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Mobile health (mHealth) is a confusing landscape, to be sure. IMS Health, which rates mHealth apps and provides a formal mechanism for app prescribing, estimates there are 63,000 health apps in the Apple and Google stores. The number and variety make it difficult for physicians to find and recommend the good ones. As a result, prescribing mHealth apps is new to most physicians.
More than a third of doctors said they prescribe mHealth apps, but half of those clinicians had only suggested that patients shop in an app store, Medical Economics reported in fall 2014. A more recent March 2015 survey by Research Now found that 16% of physicians were prescribing mobile apps. But 46% of the respondents expected to integrate this new tool into their practices within five years.
Yet not all patients have smartphones, and those who could benefit the most from mHealth apps--older patients with chronic diseases-are least likely to possess this technology. Less tech-savvy patients may also have trouble with the Bluetooth-enabled devices that are required to use many mHealth apps.
So should you consider prescribing mHealth apps? You may well face numerous uncertainties, including which to prescribe, how to integrate the data they produce into your workflow, whether and how to integrate patient-generated data in your EHR, and how to motivate patients to download and stick with the apps you prescribe.
Nevertheless, the ubiquity of smartphones and the outsized role they play in the lives of many patients make mHealth apps a compelling tool for patient engagement. What follows are some insights into and tips on mHealth prescribing from experts and physicians who have already taken the leap.
While some physicians have seen the benefits of mHealth prescribing, the evidence of their efficacy is in short supply, notes Steven Steinhubl, MD, director of digital medicine at the Scripps Translational Science Institute, in a recent interview with the Institute for Health Technology Transformation.
Matt Tindall, director of consumer solutions for IMS Health, tells Medical Economics that his firm has found only 260 scientific studies of particular apps in the literature.
Moreover, some add-on devices and apps for smartphones produce inaccurate data. Hypertension experts have questioned the reliability of some mobile blood pressure devices. Another study found that three of four skin lesion apps misidentified 30 or more melanoma lesions as benign.
Partly because of concern over the validity of commercially available apps, some healthcare systems have created their own mHealth software, says David Collins, senior director of health information systems for the Health Information Management and Systems Society (HIMSS). But most organizations have found that it’s too difficult and expensive to develop mobile apps in-house, he adds.
Some healthcare organizations offer external apps that meet their criteria to consumers in their own app stores. About 10% of healthcare systems recently surveyed by HIMSS, including prominent ones such as Ochsner Health and the Cleveland Clinic, have their own app stores.
Most physicians who prescribe mHealth apps focus on educational, wellness and fitness apps that are unlikely to harm patients. But they would still like to know which apps in those categories are the best.
There are several app ratings services, including those of IMS, SocialWellth, iMedical Apps, and iGet Better. But the ratings are scattered and most physicians are too busy to pay attention to them, observes Joseph Kvedar, MD, president of the Center for Connected Health, a unit of Partners Healthcare in Boston.
IMS, which rates all of the health apps in the Apple and Google stores, bases its scores on the responses of healthcare professionals and patients, assessment of the product functionality, evaluation of the app developer, and evidence of clinical efficacy and safety, where it exists.
Over time, IMS hopes that user feedback will improve the accuracy of its scores, Tindall says.
Internist Gregory Weidner, MD, medical director, primary care innovation and proactive health for the Carolinas Healthcare System, notes that IMS’ AppScore system is still new and in need of crowd sourcing to improve its validity. He knows this well, because the office where he practices part-time is testing IMS’ AppScript prescribing system. AppScript allows physicians to send prescriptions directly to their patients’ smartphones and observe what they do with the apps they download.
Doctors, patients and caregivers must all be involved in evaluating apps, Weidner says. “As providers and healthcare teams help people navigate that terrain and figure out what works best, we need that to be a continuous learning ecosystem where we know more today than six months ago about what works for a given patient and a given condition.”
Some physicians who prescribe apps take a more hands-on approach. Medhavi Jogi, MD, an endocrinologist in Houston, has been recommending apps to patients since 2009. He won’t tell a patient to use an app until he and/or his staff members have tried it out, he says, “because there are too many weird apps” that haven’t been vetted by anybody.
