Impact of tablet-scoring and immediate score sheet review on validity and educational impact in an internal medicine residency Objective Structured Clinical Exam (OSCE).

Introduction: The Objective Structured Clinical Examination (OSCE) is used globally for formative and summative purposes. The objective of this study was to examine the impact of tablet-scoring on sources of validity evidence for an Internal Medicine residency OSCE. Methods: We compared paper-scored OSCEs from 2014 to tablet-scored OSCEs in 2015 for missing data, amount of comments, and time to pass/fail decision. We then examined in 2016 the impact on learning of showing residents their score sheets and asking them to write an action plan immediately after an OSCE. Results: Tablet-scoring significantly reduced stations with missing data from 1.8 to 0.2%, and stations without comments from 42 to 28% with an increase in word count per comment. Time to official results reduced from 3 weeks to 12 h with tablet-scoring. Residents who wrote a learning plan after reviewing their OSCE score sheets were more likely (with medium to large effect sizes) to pursue further studying and/or change their behavior (e.g. history taking or physical examination) in the clinical environment. Conclusions: OSCE tablet-scoring improved many sources of validity evidence, especially educational impact with timeliness of feedback supporting a change in behavior, a hard to achieve goal of educational interventions.

Assessment of Remote Heart Rhythm Sampling Using the AliveCor Heart Monitor to Screen for Atrial Fibrillation: The REHEARSE-AF Study.

BACKGROUND: Asymptomatic atrial fibrillation (AF) is increasingly common in the aging population and implicated in many ischemic strokes. Earlier identification of AF with appropriate anticoagulation may decrease stroke morbidity and mortality. METHODS: We conducted a randomized controlled trial of AF screening using an AliveCor Kardia monitor attached to a WiFi-enabled iPod to obtain ECGs (iECGs) in ambulatory patients. Patients ≥65 years of age with a CHADS-VASc score ≥2 free from AF were randomized to the iECG arm or routine care (RC). iECG participants acquired iECGs twice weekly over 12 months (plus additional iECGs if symptomatic) onto a secure study server with overread by an automated AF detection algorithm and by a cardiac physiologist and/or consultant cardiologist. Time to diagnosis of AF was the primary outcome measure. The overall cost of the devices, ECG interpretation, and patient management were captured and used to generate the cost per AF diagnosis in iECG patients. Clinical events and patient attitudes/experience were also evaluated. RESULTS: We studied 1001 patients (500 iECG, 501 RC) who were 72.6±5.4 years of age; 534 were female. Mean CHADS-VASc score was 3.0 (heart failure, 1.4%; hypertension, 54%; diabetes mellitus, 30%; prior stroke/transient ischemic attack, 6.5%; arterial disease, 15.9%; all CHADS-VASc risk factors were evenly distributed between groups). Nineteen patients in the iECG group were diagnosed with AF over the 12-month study period versus 5 in the RC arm (hazard ratio, 3.9; 95% confidence interval=1.4-10.4; P=0.007) at a cost per AF diagnosis of $10 780 (£8255). There was a similar number of stroke/transient ischemic attack/systemic embolic events (6 versus 10, iECG versus RC; hazard ratio=0.61; 95% confidence interval=0.22-1.69; P=0.34). The majority of iECG patients were satisfied with the device, finding it easy to use without restricting activities or causing anxiety. CONCLUSIONS: Screening with twice-weekly single-lead iECG with remote interpretation in ambulatory patients ≥65 years of age at increased risk of stroke is significantly more likely to identify incident AF than RC over a 12-month period. This approach is also highly acceptable to this group of patients, supporting further evaluation in an appropriately powered, event-driven clinical trial. CLINICAL TRIAL REGISTRATION: URL: https://www.isrctn.com. Unique identifier: ISRCTN10709813.

Cost-Effectiveness of a Nonpharmacological Intervention in Pediatric Burn Care.

