JMIR MHEALTH AND UHEALTH Jung et al

Original Paper

The Effectiveness of Near-Field Communication Integrated with

a Mobile Electronic Medical Record System: Emergency
Department Simulation Study

Kwang Yul Jung1, MD; Taerim Kim1, MD, PhD; Jaegon Jung2, PhD; JeanHyoung Lee3, DM; Jong Soo Choi4, PhD;
Kang Mira4, MD, PhD; Dong Kyung Chang4, MD; Won Chul Cha1,4, MD
1
Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic Of Korea
2
Department of Computer Engineering, Seoul Digital University, Seoul, Republic Of Korea
3
Department of Information Strategy, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic Of Korea
4
Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic Of Korea

Corresponding Author:
Won Chul Cha, MD
Department of Emergency Medicine
Samsung Medical Center
Sungkyunkwan University School of Medicine
81, Irwon-ro
Gangnam-gu
Seoul, 06351
Republic Of Korea
Phone: 82 1053866597
Fax: 82 221487899
Email: [email protected]

Abstract
Background: Improved medical practice efficiency has been demonstrated by physicians using mobile device (mobile phones,
tablets) electronic medical record (EMR) systems. However, the quantitative effects of these systems have not been adequately
measured.
Objective: This study aimed to determine the effectiveness of near-field communication (NFC) integrated with a mobile EMR
system regarding physician turnaround time in a hospital emergency department (ED).
Methods: A simulation study was performed in a hospital ED. Twenty-five physicians working in the ED participated in 2
scenarios, using either a mobile device or personal computer (PC). Scenario A involved randomly locating designated patients
in the ED. Scenario B consisted of accessing laboratory results of an ED patient at the bedside. After completing the scenarios,
participants responded to 10 questions that were scored using a system usability scale (SUS). The primary metric was the turnaround
time for each scenario. The secondary metric was the usability of the system, graded by the study participants.
Results: Locating patients from the ED entrance took a mean of 93.0 seconds (SD 34.4) using the mobile scenario. In contrast,
it only required a mean of 57.3 seconds (SD 10.5) using the PC scenario (P<.001). Searching for laboratory results of the patients
at the bedside required a mean of only 25.2 seconds (SD 5.3) with the mobile scenario, and a mean of 61.5 seconds (SD 11.6)
using the PC scenario (P<.001). Sensitivity analysis comparing only the time for login and accessing the relevant information
also determined mobile devices to be significantly faster. The mean SUS score of NFC-mobile EMR was 71.90 points.
Conclusions: NFC integrated with mobile EMR provided for a more efficient physician practice with good usability.

(JMIR Mhealth Uhealth 2018;6(9):e11187) doi: 10.2196/11187

KEYWORDS
near-field communication; electronic medical records; emergency department; mobile health; mHealth

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The ED is part of a tertiary academic teaching hospital with

