Online communities are becoming portals for information sharing and collaborating with healthcare colleagues who may be separated by geographical distances. Web 2.0 technologies are used by millions of people to build online communities of active members who both share and generate knowledge (Gruber, 2008). A similar phenomenon is occurring in healthcare as providers recognize the benefits of using these Web 2.0 technologies in daily practice. Online communities are becoming portals for information sharing and collaborating with healthcare colleagues who may be separated by geographical distances. The capabilities of Web-supported, mobile applications based in collaborative portals offer healthcare providers (HCPs) a rapid way of connecting with other providers who share similar needs and interests. In addition, the widespread availability of wireless networks in healthcare settings has fostered the growth of mobile applications aimed at improving communication, practice, and education for HCPs.

Personal digital assistants (PDAs) were one of the first models of wireless technologies utilized by HCPs. Stroud, Smith, and Erkel (2009) surveyed 124 actively practicing nurse practitioners (NPs) regarding their opinion of the usefulness and value of PDAs; 98% reported a belief in the value of the PDA for clinical practice. The NP respondents also reported that they customized their devices to meet individual needs. In the same study, 90% of respondents had installed a drug reference program; 54% had installed a medical text/reference book; and 29% had installed clinical practice guidelines on their device (Stroud et al., 2009). Daily use was reported by 87% of respondents (Stroud et al., 2009).

...early evidence suggests that collaboration can be enhanced by Web-based technologies. As the functionalities of the once-popular PDAs have been expanded in smartphones and tablets, many HCP subspecialties have discovered the benefits of using digital tools to promote communication and collaboration. Nurses in specialty areas, such as those who practice mental healthcare in rural areas, have adapted Web-based collaborative groups for their own uses. These nurses have used websites to create communities of practice; they have found that utilizing the Web can improve their skills and mental healthcare services for members of rural communities (Cassidy, 2011). Midwives, a subgroup of Advanced Practice Nurses, have also adopted wireless technologies, supported by Web-based, collaborative environments. Brooks and Scott (2006) found that participation in technology-assisted discussion forums led to increased perceptions of collegial support, especially for new midwives (Brooks & Scott). Hence, early evidence suggests that collaboration can be enhanced by Web-based technologies.

Although technological devices are increasingly used in patient care, barriers remain to widespread adoption of the devices. For example, issues of network connectivity represent a key factor in successful adoption of wireless technological solutions for HCPs. Insufficient bandwidth in patient care areas, leading to perceptions of a system as ‘slow,’ along with insufficient capacity of network servers, have been documented as reasons for failure of information technology implementation in healthcare facilities (Spetz, Burgess, & Phibbs, 2012).

Another barrier to adoption of wireless technological solutions is the lack of content and functionalities that HCPs need in daily, patient care activities. Both Web-based environments and mobile technology applications (apps) may lack the components necessary to foster collaboration and dissemination of information between professionals. This has been the case for the community of Advanced Practice Nurses (APNs) involved in organ transplantation. Current websites containing transplant-related content for APNs do not adequately address the following concerns:

• How do I share my experience, knowledge, questions, and ideas?
• How can I keep in touch with other APNs involved in organ transplantation?
• How can I stay current with activities and events within the transplant nursing community?
• How can I access transplant-related information for nurses in a single location?
• Can I use my mobile device to communicate and collaborate with other APNs in the transplant community?

Despite the burgeoning availability of websites and apps, there is a lack of research relating to the adoption of wireless technologies by HCPs. Such research is necessary to identify how the HCPs decide to either adopt, or defray use of, these technologies. It is also consistent with key components of the nursing informatics research agenda proposed by the National Institute of Nursing Research (Bakken, Stone, & Larson, 2008).

Ideally, research on the perceptions and needs of HCPs regarding the adoption of wireless technologies should begin with a small, well-defined group. We decided to study APNs, specifically Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs), who practice in the subspecialty of organ transplantation. This subspecialty includes a small number of highly skilled nurse professionals (less than 400 in the United States) working in transplant centers across the nation. The complex clinical care provided by transplant HCPs, along with the often great geographical distances between APNs in these centers, suggest these nurses could benefit from the features offered by a website and mobile app targeted to their needs.

