Since the introduction of the iPhone in 2007, the personal smartphone has played an increasing role in hospital settings. Over 90% of trainees in paediatrics use a smartphone Reference Jyothi, Halton and Goodyear1 and over 85% use medical applications at least once a week. The use of smartphone applications in clinical practice has steadily increased as a way to engage a new generation of trainees and provide quick, easy access to data and references. Reference Valle, Godby, Paul, Smith and Coustasse2,Reference Mosa, Yoo and Sheets3
The field of paediatric cardiology spans a broad range of disciplines and subspecialties including general cardiology, non-invasive imaging, cardiac catheterisation, electrophysiology, cardiac critical care, adult CHD, pulmonary hypertension, and heart failure. Each subspecialty offers its own societal guidelines and evolving recommendations as knowledge and technology rapidly advance in each field. As of yet, there is no consolidated source of information that can quickly access these resources.
In recent years, programmes have placed increasing emphasis on evidence-based practice and guideline-directed management and therapy. Reference Lewis, Martin and Bartz4–Reference Webber, Hsu and Ivy10 Currently, there is no smartphone application (app) dedicated to paediatric cardiology evidence-based practice guidelines and recommendations. The purpose of this project was to design a paediatric cardiology handbook smartphone app to serve as a quick-access digital resource reflecting contemporary practice, including current guidelines, and to evaluate its utility for paediatric cardiology fellows.
Materials and methods
App description
The Peds Cardiology Handbook app was created by author ER for iPhone using XCode and Swift programming language (Fig 1). The app was designed to provide quick answers to clinical questions that arise in daily practice, with a focus on societal guidelines and scientific consensus statements. Topics covered included adult CHD, cardiac catheterisation, critical CHD screening, echocardiography, electrophysiology, endocarditis, genetics, intensive care, Kawasaki disease, medications, and rheumatic fever. Each page on the app included references to relevant peer-reviewed literature and textbooks.
Example screenshots from the Peds Cardiology Handbook app.
Pre- and post-app survey questions
Approval was obtained from the Institutional Review Board of the Albert Einstein College of Medicine prior to data collection. A pre-app electronic survey (Qualtrics, Provo, UT) was sent to paediatric cardiology fellows in the United States of America, followed by instructions to download the app. The pre-app survey contained eight questions, using multiple choice and Likert scales to understand the fellows’ usage of various resources and modalities in clinical practice.
Four months later, a post-app survey was sent to the same group of fellows. The post-app survey contained 12 questions, including the same questions from the pre-app survey as well as additional questions regarding usage of the handbook app (Table 1). Pre- and post-app surveys were automatically linked by an anonymous identification number. Respondents were included for analysis if they downloaded the app and completed both pre- and post-app surveys. Respondents were excluded from analysis if they were not iPhone users, as the app was only available on an iOS platform.
Survey questions.
Analysis
Data were described using standard summary statistics. Univariate analysis was performed using McNemar’s test to compare paired dichotomous variables and Wilcoxon signed-rank test for nonparametric variables, with p-values ≤ 0.05 considered significant. Analyses were conducted using Stata software, version 13 (StataCorp LP, College Station, TX, USA).
Results
Respondent demographics
Of the 230 paediatric cardiology fellows who were contacted, 67% (n = 155) completed the pre-app survey. Of that group, 90% (n = 140) were iPhone users and were, therefore, able to download the Peds Cardiology Handbook app. Of those 140 fellows, 38% (n = 53) downloaded the app and completed the post-app survey, meeting inclusion criteria for analysis. Respondent demographics are shown in Table 2. Most fellows were in their first year (36%, n = 19) or second year (45%, n = 24) of training. Over half of patients were in small-to-medium-sized programmes with 1–3 fellows per year (57%, n = 30).
Respondent data.
Pre-app survey results
Learning tools
Fellows were asked to rank their preferred methods of learning paediatric cardiology material among the following choices: in-person lectures, online videos, smartphone apps, journal articles, textbooks, and medical websites (Fig 2). The most frequent top-ranked response was lectures (53%, n = 28), followed by textbooks (15%, n = 8), medical websites (11%, n = 6), and online videos/webinars (9%, n = 5).
