Innovation is one of the hallmarks of medical progress, but traditionally physicians are, as a group, reluctant to embrace all aspects of technical change. As a knowledge-based specialty, the practice of medicine has constantly evolved to ensure wider, faster, and more accurate access to information. Information sharing has changed the way we complete research and share that information for the benefit of our patients. There remains, however, a reluctance for doctors to immerse themselves fully in or on this information highway, and often, this reluctance is based on concerns of confidentiality and a passive acceptance of established practice. Smartphones have had a major impact on rapid access to information and have made major inroads into the mechanisms of information transfer for the profession in general [1]. By and large, smartphones are increasingly used as a means to improve communication between practitioners, keep up to date with the latest medical news and practices, check up on patients post-discharge, look up reference values, and differentials and drug prescriptions as well as provide dynamic education for doctors [1-5]. Studies roughly estimate that 98.4% of doctors own a smartphone and 92% agreed that smartphones positively impacted their practice [2,5-7].

Mobile health (mHealth) is a term used to describe the advances in mobile applications and associated innovations in technology to aid patient care. Being a major constituent of mHealth, mobile devices have drastically evolved since their first introduction in 1973 [1,8]. Doctors are now able to view medical textbooks and calculate drug formulas through apps, eliminating human errors and thus saving time [8,9]. A study on mHealth published in 2017 in Turkey found that communication and information gathering were the major uses of smartphones among physicians [3,10]. With the introduction of smartphones into hospitals, there has also been, peri passu, a simultaneous increase in the demand for medical applications, which has ushered in a new era of convenience. There are currently over 40,000 medical apps available for download in various app stores, and this figure will only continue to rise with increasing popularity [4,11].

Despite this increased dependency, limited research has been conducted on the impact of smartphone usage and how it can change medical practice. While there are some data from the United Kingdom and other Western countries, there remains a lack of research in the Middle East and Asia. In this study, we aimed to identify the usage of smartphones and medical apps by doctors in the clinical setting in 2 culturally distinct countries: King Hamad University Hospital (KHUH), Kingdom of Bahrain and Queen Mary Hospital (QMH), Hong Kong. We attempted to understand how the socioeconomic status and culture of the 2 countries impacts the views of health professionals towards smartphones and their use and acceptance in the clinical setting.

We conducted a cross-sectional study over a period of 2 weeks in January 2018 in KHUH, Kingdom of Bahrain and QMH, Hong Kong, both of which are tertiary referral centers and academic hospitals. We designed an online questionnaire on Google Forms based on results from a preliminary literature search [6,7,10]. The questionnaire (which can be found in Multimedia Appendix 1 and Multimedia Appendix 2) consisted of 15 items that were categorized into the following groups: demographics of the study population, ownership and main use of smartphones, number and names of medical apps currently owned, rating usage of smartphones for medical purposes, time spent on a smartphone related to clinical use, clinical reliance on smartphones, and views on further integration of smartphones.

The questionnaire was open to all doctors irrespective of grade or specialty. To make a fair comparison, we decided to assess the same 15 departments in both hospitals with the responses from the additional departments marked as “others.” The exclusion criteria were medical students, nurses, patients, and hospital administrative staff.

We set up a booth in an open forum to allow doctors to approach the research investigators. The set-up was kept identical in both hospitals. Participants were given a brief description and purpose of the research, and consent was implied by their agreement to take part in the study. No defining personal information was recorded, and researchers were present to answer any questions raised. Participants completed the questionnaires in person through laptops or iPads provided by the researchers. The questionnaire was administered on Google Forms, and the responses were then downloaded into a Microsoft Excel sheet (Microsoft Excel For Mac Version 16.10.0, Build 18021001, Microsoft Corp, Redmond, WA). We kept the data acquired from the study in an encrypted folder on the principal investigator’s laptop (to remain for 5 years, after which it will be permanently deleted). The results were tabulated and analyzed using SPSS Statistics 25 for Mac (IBM Corp, Armonk, NY).

The study protocol was reviewed and approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (ethics approval number: UW 17-451); KHUH, Bahrain (ethics approval number: KHUH/Research/No. 179/2017); and the Royal College of Surgeons in Ireland Research Ethics Committee (ethics approval number: RCSIBAH15012018).

