'Tough Titty' and other iPad apps (Musing on 'revolutionary' apps for TM)

This month's blog discusses how the over-hyped iPad and similar tablets could be used to improve TM practices. The title includes a reference to the 1968 Beatles classic

• Revolution

Two items motivated this blog

1. Clinical chemistry blog (Aargh! - the dreaded discipline with all the automated instruments) Recently, I came across this blog from the AACC:

• Explosive growth of send out testing: Can we curb the monster?

and wondered how ideas for curbing the cost of expensive molecular testing outsourced to reference labs could be applied to transfusion medicine. It interested me as a follow-up to last month's blog:

• Snip, snip, the party's over? (Musings on the seductive rise of DNA typing of blood groups)

One strategy that amused was a scheme for pop-up prices to appear when a clinician was making an electronic test order. The pop-up could contain product or test utilization information and one to four dollar signs ($ - $$$$), as is common for hotel and restaurant listings.

The blog outlines several approaches to minimizing the cost of send-out tests and is worth reading, as is this related resource:

• The send-out testing boom. How can labs take control?

2. Slew of news items on the iPad frenzy extending to medical schools, as exemplified by

• Will iPad transform med school?

Seems there are many medical apps being developed (See Further Reading below) and I wondered how future iPad applications could be used in transfusion medicine. One potential use that came to mind was IVIG utilization.

The IVIG Challenge
In Canada (and elsewhere) an enormous amount of time, expense, and expertise has been applied to IVIG utilization. Canada's per capita use of IVIG grew by ~115% between 1998 and 2006, making Canada one of the world's highest per capita users, with most growth attributed to off-label use.

In 2008 Canada's use was still more than twice as high as the UK, and marginally higher than even the USA. Source:

• Nahirniak S, Hume H A. Guidelines for the use of IVIG for primary immune deficiency and solid organ transplantation. (editorial) Transfus Med Rev: 2010 Jan; 24(1, Suppl1): S1-S6.

As would be expected, IVIG utilization is a major focus of Canada's NAC and utilization management programs are operated by various provincial blood coordinating offices such as that of the BC PBCO.

Often utilization schemes involve personal gate keeping by physicians who are TM specialists, all of whose decisions must be standardized, an effective but high maintenance solution.

As well, strategies that involve education and training of clinicians is a hard slog, as discussed by Dzik:

• Dzik S. Use of a computer-assisted system for blood utilization review. Transfusion 2007;47(s2): 142S.

In brief, the author's hospital used multiple blood utilization strategies, including a computer-assisted system with

• Computerized physician order entry
• Computer-assisted blood utilization review and feedback

Dzik acknowledged that the computer program was rudimentary and needed to improvements. For more details, see this Sept. 2007 blog:

• What's up doc? Welcome to docovigilance

Iggy, the IVIG app

In the future, perhaps we will have Iggy, an IVIG app available to clinicians on their iPads, iPhones, etc., which may even be networked to the hospital or regional health IS. When a doc orders IVIG via an electronic order system, the Iggy app would kick in. Can't you just see it?

Hey, dude, that's $10,000 and that's just for starters! Are you really, really sure the patient will benefit? What's the evidence? Read all about it here. Oh, and dude, you are the only one to order this product for this condition in this health region in the past year. In case you were wondering, this distinction is not good. Text or Skype and we can discuss.

Other useful apps

How about these as potential TM apps?

1. Abacus - The RhIg app for those who are mathematically challenged and cannot calculate the correct number of RhIg vials to inject.

• Paxton A. Bringing new rigor to RhIg calculations. Cap Today May 2008.

2. Frappuccino - The 'FP doesn't cut it' app for all those docs who use frozen plasma inappropriately.

• ORBCoN (Transfusion Ontario). Frozen plasma toolkit

3. Prefried - The app envisioned by John Judd, who cautions that prewarm technique was never meant to be used to determine the clinical significance of antibodies and can prewarm away clinically significant antibodies.

• CBBS e-Network Forum. Prewarmed testing can cause a laboratory to miss detecting a clinically significant red cell alloantibody

4. Tough titty - The 'You don't need a titration' app for docs who request an anti-D titre in pregnant women who received RhIg at 28 weeks and show a 1+ anti-D at delivery.

• CBBS e-Network forum: Justification for requesting routine antibody identification and titer on women who have received RhIG during pregnancy

Bottom line

So.... How about TM professionals getting together with geeky app developers to create medical applications for iPads and other tablets that can improve transfusion medicine practice? To use a cliche, for once let's get ahead of the curve. The iPad is over-hyped but the potential is there.

I would love to hear your ideas for transfusion-related iPad apps, off the wall and funny or serious. Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. 

Further Reading

Mostly news about the iPad and its application in medical schools

Added Feb.1, 2011: Clinical pathology laboratories should prepare for the iPad era (Dark Daily, 24 Jan. 2011)

Stanford School of Medicine to give iPad to all incoming medical students

Is the iPad helping to modernize medicine?

Will iPad transform med school?

Associated Press looks at iPad use at Stanford's medical school (click on video)

Age of e-medicine

UCI also receive iPads

iAnnotate PDF – First iPad app required by Stanford School of Medicine

Top 5 medical apps for the iPad

25 iPad apps for health care

Medical applications

See how easy it is - tutorials

Please check the comments - good stuff! Thanks to those who contributed.