Preferred resources for learning paediatric cardiology by share of top choice ranking.
Resource use
On the pre-app surveys, fellows were asked how often they use various resources when looking for a quick answer to a clinical question (Fig 3). The resources used frequently (defined as at least once per week) were Google (89%, n = 47), UpToDate (72%, n = 38), PubMed (51%, n = 27), and smartphone apps (49%, n = 26). Resources that were less likely to be used frequently as a quick resource included printed textbooks (32%, n = 17), Wikipedia (30%, n = 16), and printed fellowship handbooks (11%, n = 6).
Frequent resource usage (at least once per week) for quick answers to clinical questions by respondents on the pre- and post-app surveys.
Quick access by topic
Before being introduced to the app, fellows were asked to assess the ease of quick access to various types of information, such as guidelines and normal values (Fig 4). Responses were given on a 4-point scale (1 = very difficult, 4 = very easy). The domains that were ranked as the most difficult were adult CHD guidelines (1.6 ± 0.6), pacemaker indications (1.8 ± 0.8), and the critical CHD screening algorithm (2.2 ± 0.8). Fellows found it relatively easy to quickly access normal ECG values (2.9 ± 1.0) and the paediatric cardiac arrest algorithm (2.8 ± 0.9).
Average fellow responses for ease of quick access to information in nine domains before and after using the Peds Cardiology Handbook app. A p-value ≤ 0.05 was considered significant. ACHD = Adult congenital heart disease; CCHD = Critical congenital heart disease; ECG = Electrocardiogram; PALS = Pediatric advanced life support.
Post-app survey results
Learning tools
When ranking preferred methods of learning paediatric cardiology material on the post-app survey, lectures remained the most popular top-ranked choice (53%, n = 28). There were no significant changes in the ranking of preferred learning modalities following use of the app. Of note, the ranking of medical smartphone apps as a learning tool did not change significantly on the post-app survey.
Resource use
Regarding resource use for quick answers to clinical questions, the only significant change on the post-app survey was increased frequent use of PubMed (74%, n = 39) by 23 percentage points (p = 0.04) (Fig 3). Google remained the most popular resource for frequent use (92%, n = 49).
Quick access by topic
After using the app, fellows found it easier to quickly access information in eight out of nine domains (Fig 4). The greatest improvements in “ease of quick access” score (1 = very difficult, 4 = very easy) from pre- to post-app were seen in echocardiographic views (2.2 ± 0.9 versus 2.9 ± 0.8, p < 0.01), pacemaker indications (1.8 ± 0.8 versus 2.4 ± 1.0, p < 0.01), adult CHD guidelines (1.6 ± 0.6 versus 2.2 ± 1.0, p < 0.01), and haemodynamic equations for the catheterisation lab (2.4 ± 0.9 versus 3.0 ± 0.9, p < 0.01). The only domain without statistically significant improvement was the incomplete Kawasaki disease algorithm (2.5 ± 0.8 versus 2.8 ± 0.9, p = 0.08).
Evaluation of app
Over half (57%, n = 30) of the fellows used the Peds Cardiology Handbook app 1–3 times per month, while 17% (n = 9) used it at least 1–3 times per week. All fellows found the app easy to use (100%, n = 53). Most fellows felt that the app was well organised (98%, n = 52), contained reliable information (92%, n = 49), and was useful for finding quick answers to clinical questions (87%, n = 46). A large majority (91%, n = 48) of fellows would recommend the app to a colleague.
When asked to describe in free text what they found to be most useful about the Peds Cardiology Handbook app, the most common response (47%, n = 25) was that it provided quick access to concise high-yield and relevant information in one place, particularly guidelines, normal value ranges, and diagnostic and treatment algorithms. The second most common response was the ease of use and accessibility of the app (43%, n = 23).
When asked to provide free text feedback and suggestions for improvement, the most common request was related to expanding app content (81%, n = 43). Of these, there were specific suggestions to expand content in electrophysiology (n = 5), echocardiography (n = 4), CHD surgical management (n = 4), pharmacology (n = 2), and catheterisation (n = 1). There were 8 fellows (15%) that did not have any feedback or suggestions for improvement.