Introduction approximately 9000 daily outpatients and 2000 inpatient beds
Background [15]. The ED holds 69 treating beds. The number of annual
visits is approximately 79,000. Although the ED is heavily
An emergency department (ED) is often characterized by chaos equipped with PCs at each station (84 PCs total), there are no
and inefficiency [1]. It is where the severity of a patient’s injury PCs at the bedsides. Most of the beds are not in private rooms
or distress varies and changes unpredictably. The location of but are open to stations except isolation beds.
patients also changes based on their clinical process or test
results, which may become available at different times. The hospital developed the proposed mobile EMR system. It
Physicians need to check changed locations and laboratory operates on the institution’s EMR system, which was also
results frequently by walking back and forth between personal developed internally. The overall system had a significant update
computer (PC) stations and patients’ beds. In a fast-paced ED, in July 2016. Figure 1 shows a schematic of the architecture of
such interruptions cause physicians to waste a substantial the EMR system.
amount of time and ultimately result in patient dissatisfaction The mobile EMR uses an Android app that gives physicians
[2]. As the installation of PCs to all bedsides is costly and access to inpatient, outpatient, and emergency department
ineffective regarding space utilization, better alternatives must information. Users can log into the system with their fingerprint
be considered. and search for locations, clinical notes, vital signs, laboratory
Related Technologies results, and medical images. The NFC function was
implemented in April 2017. When a physician links the EMR
The ED providers strive to improve the efficiency of the
mobile device to an NFC tag which contains information about
workflow by exploiting advanced technologies. With the
its location, the mobile app is automatically initiated. Using
emergence of electronic medical records (EMR), mobile EMR
fingerprint authentication, physicians can log in and view the
systems are receiving increasing attention as mobile devices
EMR of patients at the location that corresponds with their NFC
(ie, mobile phones, tablets), and mobile apps are becoming more
location. When tagging NFC tags at the entrance of a specific
common [3,4]. The portability and near ubiquity of mobile EMR
zone, the list of patients at the tagged NFC zone who are in
allow health care providers to access patient records wherever
charge of mobile device users is popped up. Figure 2 shows the
they are needed [5].
access process.
Near-field communication (NFC) is widely used in various
communication apps. In the field of health care, usage scenarios
Study Participants
including patient identification [6], blood transfusion [7], drug Physicians who worked in the ED during the study were asked
administration [8], medical staff tracking [9], and medical record to participate. Physician participants were recruited between
access [10] have already been proven. The wave of NFC April 1 to April 20, 2018. Among the 35 ED physicians, 25
technology in the health care field has been combined with the (71%) agreed to participate in this study.
internet of things technologies [11]. Through a combination of Study Scenarios and Sensitivity Analysis
mobile EMR systems, NFC technology can improve workflow
using bedside technology [12]. After a brief introduction, the physicians went through 2
sequential scenarios. The first scenario (scenario A) involved
Study Objectives locating patients in the ED from the ED gate. Physicians were
Numerous studies have investigated the qualitative and given the name of a patient and were required to locate them
quantitative benefits of each technology separately [12-14]. using either a PC EMR at the nearest site in the ED gate or
However, the efficacy of the combined technologies for mobile EMR. After locating the patient, the participant was
improved physician productivity in health care has not been guided to reach their bedside. The second scenario (scenario B)
investigated to date. More rigorous quantitative studies involved looking up a laboratory result from the bedside.
investigating usability estimates are required to develop and Physicians were brought to a patient’s bedside and were required
eventually adopt such systems in practice. Additionally, it is to determine a specific laboratory result using either a mobile
essential to determine a system’s effectiveness in clinical device or PC interface. As there were no PCs at the bedside,
settings. This study aims to determine the effectiveness of an physicians had to perform a few steps to identify available PCs
NFC-integrated mobile EMR system regarding physician and return with a report. The steps in each scenario are shown
turnaround time in an ED. in Figure 3, and the flow of each scenario is shown in Figure
4.
Methods Physicians were randomly assigned to follow either scenario A
or B using either a mobile device (mobile case) or a PC (PC
Study Setting case) as described in Multimedia Appendix 1. An independent
This simulation study took place in an academic ED in Seoul, observer recorded the activities with a camera and completed
South Korea. The study was reviewed and approved by the a case report form with time stamps during the process. Patients
Samsung Medical Center Institutional Review Board (IRB no. were not simulated. Real patients were accessed in the
SMC 2018-01-144-001). emergency department. However, since we used only partial
patient data such as name, location, and laboratory data which

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was already available, the clinical condition did not influence the study’s outcome.
Figure 1. Overall schematic description of the hospital information system architecture relationship at the Samsung Medical Center. DARWIN: data
analytics and research window for integrated knowledge; CPOE: computerized physician order entry; MIS: management information system; MDM:
master data management; CRM: customer relationship management.

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Figure 2. Usage scene when the mobile electronic medical records (EMR) communicate with the near-field communication (NFC) system and the
display of the mobile EMR progression after tagging NFC. V/S: vital sign.

Figure 3. Schematic view of simulation scenarios. (a) Locating the patient. (b) Looking up laboratory results for the patient. ED: emergency department;
PC: personal computer.

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Figure 4. The flow of locating the patient and the scenario place in the emergency department. CT: computed tomography; NFC: near-field communication;
PC: personal computer.