OBJECTIVE: To report the cost-effectiveness of a tailored handheld computerized procedural preparation and distraction intervention (Ditto) used during pediatric burn wound care in comparison to standard practice. METHODS: An economic evaluation was performed alongside a randomized controlled trial of 75 children aged 4 to 13 years who presented with a burn to the Royal Children's Hospital, Brisbane, Australia. Participants were randomized to either the Ditto intervention (n = 35) or standard practice (n = 40) to measure the effect of the intervention on days taken for burns to re-epithelialize. Direct medical, direct nonmedical, and indirect cost data during burn re-epithelialization were extracted from the randomized controlled trial data and combined with scar management cost data obtained retrospectively from medical charts. Nonparametric bootstrapping was used to estimate statistical uncertainty in cost and effect differences and cost-effectiveness ratios. RESULTS: On average, the Ditto intervention reduced the time to re-epithelialize by 3 days at AU$194 less cost for each patient compared with standard practice. The incremental cost-effectiveness plane showed that 78% of the simulated results were within the more effective and less costly quadrant and 22% were in the more effective and more costly quadrant, suggesting a 78% probability that the Ditto intervention dominates standard practice (i.e., cost-saving). At a willingness-to-pay threshold of AU$120, there is a 95% probability that the Ditto intervention is cost-effective (or cost-saving) against standard care. CONCLUSIONS: This economic evaluation showed the Ditto intervention to be highly cost-effective against standard practice at a minimal cost for the significant benefits gained, supporting the implementation of the Ditto intervention during burn wound care.

iPads, mobile technologies, and communication applications: a survey of family wants, needs, and preferences.

Families of children with communication disabilities were surveyed to explore wants and preferences relative to mobile media technology, including iPads, as a form of augmentative and alternative communication (AAC). The families surveyed reported wanting information and support from professionals, including speech language pathologists (SLPs), who are knowledgeable about AAC. These families wanted devices to meet their children's individual needs and reported that ease of use and affordability were the most influential characteristics in the purchase of mobile media devices and communication applications. SLPs who understand family decision making can utilize collaborative clinical decision making that respects families' wants and needs, while also focusing on device feature matching and family education.

Implementing electronic identification for performance recording in sheep: II. Cost-benefit analysis in meat and dairy farms.

Costs and secondary benefits of implementing electronic identification (e-ID) for performance recording (i.e., lambing, body weight, inventory, and milk yield) in dairy and meat ewes were assessed by using the results from a previous study in which manual (M), semiautomatic (SA), and automatic (AU) data collection systems were compared. Ewes were identified with visual ear tags and electronic rumen boluses. The M system used visual identification, on-paper data recording, and manual data uploading to a computer. The SA system used e-ID with a handheld reader in which performances were typed and automatic uploaded to a computer. The use of a personal digital assistant (PDA) for recording and automatic data uploading, which transformed M in a SA system, was also considered. The AU system was only used for BW recording and consisted of e-ID, automatic data recording in an electronic scale, and uploading to a computer. The cost-benefit study was applied to 2 reference sheep farms of 700 meat ewes, under extensive or intensive production systems, and of 400 dairy ewes, practicing once- or twice-a-day machine milkings. Sensitivity analyses under voluntary and mandatory e-ID scenarios were also included. Benefits of using e-ID for SA or AU performance recording mainly depended on sheep farm purpose, number of test days per year, handheld reader and PDA prices, and flock size. Implementing e-ID for SA and AU performance recording saved approximately 50% of the time required by the M system, and increased the reliability of the data collected. Use of e-ID increased the cost of performance recording in a voluntary e-ID scenario, paying only partially the investment made (15 to 70%). For the mandatory e-ID scenario, in which the cost of e-ID devices was not included, savings paid 100% of the extra costs needed for using e-ID in all farm types and conditions. In both scenarios, the reader price was the most important extra cost (40 to 90%) for implementing e-ID in sheep farms. Calculated extra costs of using the PDA covered more than 100% of the implementation costs in all type of sheep farms, indicating that this device was cost-effective for sheep-performance recording.

An innovative approach to near-infrared spectroscopy using a standard mobile device and its clinical application in the real-time visualization of peripheral veins.

