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Response to Dr O’Reilly-Shah et al

Rothman, Brian S. MD; Gupta, Rajnish K. MD; McEvoy, Matthew D. MD

doi: 10.1213/ANE.0000000000002335
Letters to the Editor: Letter to the Editor

Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee,

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To the Editor

We wish to thank Dr O’Reilly-Shah et al1 for the detailed response to our article. A single, fully up-to-date review article encompassing the vast topic of technological evolution is not possible given the constraints of both article length and the continuous nature with which advancements are made. In light of this, we will provide responses to the concerns raised by O’Reilly-Shah et al.

In response to the Connected Health points, we fully support a robust health care documentation infrastructure using common language standards that allow for true data interoperability. As noted by O’Reilly-Shah et al, SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Health Interoperability Resources) holds much promise to change the status quo of printed or scanned documentation. However, it requires resources infrequently found beyond academic medical centers. Being sensitive to the majority who lack the necessary resources, we focused on the advantages realized by HTML, JavaScript, CSS (Cascading Style Sheets), and other standards that allowed true interoperability in web technologies, cross-platform communication, and device independence.2

With regard to app development environments, we focused on variables to consider when beginning a project to avoid future costly mistakes. As the authors stated, native app development permits superior direct access to the hardware and reduced wireless reliance, while web-based applications are device independent. With so many options available for cross-platform native development environments, each with its own pros and cons, promoting any single solution was consciously avoided.

We agree with O’Reilly-Shah et al that app analytics for the medical field is an exciting opportunity. Unfortunately, a detailed discussion was beyond the scope of this review article. As an example, our group partnered with the American Society of Regional Anesthesia and Pain Medicine (ASRA) to develop the ASRA Coags Regional app, transforming the ASRA regional anesthesia anticoagulation guidelines into a searchable electronic format. App analytics provided total downloads, use frequency, unique searches, geographic location, medications searched, and regional procedure performed.3 Our experience is the tip of the iceberg. Merging mobile technology and good data science will help researchers gain new insights.

O’Reilly-Shah et al reference the Ellaway paper, indicating that mobile device learning is less effective than other pedagogical approaches. This article describes a single-institution experience with giving medical students mobile devices without: (1) a specific educational program geared toward these devices; (2) any guidance to the students; or (3) implementation instructions to faculty. This model is inconsistent with mobile learning literature and spaced education utilizing interactive designs. We intentionally focused on modern, evidence-based modalities of learning and how mobile technology facilitates these methodologies to specifically overcome the limitations of traditional pedagogical approaches.

For example, the American Board of Anesthesiologists MOCA Minute® app asks a physician questions on a quarterly basis, replacing the single 10-year exam.4 This new method supports physician learning by delivering targeted questions with short educational reading material. The app utilizes Spaced Education theory and alters questions with adaptive and dynamic processes, which have been shown to be superior in numerous large prospective randomized trials.5 Mobile and online technologies allow examiners to introduce current and relevant questions that could not be incorporated into a written exam for years (eg, Zika virus management questions were presented to learners 6 months after the outbreak).

We agree with the authors that mobile technology in health care is a broad and rapidly evolving topic. We thank them for building on our review article and hopefully stimulating thoughtful discussion regarding the potential of this platform for education and clinical and research growth.

Brian S. Rothman, MDRajnish K. Gupta, MDMatthew D. McEvoy, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville,

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1. O’Reilly-Shah VN, Jabaley CS, Lynde GC, Monroe KS. Opportunities and limitations in mobile technology.Anesth Analg. 2017;125:1416.
2. W3C. The history of the web. Available at: Accessed May 16, 2017.
3. Gupta RK, McEvoy MD. Initial experience of the American Society of Regional Anesthesia and Pain Medicine Coags Regional Smartphone Application: a novel report of global distribution and clinical usage of an electronic decision support tool to enhance guideline use. Reg Anesth Pain Med. 2016;41:334–338.
4. The American Board of Anesthesiology. MOCA minute. Available at: Accessed May 16, 2017.
5. Kerfoot BP, Brotschi E. Online spaced education to teach urology to medical students: a multi-institutional randomized trial. Am J Surg. 2009;197:89–95.
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