Most-healthful apps

An estimated 15,000 mobile healthcare applications are available for healthcare workers and consumers, and the number of mobile-device users who've downloaded one of those apps doubled over the past year. However, even with all of that astounding innovation and activity, what's been tried and true has also retained value in this fast-moving world of today's smartphones and slick Web-enabled tablet computers.

Epocrates, initially a drug reference tool, and one of the few remaining healthcare information technology survivors of the implosion of the dot-com bubble more than a decade ago, was chosen—far and away—as the top choice in Modern Healthcare's inaugural Most Important Mobile Healthcare Apps competition, according to a survey of our readers, with help from members of two leading healthcare information technology organizations. Those groups are the Association of Medical Directors of Information Systems, a professional association of physician informaticists, and the College of Healthcare Information Management Executives, a professional association of hospital chief information officers.

Rounding out the top five most important apps in our survey were: UpToDate, a 20-year-old clinical decision-support reference tool, which ranked a distant second to Epocrates, followed by Medscape, also a clinical decision-support reference and another dot-com-era survivor; Lexicomp, another drug-reference app; and e-mail—reflecting multiple apps—in the communications category.

Among the 27 categories assigned to applications recommended in our survey, it was a neck-and-neck race between the No. 1 category, physician drug-referencing tools, and the No. 2 category, clinical decision-support tools.

Much farther back in terms of user recommendations but still in the top five categories were No. 3, communication, No. 4, accessing an electronic health-record system, and No. 5, obtaining medical education materials.

Outside of our 12 highest-ranking mobile apps, survey contributors recommended 85 other applications, many chosen by only one or two survey respondents. These less popular apps address a wide range of needs, ranging from healthcare law to hazardous materials references, from a drug shortage monitor for clinicians to a self-diagnostic tool for patients (See accompanying charts).

This wide scatter of application functions selected by our survey participants came as no surprise to Ben Chodor, CEO of Happtique, a subsidiary of GNYHA Ventures, the for-profit arm of the Greater New York Hospital Association.

“It's still the Wild West,” Chodor says. “Different things are attracting different people. It's all across the board at this point.” To help hospital leaders and their staffs sort through this digital haystack of about 15,000 mobile healthcare apps, Chodor says, Happtique is developing a database of healthcare apps and assigning to them about 330 cross-referenced categories. The goal is to create a “curated” online marketplace for these products.

The mobile wave, already mounting, is only going to build as portable communications devices get slicker, the speed of wireless networks continues to increase and physicians become even more “unteathered” from traditional computer systems, experts say.

Epocrates has 330,000 physicians in the U.S. as “active members,” those who have used the application in the past six months and more than a million users worldwide, says Marianne Braunstein, vice president of product management for the San Mateo, Calif.-based developer. Epocrates launched its first application on a Palm Pilot personal digital assistant in 1999, “right in the midst of that whole dot-com craziness,” Braunstein says.

The company has since added a host of other functions to the app, including the DocAlert clinical messaging service, clinical content and patient information.

The developer survived by “hitting the sweet spot with the efficiencies that we have,” Braunstein says. “Mobile is a part of physicians' lives. They're on the move constantly.”

“To use a 1990s phrase, it's a killer app,” says Dr. John Lee, an emergency room physician at 330-bed Edward Hospital in Naperville, Ill., who made Epocrates his No. 1 choice on the survey. “I've been using it ever since I had it on my Palm device back in the late 1990s.”

Lee, who has been practicing medicine for 17 years, says he remembers the days before mobile devices such as the Palm Pilot. “We had these big references like the PDR (Physicians' Desk Reference). It was in a console with big thick metal backing that you flip over and then (when finished) the book goes back. Now you can do this on the fly. It's nice to have it on my Android, and I refer to it frequently.”

Pepid, a clinical decision-support reference app for emergency room physicians, and VisualDx, which ties images of skin ailments to a diagnostic database and helps physicians diagnose dermatological problems, were Lee's second and third choices.

The survey's two top finishers, Epocrates and UpToDate, were the No. 1 and No. 2 picks for Dr. Joel Shoolin, a family practitioner with the Oak Brook, Ill.-based Advocate Health Care and its vice president of clinical informatics.

“I'm old enough, I still have a bunch of textbooks in my office,” Shoolin says. “They're gathering dust. Pretty much everything I need now is online. If you look at all the residents, the 25-year-olds, this is all they know. The way of the world is all electronic.” Epocrates has been around a long time, he says, but “they've continued to try to modernize.”

Shoolin says he likes UpToDate as a medical reference because, like Epocrates, it strikes a balance between having just enough information to be fast and providing access to more in-depth information if needed.

“You can't find everything you want, but I can find 90%,” with UpToDate, Shoolin says. “It gets me what I want, when I want it, in an easy and readable, short and sweet fashion. It's simple.”

Nurses are big fans of mobile-reference apps, too, says Grace White, director of nursing for Mental Health Mental Retardation of Tarrant County, an 11-site community mental health provider in the Fort Worth, Texas, area.

“For the doctors and the advance-practice nurses and psychiatric nurse practitioners, Epocrates is the No. 1 thing that everybody uses,” White says. She cited Epocrates as her top-rated app. Trust is a big issue with clinicians, she says.