BACKGROUND: Excessive venipunctures are a significant problem both in emergency rooms and during hospital stays. Near-infrared (NIR) illumination devices improve venipuncture success rate but their usage is limited by their availability and economic cost. The objectives of this study were to develop a low-cost NIR spectroscopy prototype from a standard mobile device, to evaluate its efficacy and acceptance as an educational tool, and in a clinical setting. METHODS: Through a user-centric design process a prototype device was developed. Its educational efficacy was evaluated through a non-invasive, observational study (20 student clinicians, 25 subjects) and its acceptance was assessed using quantitative and qualitative analysis. A smaller clinical trial was performed by a group of 4 medical professionals over a period of 6 weeks that involved 64 patients. RESULTS: The prototype enables real-time visualization of peripheral veins on a variety of Android-based devices. The prototype was 35.2% more successful in visualizing and locating veins (n = 500 attempts) than the nursing students. The acceptance assessment revealed high perception of usefulness, satisfaction, and ease of use. In the clinical trial, 1.6 (SD 1.3) additional veins per patient were identified compared with the traditional visualization methods. CONCLUSIONS: To the best of our knowledge this is the first study that describes the design, feasibility and application of an NIR spectroscopy prototype developed on a standard mobile device.

One tool for many tasks: integrating ipads into the third-year learning experience.

Librarians worked with faculty in the School of Medicine to integrate iPad tablets into the third-year pediatric clerkship. The use of the technology allowed students instant access to information in the clinical setting and simplified the management of the course. In addition, a variety of tablet and e-reader devices were purchased for patron check-out. Library management of the devices is discussed. Use of the devices is described, and student reactions are presented.

Remote assessment of stroke using the iPhone 4.

Therapy with recombinant tissue plasminogen activator is underused in the treatment of ischemic stroke in rural hospitals, due to a lack of local stroke expertise. Telemedicine solutions for stroke are a level I, class A recommendation when a vascular neurologist is absent. However, current solutions require exorbitant startup costs, which are prohibitive for the rural hospitals in which they are needed most. This study demonstrates the efficacy of using the relatively inexpensive iPhone 4 in telestroke management. Twenty patients with stroke were assessed at the bedside using an iPhone 4, and each examination was directed remotely on another iPhone 4. Both the physician performing the bedside exam and the remote physician calculated a National Institutes of Health Stroke Scale (NIHSS) score for each patient. Each physician was blinded to the other's NIHSS score. In the 20 patients assessed, NIHSS scores ranged from 0 to 22. Interrater reliability assessed using the κ statistic demonstrated excellent agreement in 10 items (level of consciousness, month and age, visual fields, right motor arm, left motor arm, right motor leg, left motor leg, sensation, language, and neglect), moderate agreement in 3 items (gaze, facial palsy, and dysarthria), and poor agreement in 1 item (ataxia). Total NIHSS scores obtained remotely and at bedside showed an excellent level of agreement (intraclass correlation coefficient, 0.98). Our findings indicate that the iPhone 4 is an economical mobile solution that can be used to assess stroke patients remotely with high fidelity and can be readily incorporated into a telestroke network.

Mobile Medical Education (MoMEd) - how mobile information resources contribute to learning for undergraduate clinical students - a mixed methods study.

BACKGROUND: Mobile technology is increasingly being used by clinicians to access up-to-date information for patient care. These offer learning opportunities in the clinical setting for medical students but the underlying pedagogic theories are not clear. A conceptual framework is needed to understand these further. Our initial questions were how the medical students used the technology, how it enabled them to learn and what theoretical underpinning supported the learning. METHODS: 387 medical students were provided with a personal digital assistant (PDA) loaded with medical resources for the duration of their clinical studies. Outcomes were assessed by a mixed-methods triangulation approach using qualitative and quantitative analysis of surveys, focus groups and usage tracking data. RESULTS: Learning occurred in context with timely access to key facts and through consolidation of knowledge via repetition. The PDA was an important addition to the learning ecology rather than a replacement. Contextual factors impacted on use both positively and negatively. Barriers included concerns of interrupting the clinical interaction and of negative responses from teachers and patients. Students preferred a future involving smartphone platforms. CONCLUSIONS: This is the first study to describe the learning ecology and pedagogic basis behind the use of mobile learning technologies in a large cohort of undergraduate medical students in the clinical environment. We have developed a model for mobile learning in the clinical setting that shows how different theories contribute to its use taking into account positive and negative contextual factors.The lessons from this study are transferable internationally, to other health care professions and to the development of similar initiatives with newer technology such as smartphones or tablet computers.