In this article, we will review the literature and describe the development of health-related technology; present our mobile app project assessing the effects of our collaborative mobile app based on a freely available content manage framework; and report what we found. We will conclude by sharing both lessons learned while completing this project and future directions.

Review of Literature Related to Technology Adoption by Healthcare Providers

many of the features previously offered by personal digital assistants (PDAs) have merged into more sophisticated devices, such as smartphones and tablets. As the wireless technology industry has evolved, many of the features previously offered by personal digital assistants (PDAs) have merged into more sophisticated devices, such as smartphones and tablets. Though their use is not yet ubiquitous in healthcare settings, evidence suggests that popularity of the devices among HCPs is increasing. A report of mobile device usage by physicians, based on survey data collected from June 1, 2010, through February 28, 2011, suggested that three of ten physicians used mobile devices, such as smartphones and tablets, to access mobile medical news (Bulletin Health Care, 2011). Use of smartphones and tablets varied among physician specialties, with 16% of clinical pathologists reporting use (Bulletin Health Care, 2011).  Though a majority of respondents in the survey reported use of iPhones and iPads, an increasing number were turning to products based on Google’s Android system (Bulletin Health Care, 2011).

The use of technology devices specifically among APNs has also been explored. In 2009, the American Academy of Nurse Practitioners (AANP) conducted its annual membership survey, which included new items designed to assess the use of PDAs or smartphones by APNs in clinical practice. The online survey was administered over a two-week period in April-May 2009, amassing data from 3,389 respondents (Goolsby, 2009). Though 40% of the survey respondents indicated that they did not use these types of devices, the majority of respondents reported a variety of clinical uses for their PDAs and smartphones. Examples included drug information (53.9%), diagnostic studies (22.1%), lab values (18.7%), communications (16.4%), coding (14.3%), Web-browsing (8.9%), and electronic charting (1.5%) (Goolsby, 2009).

Smartphones, tablets, and apps in education have now been adopted by current students who will be the HCPs of the future. Smartphones, tablets, and apps in education have now been adopted by current students who will be the HCPs of the future. In an online survey emailed to residents and fellows employed in medical centers recognized by the Accreditation Council for Graduate Medical Education, respondents were queried about their use of smartphones and smartphone apps (Franko & Tirrell, 2011). More than 85% of respondents (n=3306) reported using a smartphone, with the iPhone, Android, and Blackberry operating systems (OSs) being the most popular OSs; 56% of respondents reported using apps in clinical practice (Franko & Tirrell, 2011). The residents and fellows reported using apps in ways similar to the APNs, i.e., using them as drug guides, medical calculators, and coding/billing guides (Franko & Tirrell, 2011).

Research supports improvements in efficiency associated with the use of point-of-care technologies in clinical practice. When compared with a group who used traditional resources, novice NP students who used wireless devices demonstrated a higher degree of accuracy and efficiency in interpreting lab values and selecting medications in patient scenarios (Krauskopf & Farrell, 2011). Time-saving was also improved, as the study demonstrated that those novice NP students who used the wireless devices “…required significantly less time to determine an answer, and did so with a level of accuracy that was at least equal to the textbook users” (Krauskopf & Farrell, 2011, p. 123).

Development of Technology for the Pilot Project

The technology needed for this project included a Web portal and a mobile device application. Both will be described below.

Web Portal

we envisioned an online area in which small groups of APNs involved in organ transplantation could communicate, sharing experiences and knowledge important for patient care and daily practice. This knowledge could then be made available to a larger APN community with an app. In planning the website and its associated mobile applications, we envisioned an online area in which small groups of APNs involved in organ transplantation could communicate, sharing experiences and knowledge important for patient care and daily practice. This knowledge could then be made available to a larger APN community with an app. Responsibilities for the project were divided between researchers in the College of Nursing (CON) and staff members of the Information Technology Systems Center (ITSC) at the University of Alabama in Huntsville. A series of design meetings were held, offering opportunities for the CON faculty to identify content and usage needs for the website and the mobile app. ITSC staff members then worked to include the items necessary for the website and app. They presented revisions of the website and mobile app at our subsequent meetings. This initial phase of the design and building of the website and mobile app took approximately six months.

