How to navigate the growing number of health-related apps and meet patient demand for more connected care.
More than one-third of physicians have recommended the use of mobile health apps to their patients in the past year, according to a recent Manhattan Research survey. Experts say that the bulk of these apps are related to diet and fitness, and that few physicians are “prescribing” apps with the expectation of receiving follow-up data. Nevertheless, physicians’ acceptance of mHealth apps and related tracking devices is clearly growing along with mobile’s influence on everyday life.
“The mobile revolution is everywhere around us,” notes Joseph Kvedar, MD, president of the Center for Connected Health (CCH), a unit of Partners Healthcare in Boston. “It’s all about mobile now, and physicians can’t help but notice that, and they feel they have to get involved in some way.”
Mohit Kaushal, MD, a partner in Aberdare Ventures, a San Francisco-based venture capital firm, agrees. “The mobile health world has been around for a couple of years, and we’ve had a lot of experimentation and there are a lot of apps out there,” he points out. “So it’s not surprising that a subset of these apps are quite valuable and that doctors are recommending them.”
On the other hand, Manhattan Research found that only about half of the physicians who recommended apps suggested specific ones to their patients. “Some doctors are going to be more savvy about what apps are around-particularly, younger ones who are more pro-technology,” Kaushal explains. “Those doctors are more likely to prescribe and suggest a particular app.”
With more than 40,000 health-related apps available, most doctors are unsure of which ones to prescribe, notes Kvedar. “There’s a fear of liability if they don’t know what they’re talking about. So they tend to be very general and say, ‘It’s probably worth looking at this category to help you track something because you need to lose 10 pounds or you need to be more active.’”
CCH has a website called Wellocracy.com that rates several trackers and apps. IMS Health has started a much more ambitious project to curate the 16,000 apps in the Apple Store that it considers relevant. A group of experts, in a recent JAMA commentary, proposed that independent or government-commissioned bodies review and certify mHealth apps. But right now, not much is available to help doctors evaluate the effectiveness of mHealth apps before prescribing them to patients.
Next: Prescribing apps to patients
The vast majority of mHealth apps on the market focus on wellness and fitness, but that doesn’t mean they can’t be prescribed to patients with chronic diseases.
Internist Rajani LaRocca, who practices at a Massachusetts General Hospital clinic in Boston, conducted group visits last year with nine elderly patients, most of whom had diabetes. To encourage them to become more active, she prescribed the FitBit Zip, a $50 tracker that measured their steps each day. All of the patients increased their activity for the first six weeks, and after a year, more than half were still using their trackers, LaRocca told Medical Economics.
FitBit users can download a related app to their smartphones or tablets that displays information about their exercise trends. This data can be transmitted to a physician’s office. LaRocca is having her patients share their data at group visits rather than transmit it to her her office; CCH is working on a program that will allow FitBit data to be sent directly into an office’s electronic health record (EHR) system.
LaRocca looks forward to this new capability. “It would be helpful. It’s an indicator of how active somebody is in general,” she says, adding that she’d recommend the activity tracker to any patient. “It’s useful for just about everybody who is interested in getting healthy or healthier.”
Another physician who recommended an app to one of her patients had less luck. Leslie Kernisen, a geriatrician in Oakland, Calif., was trying to help the patient get his hypertension under control. The elderly man and his family had been writing down his thrice-daily blood pressure readings on a piece of paper, and Kernisen suggested they instead use an app. Unfortunately, the app they selected didn’t record the time of day when he took his blood pressure. That data had aided her analysis, so she had him drop the app and return to paper reports.
Kernisen has also found medication management apps to be difficult for older patients to use, because they require the patient or their caregiver to enter their medications. “Some of my patients have long medication lists that frequently change. So that makes it almost a nonstarter,” she says.
“It will take a while for app developers to refine the design and usability of apps so they’re truly useful in most cases,” reflects Kernisen. “So while apps are easy to prescribe, they may not be helpful to the patient.”
Next: Where's the evidence?
While there is little published evidence of clinical effectiveness for mHealth apps, that information isn’t essential to doctors for recommending apps to help patients exercise, diet or quit smoking, notes Kaushal.
But such evidence is critically important to physicians who are considering prescribing apps for chronic conditions, Kvedar says. The Food and Drug Administration (FDA), which has so far approved about 100 mHealth apps, has a key role to play here, he points out.
Last September, the FDA issued a guidance document that described the types of mHealth apps it would regulate. Those include apps that convert a mobile platform such as a smartphone into a device that already requires FDA approval, such as an app that turns an iPhone into an electro-cardiogram (ECG) machine. In addition, the FDA said it would regulate apps that are designed to be used as accessories to an FDA-regulated device, such as a application that enables a mobile device to display X-rays stored in a picture archiving and communications system.
In the next few years, Kvedar forecasts, most apps and devices that help doctors diagnose and treat patients will undergo clinical trials to get FDA approval. In the past year, he observes, CCH has seen an increased demand from corporate clients who want the center to test their apps so they can take the evidence to the FDA.
In the meantime, some physicians are eager to try out apps that promise to help their chronic disease patients. For example, LaRocca says, it could be useful to get regular blood pressure readings on patients whose blood pressure goes up and down during office visits. “If you could get accurate, easily transmitted BP readings on those people, it would be fantastic.”
The same could be true for glucometer readings transmitted from mobile devices, she says. “Especially when the patient is just starting insulin, or they have an acute health problem where their blood sugar is fluctuating a lot-for those categories, it would be helpful to see [mobile glucometer data].”
She cautions, however, that physicians must prescribe such apps judiciously so that they’re not overwhelmed by a flood of data.
The experts point out that doctors must find a way to screen this kind of data and accommodate it in their workflow before they’ll be willing to use it.
Home monitoring of patients with chronic diseases presents a similar challenge, yet the Manhattan Research survey found that about a fifth of physicians monitor some of their patients remotely. Kaushal, Kvedar and other observers agree that home monitoring might be a stepping stone to the acceptance of mHealth apps used to collect patient data and transmit it to physicians.
Kvedar goes further, noting that the distinction between home and mobile monitoring is rapidly disappearing. In recent years, he notes, devices used in remote patient monitoring have become sensor-based, so that data on patients’ vital signs can be automatically recorded instead of being manually entered by patients. The use of sensors makes the information more objective and clinically useful.
“All of the [remote patient monitoring] manufacturers now have radio transmitters in their devices, and all of them have a mobile app,” he observes. “It’s moving rapidly in the direction of being seamless in that regard.”
Overall, Manhattan Research reported, 40% of physicians now believe that digital communications technologies of various kinds-including mobile apps, remote patient monitoring, secure messaging via patient portals, and telehealth consults-can help improve patient outcomes.
Kvedar finds this statistic a bit amazing. “Forty percent is extraordinary. When I was a medical student, we used computers to look up lab values. Now everything is electronic, from lab values and X-rays and notes to videoconferencing with patients and looking at their home readings.”
In coming years, he predicts, the percentage of physicians who embrace these digital technologies will rise to 50% or 60%. Then, suddenly, it will jump to 100% “because the people who don’t want to deal with it will be retiring.”