2013 was a big year for the adoption of mobile medical applications
by clinicians and consumers. It also saw the beginning of convergence between devices and apps used by clinicians and those used by consumers.
Still, industry experts say the widespread use of mobile apps and devices that are fully integrated into a comprehensive healthcare and wellness information system remains a work in progress. Authoritative curation of mobile apps is needed to ease physician uncertainty about adopting apps more widely for clinical use, some experts say. And much more progress is needed in developing and disseminating apps that enable healthcare providers to help patients manage their medical conditions.
There's still a long way to go in integrating apps into care management.
“We can see within five years apps moving from novelty to mainstream,” said Murray Aitken, executive director of the IMS Institute for Healthcare Informatics.
A recent report Aitken co-authored, based on a study of nearly 43,700 purported health or medical apps available on Apple's iTunes app store, found that only 54% of them were “genuine” healthcare apps. Of those, 69% targeted consumers and patients while 31% were built for use by clinicians. Most of the consumer healthcare apps were “simple in design and do little more than provide information,” according to the IMS report. Only 159 of the consumer apps could track or capture user-entered data, and fewer than 50 relate to condition management or provide tools and calculators for users to measure their vitals. That leaves “considerable room for growth in this sector,” the report said.
Aitken predicted that it will become commonplace for patients to leave the doctor's office with a prescription for both a drug and an app, and hospital discharge orders for patients will include downloading a mobile app on a patient's smartphone to provide an ongoing link between the provider and the patient. That will lead to better care and lower cost, he said.
For now, though, readers responding to this year's second annual Modern Healthcare survey for the Most Important Mobile Medical Applications said they continue to rely on old standbys among apps, defined as downloadable software programs that are mobile device-specific. In all, respondents identified 83 apps and devices performing 46 primary functions.
Epocrates was their top choice as the most important app for the second year in a row, followed by Medscape, Micromedex and WebMD. These top four clinician-oriented mobile medical apps—and seven in the top 10—were launched by companies founded in the 1990s or earlier. Other venerable apps in the top 10 were Lexicomp, started on paper in 1978; UpToDate, whose company was launched in 1992; and PatientKeeper, whose company was founded in 1998, with the app launched in 1999 for the Palm Pilot.
The most popular mobile medical app function in the survey was drug reference, followed by general medical reference and personal fitness. Fitbit, a wearable, consumer-oriented fitness application, ranked high among readers' choices.
In an interesting twist, readers also chose some mobile devices as their favorite apps, including iPhone, iPad, BlackBerry, the generic “smartphone,” and the generic laptop computer. The search engine Google and generic e-mail also received votes from some survey respondents.
Two of the top picks of Dr. Colin Banas, chief medical information officer at Virginia Commonwealth University Health System in Richmond, were old school—the drug reference tool UpToDate and the charge and capture tool PatientKeeper. His No. 3 was VisualDx, an image-based diagnostic support tool further down on the Modern Healthcare list.
“Truthfully, UpToDate is light years ahead,” Banas said. But it's subscription-based, so the cost probably limits its use compared with some of its free competitors. “Fortunately, I'm at an academic medical center and they pay for it. It's the No. 1 resource in our institution.” He added that it's especially useful as a teaching tool.
PatientKeeper ties in with his center's clinical and billing systems. “I can see clinical data on my app and drop charges for patients I see, which is really slick and a huge timesaver,” he said. VisualDx has a dermatology focus, with “lots and lots of pictures,” and it “helps you get a differential diagnosis.”
Renee Hofman, vice president for pharmacy services at Jewish Home Lifecare, a multi-campus long-term care organization in New York, uses multiple computerized drug references. But her favorite when she's out and about is Micromedex. “It's easy. It's quick. And it's handy to get drug and dosing information quickly if you're not familiar with the product,” Hofman said. She also picked Epocrates and Medscape. Hofman would like to see a mobile app that interfaces with all Medicare Part D drug plans. Early in the history of the federal drug-benefit program, Epocrates covered that need, Hofman said. But since then plans have diverged in the drugs they cover.
Why did some respondents name devices, Google and e-mail as their favorite “apps”? Readers said, for example, that the iPhone gave them immediate access to e-mail and communications, and that their iPad was quick and stores lots of information.
“I'm not surprised by those answers,” said Chris Wasden, managing director in the U.S. of the healthcare strategy and innovation practice at PricewaterhouseCoopers. “These are tools they've used for a long time and they're comfortable with them, and they're available in a mobile format.” He said there is convergence occurring in the minds of practitioners between apps and their delivery mechanisms.
About 95 million Americans used their mobile phones either as healthcare tools or to find health information, according to a survey of more than 8,600 adults released in October by Manhattan Research, a New York-based healthcare marketing research firm. That's up 27% from 75 million in 2012. Smartphones have become an “indispensible” source of healthcare information for many, with 38% of smartphone users saying their device was “essential” for finding health and medical information.
A recent policy brief on mobile health by the Robert Wood Johnson Foundation, published in the journal Health Affairs, cited industry experts who predict the number of mobile health apps will increase by a rate of 25% a year for the foreseeable future. Globally, 500 million consumers and healthcare providers will use a mobile health app within the next two years. By 2018, “half of the 3.4 billion mobile device users worldwide will download a health app,” according to the brief. Consumer pressure from these legions of smart-device owners is expected to drive healthcare system change, according to industry experts.