Jeffrey Livingston, MD, an ob/gyn in Irving, Tex., recommends some fitness, smoking cessation and anti-anxiety/relaxation apps to his patients. He is also piloting a gestational diabetes app a colleague has developed.
Livingston likes a fitness app that he has used himself because it is good at calculating calories and helps patients relate their caloric intake to weight loss goals. He uses a simple, two-part test for deciding whether to prescribe an app: A good app is one that “makes the life of the doctor easier, and makes the care of the patient better,” he explains.
Kenneth Kubitschek, MD, a physician practicing in Asheville, North Carolina, and a member of the Medical Economics editorial advisory board, says he has tried prescribing weight loss apps to patients but that adherence has been a problem. “The response has been generally disappointing,” he says. “Hopefully as we gain better insight into what encourages patient adherence to these newer apps, I will be utilizing them more routinely.”
It’s one thing to prescribe an app to your patient and tell him or her to use it to improve their health. But unless the doctor takes a more proactive role, Jogi has discovered, patients are unlikely to stick with the app or use it to achieve their health goals. And in order to use mHealth apps to help chronic-disease patients manage their conditions, physicians must be able to view the data generated by the devices.
While patient-generated health data raises a number of issues, let’s look first at how the data may be shared with other providers.
Currently, The biggest problem is the lac of a place in the practice to store and analyze the data these apps generate. Most EHRs cannot yet accept this data, and if the data went into a separate database, physicians would have to leave their EHR to view it. Nurse care managers could identify the relevant data and enter it manually or cut and paste it into the EHR, but that would be a lot of busywork for highly skilled professionals.
“Until these interactive apps that patients are using on their own can push out the data directly into a physician’s electronic record, their utility in decision-making for physicians is going to remain very limited,” Livingston says. “They still have value for patient education and patient engagement. But making that leap from data collection to clinical decision making, we’re still not there yet.”
Livingston is right. But rapid progress is being made on establishing interoperability between mobile apps and EHRs. For example, Carolinas Health System has built its own “platform” that can aggregate data from activity trackers, blood pressure cuffs, Bluetooth scales, and glucometers. Later this year, Weidner says, his organization will link this platform with its patient portal and its EHR.
Some outside vendors are creating similar platforms. The best known of these is Apple HealthKit, which is being used in a growing number of academic medical centers. HealthKit aggregates data from multiple devices, lets the patient see the data in one place, and can be connected with EHRs. Epic and Cerner, two of the biggest EHR vendors, have linked their systems with HealthKit. Duke Medicine, an affiliate of Duke University, is already beginning to use HealthKit to import monitoring data from patients with heart failure into its Epic EHR.
If there were no way to screen mobile monitoring data for relevant information and to use it for clinical alerts, it would be useless. HealthKit is said to be capable of detecting vital signs values that are outside normal ranges.
Duke Medicine uses a similar capability in its EHR to alert physicians when the data imported through HealthKit suggests that a patient’s condition might be a cause for concern.
Nevertheless, observers say that the current analytics for screening data are inadequate. At present, those analytic applications are “fairly limited,” says Jay Backstrom, a telehealth consultant and a partner in Subsidium Healthcare. Mobile data screening, he adds, is still largely a manual process. It will have to become much more automated before it’s ready for everyday use in physician practices.
Kubitschek says he has the ability to download Bluetooth-enabled patient data from patient apps and devices directly to his EHR, but won’t use it until there are better solutions to ensure that the information that arrives is clean and correct.
“I simply do not have the time to delve into all of that information in an appropriate fashion to find the important details, as most of the information is superfluous,” he says. “Unless intelligent screening programs can present the information to me in an actionable fashion, and only when an action is required, I don’t want to be flooded with data I do not need.”
According to a recent survey, 96% of consumers who use mHealth apps believe they can improve their quality of life. But just as with the use of patient portals, physicians have found that not many patients are interested in taking charge of their own health if it requires a substantial effort.