We performed a sensitivity analysis using the data without and occupation. Afterward, the SUS questionnaires were
considering movement intervals. This test was performed to collected and analyzed.
determine whether or not there was a consistent outcome if the
condition allowed for more available PCs, which are at the gate
Statistical Analysis
and the bedside. Continuous variables are expressed in terms of mean and
standard deviations (SD), whereas categorical variables are
Survey expressed in frequencies and percentages. The time mean
After completing all scenarios, physician participants responded difference was examined using a paired t-test. A value of P<.05
to 10 questions using the system usability scale (SUS). The SUS was considered to be statistically significant. As descriptive
is composed of a 5-point Likert scale rated from 1 (strongly statistics could not confirm a normal distribution of participants
disagree) to 5 (strongly agree) that investigates the usability of between the 2 dependent groups divided by age, gender, and
the NFC-integrated mobile EMR system [16]. The SUS score occupation, the Mann-Whitney U test was applied for time
calculation formula is as follows: interval difference analysis.

Results
Main Outcome
Measurement and Outcome Among 25 physician participants, 14 (56%) were male, and 11
The primary metric was the length of turnaround time for each (44%) were female. The general characteristics of the
scenario. The secondary metric was the usability of the system, participants are shown in Table 1.
as graded by the study physician participants. We collected
demographic data from each participant and recorded the time It required a mean of 93.0 seconds (SD 34.4) to locate the patient
intervals of each step of the process for both scenarios. We also from the entrance of the ED in the PC case but only a mean of
analyzed time intervals among groups sorted by age, gender, 57.3 seconds (SD 10.5) in the mobile case, which was
significantly faster (P<.001). Accessing laboratory results at
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the patient’s bedside required a mean of only 25.2 seconds (SD B. The differences in time were statistically significant (P<.001).
5.3) in the mobile case compared to a mean of 61.5 seconds Finding the location of patients after login required a mean of
(SD 11.6) in the PC case. These data were statistically only 6.8 seconds (SD 3.6) using the mobile device, whereas it
significant (P<.001). A schematic comparison is shown in Figure took a mean of 18.9 seconds (SD 16.9) using a PC. Accessing
5. a specific laboratory test result required a mean of 12.8 seconds
(SD 5.3) using the mobile device and a mean of 26.5 seconds
Sensitivity Analysis (SD 8.0) using a PC. These data were statistically significant
We compared the time required for login with the time for (P<.001). The results are shown in Table 2.
finding relevant information. Login using the mobile device
EMR required a mean of 13.1 seconds (SD 2.9) for scenario A Survey
and a mean of 12.5 seconds (SD 2.1) for scenario B. Login by The mean SUS score of NFC-mobile EMR was 71.90 points.
PC took longer with a mean of 36.2 seconds (SD 15.2) for The results are shown in Table 3.
scenario A and a mean of 30.5 seconds (SD 7.7) for scenario

Table 1. Characteristics of the physician participants.

Participant characteristic Value
Age (years), mean (SD) 30.6 (4.9)
Age groups (years), n (%)
≥30 12 (48)
<30 13 (52)
Gender, n (%)
Male 14 (56)
Female 11 (44)
Occupation, n (%)
Intern 4 (16)
Resident 15 (60)
Specialist 6 (24)
Time worked at hospital (years), mean (SD) 4.6 (4.0)

Figure 5. Graphical view of main results. (a) Locating the patient. (b) Looking up laboratory results for the patient. NFC: near-field communication;
PC: personal computer.

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Table 2. A comparison between the 2 scenarios of time spent on specific tasks.