A similar demographic pattern was observed, with 24.0% (24/100) of the doctors who participated in the study in each hospital belonging to the age group of 26-30 years, with the same male predominance of 67.0% (67/100) in both the hospitals.

The predominant medical specialty in KHUH was general medicine, with an 18.0% (18/100) response rate, whereas 32.0% (32/100) of the doctors from the department of surgery formed the major specialty who responded in QMH, as shown in Table 1. The demographics of the respondents are shown in Multimedia Appendix 3.

A total of 99.0% (99/100) of the doctors in both KHUH and QMH owned a smartphone. From those who owned a smartphone, 58% (57/99) and 55% (54/99) of the doctors from KHUH and QMH, respectively, identified communication as their main use of smartphones in the clinical setting (P=.004; Multimedia Appendix 4; Table 2).

Of the doctors from KHUH and QMH who owned a smartphone, 87% (86/99) and 86% (83/97), respectively, downloaded medical apps; 63% (58/92) of the doctors in KHUH and 51% (48/95) of the doctors in QMH owned 1-3 medical apps, as Table 3 shows.

Medscape and UpToDate were the most used medical apps in KHUH, with 68% (60/88) of the doctors opting for each, while Medscape was the major app used by 68% (57/84) of the doctors in QMH.

The clinical reliance on the apps was analyzed based on different means of attaining information, which involved the following categories: review medical news, hospital information system (online record of patient labs and reports), drug related, communication with patient, communication with colleagues, teaching purposes, training purposes, research purposes, patient education, patient monitoring, and continuing medical education activities.

When asked about the time spent using medical apps in the clinical setting, 29% (29/99) of the total respondents from KHUH used the apps for more than 2 hours per day, 68% (67/99) used apps for 2 or fewer hours, and 3% (3/99) of the doctors never used medical apps, whereas in QMH, 10% (10/97) used apps for more than 2 hours, 83% (80/97) used apps for 2 or fewer hours, and 7% (7/97) never used medical apps in the clinical setting. This is illustrated in Table 4. Doctors from KHUH were likely to spend more time on medical apps in the clinical setting. This difference was significant (P=.002, between the 3 time categories).

The clinical reliance of doctors on smartphones was recorded on a scale of 1 to 5 (5 being maximum and 1 being minimum). The ratings of 1 and 2 were considered “Low,” 3 was considered as “Neutral,” whereas 4 and 5 were considered “High.”

This was compared with the seniority of the doctors in both the hospitals, where Interns or House Officers and Senior House Officers or Medical Officers were grouped as junior doctors, while Residents, Registrars, or Senior Registrars and Consultants, Associate Professors, or Professors were grouped as senior doctors.

Of the junior doctors in KHUH, 57% (24/42) claimed to be highly reliant on their smartphones in the clinical setting, whereas only 29% (16/55) of the senior doctors said the same. The data at KHUH were significant (P=.005).

However, 32% (8/25) of the junior doctors were highly reliant on their medical apps, whereas 35% (25/72) of the senior doctors rated their clinical reliance on smartphones as High in QMH. These data were insignificant (P=.81).

According to the overall results in both the hospitals, a significant difference was seen, where 48% (32/67) of the junior doctors claimed high reliance on smartphones, whereas only 32.3% (41/127) of the senior doctors said the same (P=.03).

It was observed that 90.0% (90/100) and 84.0% (84/100) of the doctors in KHUH and QMH, respectively, “Agreed” or “Strongly Agreed” that smartphones have a huge potential in the clinical setting, and 78.0% (78/100) of the participants in KHUH and 69.0% (69/100) of the doctors in QMH “Strongly Agreed” or “Agreed” that smartphones should be formally integrated into the clinical setting.

In addition, 48.0% (48/100; KHUH) and 56.0% (56/100; QMH) agreed that more medical apps need to be created in order to support smartphone use in the clinical setting, and 38.0% (38/100; KHUH) and 55.0% (55/100; QMH) agreed that they would use their smartphones more if there were more medical apps available for use.

When asked about the kind of apps they would like to use in the future, drug-related apps formed the major preference for doctors at KHUH (66/100, 66.0%), whereas hospital information systems was the major preference in QMH (65/100, 65.0%), as demonstrated in Table 5.