Application of handheld devices to field research among underserved construction worker populations: a workplace health assessment pilot study.

BACKGROUND: Novel low-cost approaches for conducting rapid health assessments and health promotion interventions among underserved worker groups are needed. Recruitment and participation of construction workers is particularly challenging due to their often transient periods of work at any one construction site, and their limited time during work to participate in such studies. In the present methodology report, we discuss the experience, advantages and disadvantages of using touch screen handheld devices for the collection of field data from a largely underserved worker population. METHODS: In March 2010, a workplace-centered pilot study to examine the feasibility of using a handheld personal device for the rapid health assessment of construction workers in two South Florida Construction sites was undertaken. A 45-item survey instrument, including health-related questions on tobacco exposure, workplace safety practices, musculoskeletal disorders and health symptoms, was programmed onto Apple iPod Touch® devices. Language sensitive (English and Spanish) recruitment scripts, verbal consent forms, and survey questions were all preloaded onto the handheld devices. The experience (time to survey administration and capital cost) of the handheld administration method was recorded and compared to approaches available in the extant literature. RESULTS: Construction workers were very receptive to the recruitment, interview and assessment processes conducted through the handheld devices. Some workers even welcomed the opportunity to complete the questionnaire themselves using the touch screen handheld device. A list of advantages and disadvantages emerged from this experience that may be useful in the rapid health assessment of underserved populations working in a variety of environmental and occupational health settings. CONCLUSIONS: Handheld devices, which are relatively inexpensive, minimize survey response error, and allow for easy storage of data. These technological research modalities are useful in the collection and assessment of environmental and occupational research data.

[The QR code in society, economy and medicine--fields of application, options and chances]. / Der QR Code in Gesellschaft, Wirtschaft und Medizin--Anwendungsbeispiele, Möglichkeiten und Chancen.

2D codes like the QR Code ("Quick Response") are becoming more and more common in society and medicine. The application spectrum and benefits in medicine and other fields are described. 2D codes can be created free of charge on any computer with internet access without any previous knowledge. The codes can be easily used in publications, presentations, on business cards and posters. Editors choose between contact details, text or a hyperlink as information behind the code. At expert conferences, linkage by QR Code allows the audience to download presentations and posters quickly. The documents obtained can then be saved, printed, processed etc. Fast access to stored data in the internet makes it possible to integrate additional and explanatory multilingual videos into medical posters. In this context, a combination of different technologies (printed handout, QR Code and screen) may be reasonable.

Cost-effectiveness of implementing routine hearing screening using a tablet audiometer for pediatric cystic fibrosis patients receiving high-dose IV aminoglycosides.