First, we constructed our Web portal (called the Mobile Transplant Professional Website). It was developed using a content management framework (CMF), which allowed for the creation of a shared database among users and included social media capabilities. Drupal <http://drupal.org>, a freely available CMF, was used as the basis for construction of the Web portal. CMFs aggregate many features that designers can choose to incorporate into websites, such as user management, access control, taxonomy, templates, and session management. Many of these functions were adapted for use in the mobile Transplant Professionals Website <http://tpp.uah.edu>. Functionalities of the Web portal and mobile application were designed based on anticipated needs of the users; they were modified after beta testing. For example, the researchers anticipated that editors and moderators would primarily use the Web portal, while the APNs, as end-users, would rely on their mobile devices for collaboration and communication, as presented in Table 1.

Mobile Device Application

After the design and hosting of the Web collaborative environment was completed, we began the development of the mobile app (Mobile Transplant Professional). Because of restrictions in both cost and time for project completion, the researchers selected two operating systems (OSs), Android and iOS. These two popular OSs would also work for apps on tablets, which some HCPs might prefer because of the increased screen size and options for different font types and sizes offered by tablets. The app is presently available and can be downloaded at no cost from iTunes and Google Play (See Table 2). Examples of features presently found on the mobile app include organ-specific discussion forums, biomedical calculators, and Rich Site Summary (RSS) feeds of recent publications from databases such as PubMed.

The Pilot Project

This project was designed to test the usability, feasibility, and functionality of the technology. The research design for this initial pilot project was descriptive, using pre- and post-test surveys that were administered prior to and after release of the website and mobile app. Approval for the pilot project was granted by the Institutional Review Board at the University of Alabama in Huntsville. We invited a convenience sample of eight APNs employed at transplant centers across the United States to participate. The APNs were known to the authors and chosen based on their expressed interest in using the app. Participation in the project required that the APN own a smartphone or tablet. Participants were asked to complete an investigator-designed, 21-item, electronic survey on two separate occasions, once prior to the release of the website and app, and again after using the website and app in practice. Surveys were administered to study participants in July, 2011, and again in October, 2011.

The electronic survey contained items designed to collect demographic information about the study participants, the types of devices (and how they acquired those devices) most commonly used in practice, and participants’ patterns of use for those devices. Three open-ended questions addressed intent to use mobile devices for patient management and professional collaboration. Specific study questions for the project were:

• What are the demographics of the group of APNs who are interested in adopting the mobile app into their practice?
• How is the group of APNs presently using mobile technologies in daily practice, such as communicating with colleagues?
• How did adoption of the app alter attitudes, perceptions, and behaviors of the use of mobile technologies in daily practice for this group of APNs?

Participants received an honorarium of $100.00 USD for their completion of the pre- and post-surveys on the use of the website and mobile app. Funding for the design and implementation of the website and mobile app, along with honoraria, were provided by the University of Alabama in Huntsville Research Infrastructure Investment Grant Program.

Findings

Eight participants completed the pre-release (of Web portal and mobile app) survey; seven participants completed the post-release (of Web portal and mobile app) survey. Descriptive analysis of the demographic information in the pre-release survey revealed that study participants were mainly female (88%), and 50% were between the age of 46 to 55 years. All of the respondents were APNs, with seven reporting experience as a Nurse Practitioner and one as a Clinical Nurse Specialist. The eight respondents all had similar transplant experiences with 88% having worked with patients prior to transplant and 100% reporting experience in care for patients post-organ transplant. Survey respondents reported experience in managing different types of organ transplants in their respective facilities; however, kidney transplants (88%) were most common type of transplant experience.

Survey Prior to Web-Portal or Mobile-App Release

Most respondents (88%) stated that their employer selected and provided the device that was used most frequently in their daily practice. The APNs who participated in this project were an experienced group of HCPs; they considered themselves as advocates among their peers for the use of wireless technology and devices in patient care. In the survey, prior to release of the Web portal and mobile app, the majority of respondents reported use of a personal computer (PC), laptop, and/or smartphone in daily practice. The most commonly used device in daily practice was the PC, as reported by 62% of the project participants. Only two participants reported that the smartphone was the device most commonly used in daily practice. Most respondents (88%) stated that their employer selected and provided the device that was used most frequently in their daily practice. Fifty percent of participants used the Blackberry OS in daily practice, with three participants using the Android OS and one using iOS (Apple).