When Jogi recommends apps to patients for diet or exercise and asks them what they’ve achieved at the next visit, “half the time they’ll say they lost their phone, and I know what that means,” he says.
He estimates that about 15% of the patients to whom he prescribes apps keep using the app.
“Another 30% say they did it, but they can’t provide evidence. The rest are too lazy to do it,” Jogi says. “But if I’m directing it and say, ‘here’s what I want you to do,’ and they don’t need any password to log into the app, the rate of use is about 70%.”
Jogi, who designed his own wellness app, tells patients who use the app how much they can eat and how much they should exercise, and that he’ll go over the data with them on their next visit. “I tell them, ‘I can see all your data, so don’t try to not do it, because I’ll know you didn’t.’ That works.”
The data from the app goes into a cloud-based database, and the system alerts Jogi if a patient is not using the app. Then he has a nurse call them to find out why. He can view the data in the cloud without leaving his EHR.
In Weidner’s practice, two physicians, two health coaches, a medical assistant and a nutritionist prescribe mobile apps and other digital content. To date, the care team members have prescribed about 160 apps, which have had a download rate of between 60% and 75%, he says. The retention rates, which also vary by app, range from 25% to 50% of the filled prescriptions, he adds.
Aside from using an app, patients can share data with Jogi only during visits. “I don’t allow them to send me stuff such as screen shots or tell me to log in-it takes too much time,” he says. “But I’ll say at follow-up, let me see what you’re entering for your calories every day.”
He also doesn’t let patients send him their data “because I don’t get paid that way,” he notes. “I say, ‘bring it in at your visit and we’ll review it.’”
Weidner points out that, even if the use of mHealth apps could increase patient engagement significantly, it’s too much “to ask every doctor in the country to do this on a routine basis on top of everything else they’re doing. But as we move to a value-based healthcare ecosystem, where patients experience care differently, and the reimbursement model supports that, the potential of this is really unlimited.”
The physicians we interviewed say that some of their patients have benefitted from mHealth apps. For example, one of Jogi’s patients who used his app for four months lost considerable weight, he says. Weidner says that more than 100 of his patients have had “profound shifts in their overall health-losing substantial amounts of weight, improving metrics on blood pressure and blood sugar control, reducing the need for medication, and developing self-management and self-efficacy skills that allow these shifts to be sustained.
“Engaged patients have better health outcomes, and that’s at the heart of everything we’re doing,” he adds. “We also recognize that patients have busy and complicated lives, and if we’re going to help and support them in managing their health, we’re going to have to figure out how to integrate within their lives, as opposed to creating solutions that add one more layer of complexity.”
Livingston has seen a positive impact from mHealth apps as well. “Patients are definitely using apps as an educational tool. They’re also using it as a verification tool,” like getting a second opinion on their doctor’s diagnosis or treatment, he says.
Some experts believe that mHealth prescribing, coupled with virtual visits and other types of telehealth, eventually will reduce the need for office visits. A 2013 commentary in the Journal of the American Medical Association explained how it could happen.
Because consumers will be able to diagnose some acute symptoms and better manage their chronic conditions using mHealth apps and devices, there will be fewer unnecessary office and emergency department visits in the future, the authors wrote.
That might seem like science fiction. But if all financial and technical barriers to mHealth prescribing and data integration were removed, Jogi says, he could deliver the majority of his care remotely. That means he wouldn’t need multiple offices and would have less overhead. “The costs on my end would go down,” he says.
However, he’s concerned that such an outcome might degrade the patient-physician relationship and even devalue the skill set of physicians. It might also mean that fewer doctors would be needed, he says.
“If the data just popped up on my screen, I could make quick decisions every five minutes [for each patient], and therefore, you’d need less endocrinologists. You’d have an army of first responders, and if anything is abnormal, the physician would handle it.”
Weidner isn’t worried about that. In fact, he regards mHealth as a crucial step on the road toward team-based care that is more efficient and more patient-centered than the current approach to care delivery.
“Mobile app prescribing fundamentally cries out for redesigning the way that patients experience care, so it becomes a useful adjunct to and in some cases a replacement for some things we do today that don’t add as much value,” he says.