BACKGROUND: Cystic fibrosis (CF) patients who receive high-dose aminoglycosides can acquire inner ear damage and subsequent hearing loss. There is no current standard protocol for assessing ototoxicity in CF centers in the United States. OBJECTIVE: To evaluate the cost-effectiveness of a pharmacist-implemented routine hearing screening for ototoxicity among pediatric patients using a clinically validated tablet audiometer to allow for earlier detection of hearing loss in an exploratory analysis. METHODS: A Markov decision-analytic model was developed to assess the cost-effectiveness of implementing routine screening with monthly cycles over a 3-year time horizon. The model measured the difference in promptly detected hearing loss, delayed detected hearing loss, and undetected hearing loss, compared with current screening practices. Model inputs were obtained through a comprehensive literature review. Primary model outcomes included total health care costs and quality-adjusted life-years (QALYs) gained with a 3% yearly discount. One-way, two-way, and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. RESULTS: In a hypothetical cohort of 100 patients, routine screening using a tablet audiometer increased promptly detected hearing loss by 8 patients. There was an incremental gain of 3.2 QALYs at an increased cost of $333,826 compared with current screening practices. This resulted in an incremental cost-effectiveness ratio (ICER) of $103,771 per QALY. In the 1-way sensitivity analysis, the ICER ranged between $64,345 and $258,830 per QALY. CONCLUSIONS: Using a tablet audiometer for routine hearing screening appears to be a cost-effective option at a $150,000 per QALY willingness-to-pay threshold when only considering the immediate benefits gained. This analysis did not examine the long-term effects of early detection in language development for pediatric patients. DISCLOSURES: Huang reports funding from the University of North Carolina and GlaxoSmithKline Health Outcomes Fellowship. GlaxoSmithKline had no involvement in the study creation, analysis, or manuscript composition. The other authors have nothing to disclose.

Mobile interventions for severe mental illness: design and preliminary data from three approaches.

Mobile devices can be used to deliver psychosocial interventions, yet there is little prior application in severe mental illness. We provide the rationale, design, and preliminary data from 3 ongoing clinical trials of mobile interventions developed for bipolar disorder or schizophrenia. Project 1 used a personal digital assistant to prompt engagement in personalized self-management behaviors based on real-time data. Project 2 employed experience sampling through text messages to facilitate case management. Project 3 was built on group functional skills training for schizophrenia by incorporating between-session mobile phone contacts with therapists. Preliminary findings were of minimal participant attrition, and no broken devices; yet, several operational and technical barriers needed to be addressed. Adherence was similar to that reported in nonpsychiatric populations, with high participant satisfaction. Therefore, mobile devices seem feasible and acceptable in augmenting psychosocial interventions for severe mental illness, with future research in establishing efficacy, cost effectiveness, and ethical and safety protocols.

Point-of-care technology supports bedside documentation.

As the conversion to an electronic health record intensifies, the question of which data-entry device works best in what environment and situation is paramount. Specifically, what is the best mix of equipment to purchase and install on clinical units based on staff preferences and budget constraints? The authors discuss their evaluation of stationary personal computers, workshops on wheels, and handheld tablets related to timeliness of data entry and their use of focus groups to ascertain the pros/cons of data-entry devices and staff preferences. An assessment of the implications for costs related to the timeliness of data entry is also presented.

Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial.

BACKGROUND: Many emergency ambulance calls are for older people who have fallen. As half of them are left at home, a community-based response may often be more appropriate than hospital attendance. The SAFER 1 trial will assess the costs and benefits of a new healthcare technology--hand-held computers with computerised clinical decision support (CCDS) software--to help paramedics decide who needs hospital attendance, and who can be safely left at home with referral to community falls services. METHODS/DESIGN: Pragmatic cluster randomised trial with a qualitative component. We shall allocate 72 paramedics ('clusters') at random between receiving the intervention and a control group delivering care as usual, of whom we expect 60 to complete the trial.Patients are eligible if they are aged 65 or older, live in the study area but not in residential care, and are attended by a study paramedic following an emergency call for a fall. Seven to 10 days after the index fall we shall offer patients the opportunity to opt out of further follow up. Continuing participants will receive questionnaires after one and 6 months, and we shall monitor their routine clinical data for 6 months. We shall interview 20 of these patients in depth. We shall conduct focus groups or semi-structured interviews with paramedics and other stakeholders.The primary outcome is the interval to the first subsequent reported fall (or death). We shall analyse this and other measures of outcome, process and cost by 'intention to treat'. We shall analyse qualitative data thematically. DISCUSSION: Since the SAFER 1 trial received funding in August 2006, implementation has come to terms with ambulance service reorganisation and a new national electronic patient record in England. In response to these hurdles the research team has adapted the research design, including aspects of the intervention, to meet the needs of the ambulance services.In conclusion this complex emergency care trial will provide rigorous evidence on the clinical and cost effectiveness of CCDS for paramedics in the care of older people who have fallen. TRIAL REGISTRATION: ISRCTN10538608.

