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Department for Medical Informatics, Biometrics and Epidemiology, Ruhr-University, Bochum, Germany
Address correspondence and reprint requests to Priv. -Doz. Dr. med. Michael Imhoff, Am Pastorenwaldchen 2, D-44229 Dortmund, Germany. Address e-mail to mike{at}imhoff.de.
Cellular telephones are ubiquitous in our modern world, with an estimated 1.6 billion mobile phone users around the globe. Today we can assume that almost every health care professional has a private cell phone. There is also an increasing amount of telemedicine applications-based mobile phone technology (1,2). But these useful, and sometimes nerve-racking, instruments of communication are prohibited in most hospitals because they may interfere with medical devices and thus endanger our patients.
In this issue of Anesthesia & Analgesia, Dr. Soto et al. (3) give us insight into healthcare professionals’ clinical experience with the use of cell phones in hospitals. The authors are to be commended for addressing this timely and important topic. After analyzing an impressive 4018 responses to questionnaires distributed at the 2003 American Society of Anesthesiologists annual meeting, they have concluded that the small risk of electromagnetic interference (EMI) between cell phones and medical devices is outweighed by the potential benefits of improved communication, which could eventually help reduce the risk of medical error.
Of course, one may argue that the study by Dr. Soto et al. has some serious shortcomings. There was not a clear definition of medical errors, the severity of EMI-related incidents was not clear, and, probably most importantly, the reported medical errors and EMI incidents may not be representative because many additional errors and incidents may go unnoticed in clinical practice. However, the authors acknowledge and discuss these problems more than adequately.
Even with its limitations, this study is very important because it makes us think about our intra-hospital communication process from a broader perspective. It raises three important questions: Is the risk of EMI from cell phones small, or even negligible? Are cell phones really the solution to our communication problems? How can we use mobile phones safely in our hospitals?
Dr. Soto et al. review most of the relevant literature and conclude that the risk from EMI is very small. But a second look invites caution. Global system for mobile communications phones have stronger peak electromagnetic fields than their analog predecessors and emit signals whether a call is answered or not. Moreover, when a cell phone rings, it transmits at full power until the call is answered (3,5). Even in stand-by mode, the field strengths of modern cell phones can significantly exceed the minimum requirements for EMI immunity of medical devices (6,7). Some authors even conclude that current EMI compatibility standards are inadequate (5).
Several studies and reviews show that serious device malfunction resulting from EMI is rare. Although potentially life-threatening malfunction cannot be excluded, and potentially dangerous interference may occur in up to 10% of all cases (3,5,7,8), all studies conclude that EMI only occurs when the cell phone is very close to the medical device and that EMI does not occur when the cell phone is more than 1 (better 2) meter away (4,5,9).
A complete ban of cellular phones in hospitals is unrealistic and cannot be consistently enforced. Therefore, some authors have suggested reengineering either cell phones or medical devices (10). This is even more unrealistic, however, because of the market size for cell phone manufacturers and the excessive costs for medical device manufacturers.
Although senior developers from medical device companies agree that the use of cell phones in hospitals makes sense and that EMI between cell phones and medical devices is not frequent because all modern medical devices fulfill or exceed all EMI standards and regulations, there is still the remote chance that such a situation may be deleterious for the patient. In addition, some older medical equipment still in use today does not comply with current standards. Therefore, all vendors strongly advise against or explicitly forbid the use of cell phones in areas where their equipment is used, not least to safeguard themselves against litigation.
In its seminal report on medical errors, the Institute of Medicine identified insufficient communications between health care professionals as one of the causes of medical errors (11). But are these communication problems a symptom of insufficient communication technology or of problems of our processes and workflows? Leape et al. (12) reported 10 yr ago that numerous medical errors can be related to shortcomings of interservice communications, exactly those situations that Dr. Soto et al. were referring to in their questionnaire. Dr. Leape et al.’s conclusion at that time was that many communication-related errors could have been prevented by the use of medical information systems—not by telephones.
If we identify communication tools as one remedy to our communication problems, the next question has to be: What are the best communication tools? Cordless phones have only 1% of the power output of a cell phone. Even wireless local area network devices generate only a fraction of the power. Moreover, in many of the situations where Dr. Soto et al. found that cell phone communication would have alleviated a shortage of information, an electronic patient record or a clinical information system could have prevented this shortage of information from the beginning.
In any case, if we actually want to use mobile phones in our hospitals—and Dr. Soto et al. have given us some good arguments for this—we, as health care professionals or hospital administrators, have to find a practical way to maximize the clinical utility of mobile phone technology while minimizing the risks. For practical reasons, the best compromise is probably the "1 meter rule" proposed by several authors (3,9). Also, the use of mobile phones in hospitals should be restricted to health care professionals. Visitors and patients should not be allowed to use cell phones outside designated areas (13), not only to limit the risk of EMI but also to reduce the overall annoyance from private cell phone use in patient care areas.
We may also want to consider alternatives to cell phones, such as voice over Internet protocol using wireless local area networks or cordless phones. Especially the latter have such low power output that EMI can be eliminated. Moreover, cordless phones have further advantages, such as no airtime charges and less (unwanted) private use (14). The use of wireless local area networks, which also appears to not induce any EMI with medical equipment, may even enable mobile access to medical information systems that may facilitate communication at the point-of-care far beyond the possibilities of telephones of any kind (15). One of the biggest advantages of cell phones is the existing wireless infrastructure. But this is not true in hospitals where poor reception, especially in operating rooms, emergency rooms, and intensive care units, requires a dense infrastructure of repeaters.
Some institutions have already actively implemented the use of cell phones in clinical practice, and have implemented guidelines for their use. Others have reported positive effects of the use of cell phones and have even made them their primary method of communication throughout the hospital (16). These groups do not report any significant cases of EMI.
The study by Dr. Soto et al. provides good evidence that cell phones can help improve communications among health care professionals and may help prevent errors that result from poor communication. Many health care professionals, including the author of this editorial, have had this experience firsthand. This improvement in overall communication most likely outweighs the negative effects of EMI by far. Still, it does not hurt to look for alternatives.
Above all, we should work at improving our communication culture and processes. We should not forget that the use of cell phones near medical devices or in medical facilities in general falls within the legal responsibility of the hospital and/or the individual caregiver. But then, that is true for the entire process of care.
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  S. Ettelt, E. Nolte, M. McKee, O. A. Haugen, I. Karlberg, N. Klazinga, W. Ricciardi, and J. Teperi Evidence-based policy? The use of mobile phones in hospital J. Public Health Med., December 1, 2006; 28(4): 299 - 303. [Abstract] [Full Text] [PDF]
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