Junior doctors in KHUH were more reliant on smartphones and medical apps than their senior colleagues. However, in QMH, senior doctors were more reliant. This may represent the higher number of senior doctors in QMH (Multimedia Appendix 3).

The results showed that more than half of the junior doctors in KHUH said they were highly reliant on smartphones, whereas the majority of the senior doctors in KHUH asserted low clinical reliance. However, the results in QMH insignificantly varied, with senior doctors being more dependent on medical apps. This could be attributed to the fact that 74% (73/99) of the respondents who participated in QMH were senior doctors, and this could have presented bias in the results.

The results obtained from KHUH are in accordance with a UK-based study done in 2015 within the surgical profession. It was found that junior doctors were more up to date with technology and hence were more clinically reliant on medical apps as compared to their senior colleagues [12]. A similar study conducted by Samsung Medical Center reported that 83.3% of the total access of information via smart devices was also done by junior physicians [13].

With easy and flexible access to medical apps, it has vast potential to enhance current medical practice by attaining fast and comprehensive knowledge, thereby improving the outcome of clinical decisions [4].

The majority of participants from both hospitals agreed that smartphones have a future in clinical practice and that doctors would use their smartphones more if there were more apps created. This illustrates a genuine interest from clinicians to optimize smartphone technology in the workplace if (1) smartphones are formally integrated into the clinical setting and (2) more medical apps are created that support smartphone use in medical practice. As a result, the implications can be further categorized based on the different stakeholders involved.

As with the majority of studies, the design of the study is subject to limitations. First, it was predecided — keeping in mind the number of doctors currently in QMH and KHUH — that the study will be concluded after receiving 100 responses in each hospital, with a total of 200 participants. Despite the small sample size, we believe our results are representative of the survey population due to the high response rate and lack of selection bias inherent in an online survey, which also ensured consistency. A possible bias of our study is social desirability bias. The participants, while completing the survey, could have responded in a way that portrayed them in a positive light or would be viewed favorably to us. We tried to minimize this by keeping the participants anonymous so as to remove undue pressure and allow them to respond freely.

Our survey depended on the doctor’s ability to recall past events, which could have introduced recall bias. We took this into account prior to conducting the study by devising a high-quality questionnaire, allowing participants sufficient time for adequate recall, and being present physically at the booth to answer questions they might have [22].

Finally, although participants were selected randomly based on opportunity, it was observed that 73.7% of the doctors recruited in QMH were seniors (Residents, Associate Professors, Professors, or Consultants), making the cohort of senior doctors considerably greater than that of junior doctors. We believe this could be due to the fact they were more willing to participate as they were not as busy as junior doctors. However, as senior doctors form an essential part of the clinical setting in Hong Kong, we chose to include their responses in our study.

Interestingly, despite cultural differences between Bahrain and Hong Kong, there were no significant differences noted between the results obtained from the 2 countries. These results suggest a substantial acceptance of smartphone technology by doctors in clinical settings. Hence, more emphasis should be placed on creating medical apps that support doctors in patient care, especially for drug-related uses and hospital information systems, which were found to be the major preferences for future apps by doctors in this study.

However, with an increase in the usage of smartphones in the medical field, there are growing concerns about the protection of patient information. There is a need to establish policies to officially integrate the technology in accordance with ethical guidelines and thus encourage future studies to discuss guidelines that are patient-centered and respect patient privacy. This will aid health care professionals in attaining their information from accurate sources and also regulate a system to monitor the usage of mobile devices within hospitals to prevent the breach of patient privacy and confidentiality. Though challenging, implementation of evidence-based guidelines governing smartphone use as well as limiting access to patient information outside of the hospital can help overcome these issues [3,21]. Nevertheless, it is clear through our research and the increased number of collaborative studies on the topic in the last decade [23] that the potential for mobile communication to transform health care and clinical intervention in the community is tremendous [24]. There is, therefore, great scope to harness the potential of mobile use in the clinical setting to improve several aspects of health care [23]. Future studies should aim to expand on the existing research by exploring different contexts, especially ones that compare multiple different contexts such as the current study. This will help to gain a better understanding on whether culture can influence smartphone uptake in the clinical setting.