In reviewing perceptions and attitudes of the participants regarding the use of mobile devices prior to the release of the Web portal and mobile app, 75% felt that they did not have easy access to transplant nursing/nurse practitioner-related information in a centralized location. Three of the eight participants (32%) strongly disagreed with a statement regarding the ease of use of a mobile device for querying colleagues in the field of organ transplantation when questions arose. One participant reported use of a mobile device to query colleagues in the transplant community more than twice daily, while four participants (50%) reported similar use on a monthly, or less than monthly basis. Participants were equally divided on the frequency of mobile device use to connect with colleagues in the transplant community, with four (50%) reporting this activity daily, and four (50%) reporting this activity less than monthly or never. Six of the participants (75%) believed in the potential use of the mobile device to collaborate with colleagues in the transplant community; 75% reported use of a mobile device in managing transplant patients.

Fifty percent stated that they used mobile apps daily in practice, citing examples such as Epocrates, Canto, and biomedical calculators to determine, for example, body mass index and creatinine clearance. One participant cited use of the United Network of Organ Sharing (UNOS) Lung Allocation Score Calculator, found on the UNOS website. Many participants (75%) felt that a mobile device would be very helpful in obtaining pharmaceutical information. All of the participants considered themselves to be advocates for the use of technological devices among their colleagues in organ transplantation. Participants were asked an open-ended question about factors that would increase their personal use of mobile devices for communicating with colleagues and/or for patient management, they identified factors, such as ease of use, cost, and a need for one app that would offer multiple types of information on a widely used platform (e.g. transplant-related practice guidelines, drug information).

Survey Post Beta Testing

With the exception of one participant who was lost to attrition, participants’ demographics for the survey administered after beta testing of the Web portal and mobile app were similar, with the group again being mostly female NPs (with a single male in both the pre- and post-beta-testing groups) between the ages of 46 to 55 years with experience in both pre- and post-transplant patient management. There was no change in the types of devices and platforms that were used in both the pre- and post-release surveys, with both the PC and smartphone being the most common devices used in daily practice. The PC continued to be the most frequently used device in the post-beta-release survey as reported by 58% of the participants. Participants continued to report negative attitudes regarding the ease of access to transplant-related nursing information in a centralized location, as reported by 58% of the participants.

participants indicated that they would be more likely to use a mobile device to manage transplant patients if “I could look at … [patient] medical records” or “if I was able to access the hospital electronic medical record using it.” Other attitudes and perceptions assessed by the survey continued to demonstrate little or no change in the post-beta-release survey. Four of the participants (57%) reported that they used their mobile device to query colleagues in the transplant community monthly or less than monthly. Pre- and post-beta-release survey groups remained divided in their self- reports of frequency of mobile device use to connect with colleagues in the transplant community. For example, in the post-beta-release survey 57% reported using their mobile devices daily to connect with colleagues in the community, while three participants (43%) did this less than monthly or never. Interestingly, in the post-beta-release survey, fewer participants (43%) identified the use of a mobile device to manage transplant patients. Participants in both groups continued to identify themselves as strong advocates for the use of mobile technologies in caring for transplant patients. Participants continued to cite use of apps, such as Epocrates and UpToDate. One participant mentioned efforts to convince an employer to adopt Apple products in lieu of the Blackberry platform provided by the facility, mentioning the easy use of “…user friendly apps for ICD9 codes, meds, and calculations.” Choice of product and platform continued to be an issue for the project participants, who stated that they would be more likely to use a mobile device for communication with colleagues if a “central application that would allow me to get to everything,” or would be available, or if they had an “Apple product, iPhone, or iPad.” Other participants indicated that they would be more likely to use a mobile device to manage transplant patients if “I could look at … [patient] medical records” or “if I was able to access the hospital electronic medical record using it.”