Task Time (seconds), mean (SD) P value
Mobile case Personal computer case
Scenario A
Login 13.1 (2.9) 36.2 (15.2) <.001
Accessing relevant information 6.8 (3.6) 18.9 (16.9) <.001
Total 19.8 (4.7) 55.2 (29.0) <.001
Scenario B
Login 12.5 (2.1) 30.5 (7.7) <.001
Accessing relevant information 12.8 (5.3) 26.5 (8.0) <.001
Total 25.2 (5.3) 57.0 (11.6) <.001

Table 3. Score results (n=25) from the system usability scale (SUS) to assess the near-field communication mobile emergency medical record
(NFC-mobile EMR).
Question Mean (SD)
1. I think that I would like to use this NFC-mobile EMR frequently. 3.92 (0.95)
2. I found the NFC-mobile EMR unnecessarily complex. 1.76 (0.83)
3. I thought the NFC-mobile EMR was easy to use. 4.40 (0.50)
4. I think that I would need the support of a technical person to be able to use the NFC-mobile EMR. 2.72 (1.10)
5. I found that the various functions in the NFC-mobile EMR were well-integrated. 4.24 (0.72)
6. I thought there was too much inconsistency in the NFC-mobile EMR. 4.20 (0.64)
7. I would imagine that most people would learn to use the NFC-mobile EMR very quickly. 4.48 (0.59)
8. I found the NFC-mobile EMR very cumbersome to use. 1.56 (0.51)
9. I felt very confident using the NFC-mobile EMR. 3.88 (0.78)
10. I needed to learn a lot of things before I could get going with the NFC-mobile EMR. 1.92 (0.57)
Total score 71.90 (7.61)

We also evaluated usability with the SUS questionnaire. The

Discussion SUS was used after the physician participant had an opportunity
Principal Findings to use the system being evaluated. A score over 70 on the
questionnaire (range 0-100) indicated that the NFC-integrated
This study aimed to improve physician efficiency by reducing mobile device EMR was “acceptable,” and the adjective rating
the time spent walking to check patient information with the was “good” [18]. There was no significant statistical difference
aid of the technological integration between NFC and mobile among groups based on age, gender, and occupation.
device EMR. To the best of our knowledge, this is the first study
to examine the efficiency of this system and comparing it with Advantages and Disadvantages
the PC EMR. The mobile total turnaround time for performing Various measures have been implemented to address ED
tasks was significantly reduced in both scenarios. Sensitivity inadequacies. Improving the ED work efficiency is one crucial
analysis showed that mobile device EMR incorporated with in-hospital factor. Ideal physical structures for work have already
NFC was significantly faster than PC-integrated EMR regarding been demonstrated [19]. Several studies have shown the positive
login time and accessing laboratory results. effect of developing clinical guidelines and protocols for
As the familiarity of mobile device use could be different among effective evaluation of efficiency [20,21]. Newer technologies
the demographic groups, we compared the total time interval such as radio frequency identification-integrated point-of-care
difference between PC and mobile cases. Multimedia Appendix testing [22], triage kiosks [23], and dashboards [24] have been
2 shows that the mobile case was consistently faster for all well studied. Ubiquitous near patient access to EMR via NFC
groups. However, there were significant differences in the time is determined to be useful in this regard. Compared to installing
interval between age and occupation during scenario B. These new structures in an already heavily equipped ED, implementing
findings are contrary to the general belief that the younger an NFC tag system is a relatively easy way to improve workflow
generation is more familiar with newer technology [17]. A regarding cost and space utilization.
further study on mobile device familiarity is needed because As most mobile EMR functions are more readily accessible
the simulation was done with a small sample size. with PCs, our study paid attention to superiority only available