Meanwhile, the regulatory picture for mobile health apps cleared up a bit in 2013. In September, the Food and Drug Administration signaled a limited approach to regulating medical mobile app developers. It said it would focus only on those products that pose the most potential risk to patients and consumers, while exercising enforcement discretion over medical devices that pose minimal risk to people. “We're not expanding our universe at all,” said Dr. Jeffrey Shuren, director of the FDA's Center for Devices and Radiological Health, in announcing the agency's “Mobile Applications Guidance for Industry and Food and Drug Administration Staff.” The FDA has cleared about 100 mobile medical apps, such as mobile electrocardiographs, including about 40 in the past two years, via a regulatory process averaging 67 days.
How we assessed the apps
This year's second annual Modern Healthcare readers' survey for the Most Important Mobile Medical Applications included 198 respondents
contacted in November who said they use a mobile computer device at work.
They were asked to name their top three mobile healthcare applications, the most important functions and why they use them.
There were 83 discrete apps and devices
selected, performing 46 unique functions.Of the app functions identified,
24% were drug reference, 21% were general medical reference, 9% were personal fitness tracking and 46% were scattered across 43 other categories.
Convergence of clinical- and patient-oriented mobile health is already well underway at the Veterans Health Administration
. The VA long has championed electronically supported home health programs and other telehealth innovations. Now, it has more than three dozen customized mobile apps released or under development, and a host of pilot projects underway.
In one pilot, launched in May, the VA provided iPads to 1,100 caregivers of seriously injured veterans of recent wars. The devices were loaded with a suite of 10 apps created to help the caregivers and veterans securely access, track and share personal health information with their VA care teams. The VA is creating both staff-oriented and patient-oriented apps, said Kathy Frisbee and Dr. Neil Evans, who co-direct the VA's office for connected health, which oversees the ambitious app development effort. Most apps are or will be linked to the VA's VistA EHR that serves more than 150 VA hospitals and more than 700 clinics.
For providers, Frisbee said, “we are spending a considerable amount of effort to learn to develop the visualization and the analytics to make this data useful to the care team.” For both clinicians and patients, she said, “we realize we run the risk that people could be overwhelmed with this data.”
For a physician, and especially for a primary-care provider such as Evans, “these mobile apps can be just effective as some of the other things we prescribe. There is an awful lot of optimism about their potential, but there is a lot of work to do.” That's not just on the technology, but also on understanding the psychology of mobile app effectiveness. “I talk to a lot of patients who say they want to quit smoking, but how do you make that happen?” Evans said. “How that's messaged and how do you design that? What data do you surface to help people make better choices. It takes some work.”
At the core of the convergence between consumer and clinical use of mobile apps and their data is what Wasden calls feedback loops. Patients average only 60 minutes a year with a physician. “In essence, there is no feedback with your physician,” he said. “If healthcare is to change, we're going to need feedback loops, and these mobile tools and services are creating feedback loops that are much more frequent and intense” for disease management and preventive health.
For example, patients could get a text message or e-mail alert saying, “You are at 50% of your goal” on cholesterol or weight loss. The apps will not merely provide data, but tell users what the information means and prompt them on what to do next. Targeted messages such as that change behavior, he said. In the near future, he said, physicians will prescribe not only an app for weight loss but an entire weight- loss program, including a wireless scale, glucometer, and a call center for diet coaching and feedback.
But right now, many mobile apps lack adequate protections for security and confidentiality. “It's the Wild West of the app phase,” said Craig Michael Lie Njie, a technology consultant, privacy advocate and mobile app developer who headed the San Diego-based Privacy Rights Foundation's critical look at data practices of mobile health app developers. Of the 43 consumer apps he reviewed, 72% were rated high or medium privacy risks.
“Most developers aren't doing this right,” he said. “They're not encrypting the data, they're storing too much.” A pregnancy app he reviewed automatically captured and sent geographic location data, for example. “That's an overreach,” he said. For now, Lie Njie advised, “Don't put anything in an app that you wouldn't post on Facebook.”
One conundrum for healthcare provider systems is that their employees want to use their personal mobile devices and apps at work, known in the industry as BYOD, or “bring your own device,” said Alan Brill, senior managing director at Kroll, a data global security firm.
“If you look across a lot of healthcare organizations, the way I'd characterize it right now would be scared stiff,” he said. “The thing that's scaring them is not just BYOD, but a combination of BYOD and BYOC, bring your own cloud”—using cloud-based storage for the applications. Cloud data centers are located all over the world, with a typical customer having no idea where they actually store the data. “You have this conflict between the organization having an absolute need to control sensitive information, and the individual who wants to use this information for the benefit of the organization, to help them do a better job.”
Brill said there is no “magic solution.” What's needed is a system of procedures consistent with the regulations. “If you don't want any of your people using a storage system for (electronic, protected health information), you have to make sure you have some rules that say you aren't allowed to do this and why.”
Another technique is to install a reserved storage area, or “sandbox,” on each mobile device that stores sensitive data. Employees then agree not to put protected data in other parts of the device. Data in the protected storage area can be remotely destroyed. Follow Joseph Conn on Twitter: @MHJConn