The limited changes in perceptions and attitudes in the post beta testing, although disappointing, helped us to realize that we may have trialed our site with an inappropriate audience. Perhaps we should have focused more on the newer practitioners in our field, rather than on the sample of experienced practitioners which were convenient for us. This realization helped us better understand the need for studying the most appropriate audience, rather than the most convenient audience.

In the post beta testing survey, the following additional, open-ended items designed to evaluate the Web portal and app were asked:

• What features did you like best and why?
• What features did you use the most frequently?
• What features were the least helpful?

Participants identified the biomedical calculators, article feeds, and the Link/Upcoming events section as being useful. Participants identified the biomedical calculators, article feeds, and the Link/Upcoming events section as being useful. Some recommended modifications, such as the addition of a page on live organ donation, pediatric donations, and other calculators to determine, for example, the lung calculation score. One participant ended her comments with the statement: “I love how everything can be accessed from one app, great resource and something I would definitely use in the future.” This participant’s comment would seem to support use of apps in patient care, though not necessarily the social aspect of our Mobile Transplant Professional app.

Lessons Learned

Building a website and mobile app are relatively simple tasks that do not require advanced credentials.  Both the website and mobile app were designed by us authors, six people whose talents as a group included expertise in clinical content, patient care, and Web/mobile app design. The process of designing and releasing the website and app yielded valuable lessons for the team (See Table 3).

As authors, we had a collective interest in studying factors underlying the incorporation of mobile devices and apps into the practice of HCPs. As we worked together in designing this website, we learned, and came to appreciate, the benefits of having a multidisciplinary team available to design and construct our Web-based App.

Maintaining relevant clinical content is essential for success... Pages containing biomedical calculators have been used the most. The identification and funding of marketing strategies to promote use of websites and apps should be planned prior to their release and should capitalize on the needs of HCPs in patient care. Maintaining relevant clinical content is essential for success. Forum feeds, a feature of the website and app that were included in order for users to collaborate, have experienced limited activity. Pages containing biomedical calculators have been used the most. This finding is consistent with reports in the literature on the importance of “direct client care benefits,” which for many HCPs may serve as the impetus to adopt new technology applications (Garrett & Klein, 2008, p. 2151). Replies from participants in the post-release survey indicating continued use of apps for tasks, such as pharmaceutical referencing and evidence-based-practice inquiries, further support these findings.  Other elements specific to the targeted population, such as pages for live organ donations and pediatric donations, would likely also increase the utility of the website and app. Team members need to continuously search for new information and apps that would be helpful for the intended audience

Security of content housed on sites and apps is another important consideration. Security of content housed on sites and apps is another important consideration. Verification of user registrations and credentials by a qualified administrator is necessary to prevent access by unethical individuals. Site security and data encryption, if necessary, are continuously important tasks, beginning with pre-release planning. This is especially critical for websites and mobile apps that house and/or transmit patient-specific data.

At the time of this writing, our Web collaborative environment <http://tpp.uah.edu> continues to be hosted by staff members at ITSC, who are also responsible for expansions (e.g., mobile app updates). As mobile apps for healthcare providers continue to proliferate, assigning responsibility for ongoing content, administration, and updates will be essential details for designers to consider. It is important that appropriate content additions be scheduled at regular intervals, perhaps even daily if needed, to maintain user interest in the website and app.

Future Directions

As mobile apps for healthcare providers continue to proliferate, assigning responsibility for ongoing content, administration, and updates will be essential details for designers to consider. In conducting this project. we learned that the presence of a website or mobile app is no guarantee of its utilization in the targeted market, or that its existence will foster a sense of community and connection in subspecialty groups. Although the registration and use rates for the website and mobile app are less than the research team had hoped, it must be remembered that the group of APNs, who were targeted in development and marketing, specifically NPs and CNSs who are involved in providing transplant care, is not large. As of this writing, we have already introduced the website and app at national meetings for transplant professionals, through both podium presentations and exhibit booths.