Cost Analysis of Health Facility Electronic Integrated Disease Surveillance and Response in One District in Sierra Leone.

Global health security depends on effective surveillance systems to prevent, detect, and respond to disease threats. Real-time surveillance initiatives aim to develop electronic systems to improve reporting and analysis of disease data. Sierra Leone, with the support of Global Health Security Agenda partners, developed an electronic Integrated Disease Surveillance and Response (eIDSR) system capable of mobile reporting from health facilities. We estimated the economic costs associated with rollout of health facility eIDSR in the Western Area Rural district in Sierra Leone and projected annual direct operational costs. Cost scenarios with increased transport costs, decreased use of partner personnel, and altered cellular data costs were modeled. Cost data associated with activities were retrospectively collected and were assessed across rollout phases. Costs were organized into cost categories: personnel, office operating, transport, and capital. We estimated costs by category and phase and calculated per health facility and per capita costs. The total economic cost to roll out eIDSR to the Western Area Rural district over the 14-week period was US$64,342, a per health facility cost of $1,021. Equipment for eIDSR was the primary cost driver (45.5%), followed by personnel (35.2%). Direct rollout costs were $38,059, or 59.2% of total economic costs. The projected annual direct operational costs were $14,091, or $224 per health facility. Although eIDSR equipment costs are a large portion of total costs, annual direct operational costs are projected to be minimal once the system is implemented. Our findings can be used to make decisions about establishing and maintaining electronic, real-time surveillance in Sierra Leone and other low-resource settings.

Cost and implementation analysis of a personal digital assistant system for laboratory data collection.

SETTING: One hundred and twenty-six public health centers and laboratories in Lima, Peru, without internet. BACKGROUND: We have previously shown that a personal digital assistant (PDA) based system reduces data collection delays and errors for tuberculosis (TB) laboratory results when compared to a paper system. OBJECTIVE: To assess the data collection efficiency of each system and the resources required to develop, implement and transfer the PDA-based system to a resource-poor setting. DESIGN: Time-motion study of data collectors using the PDA-based and paper systems. Cost analysis of developing, implementing and transferring the PDA-based system to a local organization and their redeployment of the system. RESULTS: Work hours spent collecting and processing results decreased by 60% (P < 0.001). Users perceived this decrease to be 70% and had no technical problems they failed to fix. The total cost and time to develop and implement the intervention was US$26092 and 22 weeks. The cost to extend the system to cover nine more districts was $1125 and to implement collecting patient weights was $4107. CONCLUSION: A PDA-based system drastically reduced the effort required to collect TB laboratory results from remote locations. With the framework described, open-source software and local development, organizations in resource-poor settings could reap the benefits of this technology.

The cost of developing a computerized tailored interactive multimedia intervention vs. a print based Photonovella intervention for HPV vaccine education.

Mobile technology is opening new avenues for healthcare providers to create and implement tailored and personalized health education programs. We estimate and compare the cost of developing an i-Pad based tailored interactive multimedia intervention (TIMI) and a print based (Photonovella) intervention to increase human papillomavirus (HPV) immunization. The development costs of the interventions were calculated using a societal perspective. Direct cost included the cost of planning the study, conducting focus groups, and developing the intervention materials by the research staff. Costs also included the amount paid to the vendors who produced the TIMI and Photonovella. Micro cost data on the staff time and materials were recorded in logs for tracking personnel time, meeting time, supplies and software purchases. The costs were adjusted for inflation and reported in 2015 USD. The total cost of developing the Photonovella was $66,468 and the cost of developing the TIMI was $135,978. The amortized annual cost for the interventions calculated at a 3% discount rate and over a 7-year period was $10,669 per year for the Photonovella and $21,825 per year for the TIMI intervention. The results would inform decision makers when planning and investing in the development of interactive multimedia health interventions.