Mobile health (mHealth) apps are exploding in number and popularity, a development that presents new challenges for physicians: How do they determine which among the thousands of health-related apps on the market will help their patients? And how do they receive and process data from these apps in a form they can use?
To help answer those questions, Medical Economics spoke recently with Tom Malick, senior product manager at Rightpoint, a digital consulting firm whose services include app design, marketing and development. Malick has worked with mHealth app developers to help increase adoption of their apps, and many of the insights developed from that experience also apply to doctors and patients.
A transcript of the conversation, edited for brevity and clarity, follows.
Medical Economics: With all the mHealth apps available today, how does a doctor know, or go about deciding, which ones are going to be effective and help patients achieve their health goals?
TM: That’s a great question. I’d bifurcate the conversation about how to choose an app into two parts. One is the more technical part, things like privacy safeguards, regulatory safety standards, interoperability. The FDA is actually doing some work right now in certifying those base level things, but you definitely need to check those boxes.
The more challenging part is determining what the app is supposed to do, and does it work for my patients? You can have apps that simply educate the patient, you can have apps that track biometrics and encourage actions based on those biometrics, they could titrate medications, they could assist with medication adherence, they could be related to a physical monitoring device.
So there could be lots of things the doctors may want. But I think the thing people are really concerned about today is that we have something like 10,000 baby boomers hitting 65 every day for the next 15 years. And many of them have two or more chronic conditions. And I think PCPs are struggling with how to manage that.
To help frame that, look at pharma. In many cases when pharma releases a drug the FDA just looks for it to be better than the placebo it was tested against, and that it doesn’t harm the patient. I think doctors should use that type of thinking when they look at an app. Because what we’ve found is that the Hawthorne effect is very powerful. And the Hawthorne effect is that the act of measuring something means you’ll change your behavior. When you start to measure your steps daily you’ll start to walk more just because you realize you’re measuring it.
That has a huge amount of relevance for clinicians. Just keeping people focused on their health in some way and to track it is really important. But here’s where the most difficult part comes in. How will the doctors leverage that data? In a scenario where a doctor has recommended multiple apps to a patient, currently they [the doctor] would need separate login information for each of those apps to access that patient’s data. Clearly that’s untenable for doctors, most of whom are struggling just to find the time to review information in the patient’s EHR before the patient visits.
The other thing that is absolutely critical: Think about if you’re a patient with diabetes, and you’ve gone through six months of logging data, always diligently monitoring your blood glucose readings. And you get to your doctor’s office only to find out they didn’t even look at it. It’s pretty demoralizing. And you can’t expect the patient to continue monitoring after that.
So I think there basically needs to be a handshake agreement between the doctor and the patient, in terms of setting expectations as to how the app will be used, and what data the doctor will look at. The timeliness of their readings becomes very essential in getting people to use that app.
ME: So how does a doc get around that? Is it just by limiting the number of apps they recommend to an individual patient, so they don’t get flooded by data?
TM: I think docs would love to be able to navigate this world. But the truth is, they’re somewhat held hostage by their computer systems.
Here’s an example. In the current EHR environment everyone says we’ve got everything electronic and it’s wonderful, but the vast majority of the data sitting in the EHRs is just faxed data that’s been scanned and entered into it, not structured in any way. And you may have faxes from 10 different providers of all your medical history that’s almost indecipherable by your primary care provider. And in that vein, they certainly don’t have time to actually structure all that data.
For an app to be effective it has to integrate into the EHR and be consumable by the doctor in a way that doesn’t add to their administrative burden.
ME: Do such apps actually exist?
TM: I think a lot of people certainly want those apps to exist. I think a good example is Livongo, which has done a great job in terms of meeting the patient where they’re at, which is really important from a user experience perspective, but also understanding that they can’t just drop an app on a doctor and expect it to work if it’s not interconnected in the medical ecosystem.
Apps that live on islands die on islands, so apps that kind of go it alone, it’s going to be really difficult to get doctors to use them.
The other thing we should address is the reimbursement aspect. Doctors don’t generally recommend procedures and things that aren’t reimbursable. Livongo is an example [of an app] that’s now reimbursable on some Medicare Advantage plans. So those apps that integrate with the rest of the ecosystem are the apps that will really shine in the future.
The real gold standard is where you have enough medical research, you’ve met all the privacy and security standards, and you’ve gotten to the point where Medicare is going to reimburse for your app. I think it’s the ultimate litmus test for whether a doctor should recommend an app.
I think another consideration for whether doctors should recommend an app is its usability. Will the user love it? Some apps that are out there now, like Facebook and Twitter, are designed where people absolutely love and want to open them all the time. Don’t we want that in medicine, where someone who has diabetes can’t wait to open their diabetes app? For people with chronic conditions, the hardest thing for them sometimes is to confront that condition. And opening an app every day reminds them of that [condition].
So that app needs to be designed in such a way that it’s inherently motivating. And I think when a lot of folks go to build an app they do it backwards. They try to back it into the existing system whether it be pharmaceuticals or remote monitoring or payment. And the apps that have really blazed a trail have said, ‘We’ll worry about that later. What we want to do first is to make sure that people love it and want to use it and stick with it.’ That motivating part is so important to the success of the app.
ME: Is anyone doing that?
TM: The more consumer-oriented apps, like Fitbit, have somewhat pulled this off. They’ve married the wellness world with the killer app world, and have apps that people want to open all the time. And doctors have struggled about what to do with that data. The truth is that doctors are constantly triaging in their mind. The doctor’s going to focus on the obese patient with diabetes over someone who’s in fairly good health and walking 10,000 steps a day. That’s why some worried well patients end up being disappointed their app data isn’t being taken more seriously.
ME: Are there any particular types of patients we know are really being helped by health apps?
TM: It’s quite a mixed bag. It looks like some apps do virtually nothing, while others certainly help patients control their blood sugar, reduce their blood pressure and things of that nature. Often the apps that really do well struggle to make money. And some of those have gone away.
That itself would be a great study, to find out how many apps that showed efficacy are no longer around today. And I bet that number would be alarmingly high. The ability for someone to say, ‘I want to help a patient is a lot easier unfortunately than to get that intervention in medicine today, and that’s a shame.
Do we know if any other countries are doing better than us? ---Germany has made a move recently that I’d love to see in the U.S: They’ve outlawed the fax machine. Someone asked me, what regulations could the U.S. government put in that would help apps thrive? And I would say getting rid of the fax machine would be the single most important step you could do. To me, the American healthcare system has a weakness.
Our data chain is only as strong as its weakest link. And by allowing providers to fax unencrypted information indiscriminately from provider to provider has not pushed us enough to creating structured data. And this means there hasn’t been a demand side for app data getting into the EHR. Because there hasn’t been a push for getting rid of that weakest link in the chain.
So policywise, in many ways the Europeans are ahead of us. In terms of technology, the overburdensome regulatory environment that they live in makes it more difficult to create apps and all sorts of technology in general, whereas in the U.S. we’ve been able to really blaze a trail. So maybe we could learn a little from each other.