Immediate plans for the Web portal and app are to promote its continued use to the larger community of HCPs in organ transplantation by linking it to other sites, displaying at national, transplant-related events, and initiating other promotional efforts. We also hope to develop a patient-specific portal that would improve care transitions for patients in geographically remote areas. Additionally, we plan to develop de-identified, transplant-related databases, housed on the Web portal, along with visual analytic tools used for rapid answers of clinical questions, to serve as additional resources for practicing nurses.

Summary

As healthcare facilities continue to adopt devices and technologies that improve clinical care, it is important to maintain a focus on devices and technologies that facilitate care by HCPs at the bedside. In this project, a group of APNs involved in organ transplantation were invited to participate in beta testing of a website and app that was custom designed for use in managing patients in the field of organ transplantation. The participants had a history of use of devices and apps in daily practice and were able to clearly articulate their needs and desires for changes in platforms, devices, and content that would further increase function. As we continued to work on this project, we recognized the value of identifying the specific needs of a specific group of HCPs when designing apps and Web pages to strengthen the patient care these HCPs provide. A centralized website location with multiple features, allowing users to access patient records, educational offerings, calculators, pharmaceutical references, organ transplant registries, and other content, can guide providers who are involved in enhancing patient care through the use of technology.

Acknowledgement: The authors would like to extend their thanks to the University of Alabama in Huntsville Research Infrastructure Investment (URII) Grant Program, for support of this project.

Authors

Susan Alexander, DNP, RN, AHNP, AHCNS 
E-mail: susan.alexander@uah.edu

Dr. Alexander is a Clinical Assistant Professor in the College of Nursing at the University of Alabama in Huntsville, where she teaches both traditional and online graduate courses in the Family Nurse Practitioner program. Her scholarly focus addresses the way in which students and healthcare providers adopt and use technological devices, such as smartphones and tablets, in clinical practice.  She has also participated in campus projects designed to implement new software applications for online education. Dr. Alexander received her Doctor of Nursing Practice degree at the University of Alabama in Huntsville and holds certification as an Adult Health Nurse Practitioner and Adult Health Clinical Nurse Specialist; she is board-certified in Advanced Diabetes Management.

Haley Hoy, PhD, RN
E-mail: haley.hoy@vanderbilt.edu

Dr. Hoy is an Assistant Professor in the College of Nursing at the University of Alabama in Huntsville where she serves as Interim Dean of Graduate Affairs and teaches in the Acute Care Nurse Practitioner track. She also holds a clinical position at Vanderbilt University Medical Center in the Lung Transplant program in Nashville, TN. Dr. Hoy is a member of the Editorial Review Board of Progress in Transplantation and is involved in a research project designed to increase rates of organ donation by implementing an online educational module for staff nurses. She earned her PhD in Nursing at Vanderbilt University.

Manil Maskey, MS
E-mail: mmaskey@itsc.uah.edu

Mr. Maskey is a research scientist at the Information Technology and Systems Center, housed at the University of Alabama in Huntsville. He has experience in the design and development of mobile applications and collaboration frameworks, and has worked on various projects involving the use of mobile applications in healthcare. He earned his BS in Mathematics/Computer Science at Fairmont State University in Fairmont, WV; his MS in Computer Science at the University of Alabama in Huntsville; and is a PhD candidate in Computer Science at the University of Alabama in Huntsville.

Helen Conover, MS
E-mail: hconover@itsc.uah.edu

Ms. Helen Conover serves as a technical lead for the Information Technology and Systems Center at the University of Alabama in Huntsville. She has experience in data management, metadata standards, and user interfaces. Ms. Conover received her BA from Rice University in Houston TX and MS in Computer Science from the University of Alabama in Huntsville.

John Gamble, BS
E-mail: gamble.cs@gmail.com

Mr. Gamble earned his BS in Computer Science from the University of Alabama in Huntsville. As a student member of the research team, Mr. Gamble’s primary responsibility focused on content management for the website and app.

Anne Fraley, BSN, RN
E-mail: annemariefraley@yahoo.com

Ms. Fraley earned her BSN from the College of Nursing at the University of Alabama in Huntsville. Her responsibilities in this pilot project included content identification for the website and app, along with the development and testing of the survey instruments used in this study.

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published May 13, 2013