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in mobile EMR. Mobile device systems outperform PC systems ED processes are complicated, with multiple steps from various
concerning mobility and personalization (at the provider level, providers often originating from outside the ED.
and patient level). We have measured the turnaround time as
the primary outcome of these merits. Thus, we have shown that
Limitations
physicians can gain access to information without physically First among the limitations of this study is that this investigation
moving the location of their patients. was conducted at a single center. Additional studies conducted
at multiple centers or EDs are needed to improve the
Portability of mobile EMR could be improved by incorporating generalizability of our conclusions.
accessibility through NFC. Our study revealed a statistically
significant difference in login time which was more effective Secondly, participants had different levels of familiarity with
by mobile EMR than by PC EMR (Table 2). A previous study mobile devices and NFC tags. Only some participants were
by Holden [25] demonstrated that the issue of accessibility to familiar with NFC because the system was built over a year
EMR such as system login and system response time could ago, which might cause bias.
negatively impact the usability of mobile EMR. NFC integrated Thirdly, each participant encountered various encumbrances
response and fingerprint login at the location of interest using because this study was conducted in an actual emergency room.
a mobile device could be beneficial because the process is For example, when attempting to locate a patient in the middle
simplified and less time-consuming. This system also appears of a scenario, the nearest PC may have been occupied by another
to reduce security concerns from failed logouts or departure staff member, which led to the physician being forced to use a
without logging out, by using the individual’s mobile device. PC that was further away. Also, while moving to a patient’s
An increase in the length of time physicians spend at the bedside bedside, there was an occasion when a participant was forced
is likely to increase patient satisfaction [26]. With this bedside to stop because a moving stretcher cart or medical staff member
technology, the physician can show radiologic results or blocked the aisle. In addition, some of the PCs used were
laboratory results to patients who cannot ambulate. comparatively slow. As mentioned above, unpredictable
circumstances might influence the overall time measured for
Inconsistent loading time due to varying network coverage could each scenario. As shown in Multimedia Appendix 3, the
be a disadvantage for this technology. For example, mobile variability of turnaround time fluctuated. However important,
devices without NFC function cannot be used. Physicians might these events could not be systemically quantified.
routinely tend to use PC EMR because PC EMR covers mobile
EMR. A previous study by Duhm et al [14] demonstrated that Finally, the usability assessment for NFC-mobile EMR via SUS
a physician usually underestimates actual time savings during could be overrated because responses were filled out
their professional capacity. The results of this study make a immediately after performing scenarios, which in most cases,
compelling argument and provide preliminary evidence in resulted in the superiority of NFC-mobile EMR. Further studies
support of adequately addressing this tendency, particularly could investigate usability over a more extended period of the
concerning reduced workflow using mobile EMR with NFC physician’s working practice.
functionality.
Conclusion
However, to enhance emergency physician performance, a NFC-integrated mobile EMR is effective for reducing the
multidimensional approach is required, rather than a single tool. turnaround time of physicians when practicing in the field and
has excellent usability.

Acknowledgments
The authors would like to acknowledge the support provided by the Basic Science Research Program through the National
Research Foundation of Korea (NRF) funded by the Ministry of Education (grant number 2018R1C1B6002877).

Conflicts of Interest
None declared.

Multimedia Appendix 1
Randomly allocated scenario quest for each participant. PC: personal computer.
[PDF File (Adobe PDF File), 19KB-Multimedia Appendix 1]

Multimedia Appendix 2
Comparison of time spent among age, gender, and occupation for each scenario.
[PDF File (Adobe PDF File), 24KB-Multimedia Appendix 2]

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Multimedia Appendix 3
Graphical comparison between mobile and personal computer scenario time of all participants.
[PPTX File, 51KB-Multimedia Appendix 3]

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Abbreviations
ED: emergency department
EMR: emergency medical record
NFC: near-field communication
PC: personal computer
SUS: system usability scale

Edited by G Eysenbach; submitted 31.05.18; peer-reviewed by S Lim, J Wu; comments to author 09.07.18; revised version received
31.07.18; accepted 31.08.18; published 21.09.18
Please cite as:
Jung KY, Kim T, Jung J, Lee J, Choi JS, Mira K, Chang DK, Cha WC
The Effectiveness of Near-Field Communication Integrated with a Mobile Electronic Medical Record System: Emergency Department
Simulation Study
JMIR Mhealth Uhealth 2018;6(9):e11187
URL: http://mhealth.jmir.org/2018/9/e11187/
doi: 10.2196/11187
PMID: 30249577

©Kwang Yul Jung, Taerim Kim, Jaegon Jung, JeanHyoung Lee, Jong Soo Choi, Kang Mira, Dong Kyung Chang, Won Chul
Cha. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 21.09.2018. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR
mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on
http://mhealth.jmir.org/, as well as this copyright and license information must be included.

http://mhealth.jmir.org/2018/9/e11187/ JMIR Mhealth Uhealth 2018 | vol. 6 | iss. 9 | e11187 | p. 10

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