2. The frequency of smartphone operating systems (IOS, An- droid, Windows mobile, etc.). 3. The frequency of medical applications among smartphone owners. 4. The rate of medical app utilization among emergency medicine residents and interns. 2.5. Statistical Analysis Data analysis was performed using SPSS version 22. Data were analyzed using descriptive statistics. Quantitative vari- ables were reported as mean and standard deviation and qualitative ones as frequency and percentage. The results of the pilot study were not included in the final analysis. Stu- dent t-test was used for comparing the mean age of interns and residents. P < 0.05 was considered statistically signifi- cant. 3. Results: The survey of 65 participants (response rate 86%) was ana- lyzed (50.8% female). 62 (95.38%) of them owned a smart- phone. Table 1 summarizes the baseline characteristics of participants. The mean age of interns and residents were 25.03 ± 1.13 and 30.27 ± 4.68 years, respectively (p < 0.001). There was no significant difference between interns and res- idents in owning a smartphone (p = 0.5). Table 2 shows the popularity of smartphone operating systems and medi- cal apps as well as frequency of their daily use and indica- tions. Android was more popular than IOS (67.7% against 25.8%) and the most popular medical apps were Medscape and UpToDate, respectively. 38 (61.3%) of the respondents were using their apps more than once a day and mostly for drug information. Figure 1 shows the distribution of med- ical apps installed on different smartphone operating sys- tems (range 0 to 25 apps). Although WikEM was the only emergency medicine app that was mentioned in the ques- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2017; 5 (1): e14 Table 1: Baseline characteristics of the participants (n=65) Items Number (%) Sex Male 32 (49.2) Female 33 (50.8) Level of education Interns 39 (60) 1th year resident 5 (7.7) 2nd year resident 15 (23.1) 3th year resident 6 (9.2) Owned a Smartphone Yes 62 (95.4) No 3 (4.6) Table 2: Popularity of operating systems and medical apps among study participants Variable (n = 62) Number (%) Operating systems Android 42 (67.7) IOS 16 (25.8) Windows 4 (6.5) Frequency of app use Never 2 (3.2) Rarely 4 (6.5) Once a week 5 (8.1) 2-3 times a week 13 (21.0) 1-2 times a day 18 (29.0) Many times a day 20 (32.3) Medical apps Medscape 53 (85.5) Pubmed 7 (11.3) Omnio 8 (12.9) WikEM 1 (1.6) Up To Date 27 (43.5) Others 12 (19.4) Usage indication Drug information 53 (85.5) Differential Diagnosis 27 (43.5) Diagnosis 26 (41.9) Treatment 38 (61.3) Procedural Skills 16 (25.8) Others 9 (14.5) tionnaire, 61 (98.4%) participants had not installed it on their smartphones. English (83.9%), Persian (12.9%), and other languages (3.2%) were preferred languages for designing a medical software among the participants, respectively. 4. Discussion: The findings of the present study showed that smartphones are very popular among Iranian interns and residents and a substantial number of them own a smartphone and are using medical apps regularly in their clinical practice. It was shown that using handheld computers and smartphones saves time and expedites decision making and treatment in both pre-hospital and hospital settings (2, 3, 16, 17). It also Figure 1: Distribution of installed apps and operating systems among the respondents. makes patient care more evidence based and prevents med- ication errors (3). In emergency medicine, there are guide- lines and protocols to minimize wasted time in emergency situations, but when considering patient care, it is reason- able to spend a few moments on finding appropriate infor- mation. Previous studies claimed that residents and younger physicians are more interested in using smartphones (18). Although interns were significantly younger than residents in this study, no significant difference was found between them in owning smartphones. Although it is easier to read a text in one’s native language, English was the most preferred lan- guage for designing a medical app among the respondents. In this study, most interns and residents were using medical apps for finding drug information and treatment options. Al- though neither the information they needed to find on their smartphones nor the amount of time they spent on finding needed information were studied, it is thought that checking necessary information in a critical situation, e.g. epinephrine dose in anaphylaxis, might have a negative impact on pa- tient outcome. An impact study is needed in this regard. No data could be found about market share of operating sys- tems in Iran. In 2014, the International Data Corporation (IDC) stated that Android, IOS, Windows Phone and Black- berry OS have 76.6%, 19.7%, 2.8% and 0.4% of the worldwide smartphone market share, respectively (19). In this study, 25% of participants were using IOS. The market share of op- erating systems is entirely related to brands and manufactur- ers. If we assume that the market share of these operating systems in Iran is similar to what was found among the par- ticipants, then we can conclude that the market shares are not significantly different from IDC report and international sanctions on Iran could not change the market shares. This This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Jahanshir et al. 4 is mostly because 85% of smartphones and tablets are im- ported into Iran illegally (20). Although respondents stated that Medscape and UpToDate were the most used medical apps in their smartphones, but what they were using as Up- ToDate was actually an offline version of UpToDate website, which is not really an app. WikEM, which is a free emergency medicine app, was not popular among the respondents. De- spite international sanctions on Iran, which has restricted the access to app stores and some medical apps from Iran, smartphones and medical apps are as popular as they are in other countries and Iranian emergency physicians use them regularly in their clinical practice. It seems that purchasing a smartphone or installing a medical app, is a function of the physicians’ need rather than their age. Although there are ev- idence that suggest the use of medical apps may improve pa- tient care in the hospitals, this needs to be evaluated in emer- gency situations. In critical situations such as the emergency department and its acute area, using a medical app to find the best drug or its dose is time consuming and may defeat the purpose of patient safety. 5. Limitations: Only interns and residents were asked to fill out the question- naire; therefore, the popularity of new technologies among younger people may interfere with the generalizability of the results of this study. 6. Conclusion: The findings of the present study showed that smartphones are very popular among Iranian interns and residents in emergency department and a substantial number of them own a smartphone and are using medical apps regularly in their clinical practice. 7. Appendix 7.1. Acknowledgements The authors wish to thank all of the interns and residents who participated in this study. 7.2. Authors contribution All of the authors have equally contributed in designing and executing this study. Dr. Vahedi and Dr. Momeni have re- viewed medical literature. 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