“If someone just invents a new app, you don't know if you can trust it,” White says Because of its longevity, Epocrates has that going for it, too, she says.

Her No. 2 pick was the Infection Control Pocket Guide, an iPhone/iPad app that references Centers for Disease Control and Prevention guidelines. White's No. 3 choice was a drug reference guide called, simply, Psych drugs, specifically for psychiatric medication.

Nurses, some of whom are prescribers, work with patients using both of these drug guides to ensure those patients on multiple medications won't have drug-drug reactions. They also use the guides for counseling patients as to drug side effects, she says.

Dr. Daniel Vance practices at an 11-physician, three-nurse-practitioner primary-care group in Cleveland, Tenn., owned by 220-bed Skyridge Medical Center, part of Community Health Systems. Vance says he uses his No. 1 pick, UpToDate, on his iPhone or iPad “for just about everything as a source of medical information. I've been using it since it was on floppy disk.”

UpToDate was founded in 1992, before the dot-com boom, in the basement of the home of Dr. Burton Rose, a nephrologist and textbook author, after he pitched the idea of creating a PC-based medical specialty reference guide and was turned down by his publisher, according to a history on the UpToDate website. Today, it provides reference materials for 20 medical specialties and claims more than 600,000 customers in 150 countries.

Last week, the Chicago-based Healthcare Information and Management Systems Society released a report on its second annual survey on mobile technology, collected via the Web and telephone interviews with 180 healthcare IT leaders, predominantly from large hospitals.

Less than a quarter (22%) of the HIMSS-surveyed IT leaders indicated all of the data captured on mobile devices used by their organizations was integrated into their organizations' EHR systems. But another 22% said only a quarter of mobile data was captured on their EHRs, while 21% reported none of it was. When asked about their clinicians' concerns about mobile IT uses, privacy and security topped the list, well ahead of technical issues such as speed, support and device durability.

Consumers, meanwhile, are arming themselves with mobile devices at a breathtaking clip.

Sometime in 2012, an “inflection point” will have been reached in which shipments of smartphones outstrip those of PCs and notebook computers combined, according to estimates by Morgan Stanley researchers Katy Huberty and Ehud Gelblum. By the end of next year, they predict, shipments of smartphones will exceed PCs and notebooks by roughly a third.

But when it comes to functionality in mobile health IT, consultant Dr. Harry Greenspun, says, “What we've done is scratched the surface.” Greenspun is the lead author of a recently released report, mHealth in an mWorld: How Mobile Technology is Transforming Health Care, which says the number of mobile-device users who downloaded at least one medical or public healthcare support app will double between 2011 and 2012.

Integration, not innovation, is the missing link in mobile health technology, says Greenspun, senior adviser for healthcare transformation and technology at the Deloitte Center for Health Solutions.

“Innovation is great,” he says, “but if you're just creating yet another siloed clump of data that's not connected to the mainstream of healthcare and assessed by analytics, how does this actually tie into a hospital and a doctor? Ultimately, you have to see, does this stuff add value?” Unless it is made to fit into clinical workflow and is accompanied by payment incentives, “it's not going anywhere,” he says.

Chris Wasden, global healthcare innovation leader for PricewaterhouseCoopers, sees mobile health technology following the same arc as the Internet, evolving from a research to a transactional tool.

Like Greenspun, Wasden foresees a major challenge for healthcare organizations in adapting their existing EHR systems to handle the coming tsunami of mobile-generated data, as well as reorganizing their care models to make best use of the data flood.

“This requires significant rethinking of our approach,” Wasden says. “Ninety percent of it is probably going to be normal. With all this digital, docs and hospitals are saying, 'We don't want this.' It may be useful, but they only want to see it on their terms.”

This will give rise to a new cast of data intermediaries, a new cast of angels watching over us, Wasden says.

“Look at the VA and the NHS,” he says, referring to the U.S. Veterans Affairs Department and United Kingdom's National Health Service. At the VA, “they've put 100,000 patients on remote monitoring technology.” Those patients are overseen by an army of specially trained nurses.

“In the U.K. … the NHS is telling doctors that they would prefer that they prescribe apps rather than see a patient first themselves,” Wasden says. “The question is, when will it come to the U.S.?”

A little more than three years ago, clinical psychologist Julia Hoffman applied for and received from the VA's National Center for PTSD $30,000, which she called “seed money” to create a mobile application to serve active-duty military personnel and veterans who either had been diagnosed with post-traumatic stress disorder or thought they might have it.

In April 2011, the VA posted to public online app stores the fruits of that labor, the stand-alone mobile app PTSD Coach. Since then, the app for both Apple and Android operating systems has been downloaded 90,000 times in 73 countries, says Hoffman, who serves as the VA's mobile-apps lead for mental-health services, working out of the VA Palo Alto (Calif.) Health Care System. Hoffman's office is the next building over from the corporate headquarters of Facebook.

Canada, Australia and eight other countries are customizing the app for their own citizens, Hoffman says.

Early next year, the VA will release 26 new mobile apps for clinicians and consumers in a development project spearheaded by its newly named Office of Connected Health, with which Hoffman works as a partner.

“These are innovations born of necessity,” Hoffman says.