Discussion
This project has demonstrated the successful development and implementation of a paediatric cardiology handbook smartphone app. Our survey data of paediatric cardiology fellows indicate that the app is a useful, reliable tool for providing quick access to various guidelines and references. After using the app, fellows found it easier to quickly access resources in almost all domains evaluated, particularly in permanent pacemaker indications, echocardiographic views, adult CHD guidelines, and haemodynamic equations for the catheterisation lab.
The field of paediatric cardiology has seen several novel approaches to aid in trainee education and clinical decision-making in recent years. Simulation training has been shown to improve procedural skills such as echocardiography and clinical performance in the cardiac intensive care setting Reference Dayton, Groves, Glickstein and Flynn11,Reference McBride, Beke and Fortenberry12 . There is also an increasing role for virtual reality training to improve fellow education and patient care Reference Sacks and Axelrod13 . To our knowledge, this is the first description of a smartphone application dedicated to providing consolidated quick access to high-yield educational material and concise summaries of current guidelines across all paediatric cardiology subspecialties to facilitate fellow education and practice of evidence-based medicine.
The results of our pre-app survey highlight the need for a convenient, reliable paediatric cardiology handbook. A majority of fellows (89%, n = 47) reported using Google at least weekly for answers to clinical questions. Though Google’s search engine can be a powerful tool, its results are not peer-reviewed or verified by the medical community. It seems likely that its frequent use is due to its easy interface and accessibility. Nearly half of the fellows (49%, n = 26) reported using smartphone medical apps frequently for quick answers, suggesting that a dedicated paediatric cardiology app could become a high-yield resource for many trainees. These findings should challenge paediatric cardiology educators to create innovative tools and resources with a focus on ease of use.
The primary function of the app was not to teach fundamental principles or concepts. As our survey data show, despite the importance of technology for today’s trainees, in-person lectures remain the most popular method for learning paediatric cardiology. Compared to an experienced educator, a smartphone app may be less able to explain the nuances of CHD and pathophysiology. Instead, the goal of the Peds Cardiology Handbook app was to provide quick answers to clinical questions that arise in daily practice, with a particular focus on guideline recommendations that may be difficult for trainees to memorise and recall quickly.
Development of this app was motivated by the large amount of continuously evolving recommendations and guidelines in the world of paediatric cardiology. Outcomes in patients with CHD have significantly improved over the last few decades, in part due to the increasing role of evidence-based practice guidelines Reference Pearson, Kaltman and Lauer14,Reference Clarke-Myers, Cooper and Hanke15 . By consolidating the knowledge of our field into a dynamic, easy-to-access smartphone app, paediatric cardiology fellows can more readily reference and become more familiar with these guidelines. Interestingly, after using the app, there was a significant increase in the number of fellows that reported frequent use of PubMed as a quick resource for clinical questions (51% pre-app to 74% post-app, p = 0.04). Use of the app may have encouraged fellows to examine the referenced literature for evidence to guide their clinical decision-making. Future research will investigate if practitioner usage of a smartphone handbook increases the practice of evidence-based medicine by facilitating access to current literature and guidelines.
Based on feedback received in the post-app survey, the app will continue to be expanded to include a wider range of paediatric cardiology topics. Updates to the application continue to be made intermittently, with new content automatically pushed to users’ devices through the iOS App Store.
Limitations
This project has several limitations. Only 23% of fellows who were contacted proceeded to download the app and complete both surveys, which may have led to a selection bias; perhaps these fellows were already more likely to benefit from and use a medical smartphone app. Since there is no Android version of the app, fellows who did not use an iPhone were excluded (15 total), limiting the generalizability of our conclusions. Though the app may be responsible for the improvements seen in quick access to information, this is confounded by improvements that may have been due to each fellow’s maturation and development over the four-month study period.
Conclusions
The Peds Cardiology Handbook smartphone app was found to be a useful, reliable tool for paediatric cardiology fellows that provides quick access to important guidelines and references in one easy-to-access location. Use of this app may facilitate and encourage evidence-based practice by fellows and will be explored in future studies.
Acknowledgements
None.
Financial support
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Social media synopsis
The Peds Cardiology Handbook iPhone app provides quick access to high-yield information, including guidelines and references.
