Summary: Providers have proven eager adopters of health care "apps," the software applications used on cell phones and other mobile devices to perform specific tasks, such as charting data points or aggregating information. Apps can be easily integrated into providers' workflow, delivering information when and where they need it. Disease management apps, in particular, can improve communication between patients and providers and promote adherence to recommended care. Still, for apps to achieve their potential to improve health care quality, they will need to be factored into reimbursement models and meet clear clinical needs.
By Martha Hostetter
Billions in federal incentive payments are being used to encourage hospitals and other health care organizations to use electronic health record systems (EHRs). Meanwhile, without much prompting, providers have proven eager adopters of health care "apps," the software applications used on cell phones or tablet computers to perform specific tasks, such as charting data points or aggregating information.1 A recent survey of 4,000 physicians found that nearly 80 percent use smartphones capable or running apps—a far greater proportion than among the general public.2 Another report estimates that by 2012 about half of physicians who have smartphones will use them in their work for administrative functions, research, and patient care.
Part of the reason apps appeal to physicians while EHRs may not is that apps are easily integrated into their workflow—delivering information when and where they need it. Moreover, most apps are flexible enough to run on a variety of different mobile devices, which many physicians already own.
"Beth Israel Deaconess Medical Center has 1,000 physicians using their own iPads because they give them pleasure, they are useable, and they work for them," says Farzad Mostashari, M.D., Sc.M., the U.S. Department of Health and Human Services' national coordinator for health information technology. "This kind of bottom-up embrace of technology is not mutually exclusive with a hospital's need for enterprise-wide, secure clinical information systems."
Types of Health Care Apps for Providers
Clinical Reference Apps
- This category of health care app is designed to improve care by giving providers easy access to clinical information and medical alerts as well as better diagnostic tools. Examples include Epocrates or PubMed mobile, which are used by medical students and clinicians to access the latest information on diseases, drugs, and medical tests. Some reference apps have features that enable users to identify pills and potential drug interactions, use medical calculators, or look up medical billing codes.
Diagnostic Apps
- Another category of apps uses algorithms to help physicians make treatment decisions. The Agency for Healthcare Research and Quality's Electronic Preventive Services Selector lets clinicians identify appropriate screening, counseling, and preventive services, helping to promote delivery of recommended care. A breast cancer risk assessment app was one of 10 finalists in a nationwide challenge to medical students and physicians sponsored by the American Medical Association to develop concepts for new apps. Conceived of by a breast surgeon, the app consolidates the common formulas, guidelines, and values used to assess a woman's risk for developing breast cancer and could be used to help decide whether to pursue aggressive monitoring using magnetic resonance imaging.
Public Health Apps
- These apps aggregate information from multiple sources to monitor population health, for example by tracking disease clusters in real time. A Web-based tool the federal government is developing will let providers search for information about outbreaks of diseases such as strep, whooping cough, and bacterial meningitis in their community, relying on biosurveillance data that providers already report to the Centers for Disease Control and Prevention. In addition, the federal Community Health Data Initiative is releasing unprecedented amounts of public health data, including measures of health care quality, cost, utilization, and disease prevalence, to encourage creation of applications that make the data more accessible and useable.
Telehealth Apps
- Telehealth apps incorporate biometric sensors, which capture and transmit data that can be used to adjust treatment regimens. At the Cleveland Clinic, researchers are developing an iPad app to assess the severity of brain injuries. Since the iPad has built-in technology to gauge acceleration and spatial orientation, sports trainers and coaches can use it to measure the effects of head injuries on athlete's balance—an indicator of neuromotor functioning that is often difficult to measure. Another app lets users hook up an EEG scanner to their smartphones to monitor their brain's electrical activity and share the recorded images with their physicians; it could be used by those suffering from chronic seizures or for research into addiction or other behavioral conditions.
Disease Management Apps
- These may hold the greatest potential to improve outcomes by helping patients and their providers manage chronic conditions such as diabetes and asthma. Most of these apps use interactive tools to engage patients and encourage them to track their symptoms, follow recommended care, and share their experiences with other patients as well as their providers. One examples is iMPak's Health Journal for Pain, an electronic diary that prompts patients to respond to questions about their pain levels and feeds this information to their providers via a web portal or EHR. Other apps help patients monitor and record their blood pressure levels to provide a more complete picture of their health than when such tests occur only in the office setting.
Disease management apps can vastly improve communication between providers and patients. Instead of trying to answer the question "How have you been feeling?" during a 15-minute office visit, patients can use the tools to record and share concrete details of how they actually experience their condition day to day—what has been described as "observations of daily living."3 "Disease management apps that incorporate observations of daily living stimulate patients to record the circumstances surrounding an increase or decrease in their symptoms," says Claudia Tessier, CEO of the mHealth Institute, a membership organization of industry representatives, providers, and patient advocates that promotes mobile health technologies. "Over time, you or your provider might see patterns—of sleep, weather, family interactions—and be able to recognize triggers." Disease apps can also be used by researchers to closely track patients' conditions and the effects of certain interventions, with information broadcast to them in real time.
Disease management apps are particularly useful for patients who suffer from one of the many chronic conditions that do not have clear biomarkers for diagnoses or treatment, says Brett Shamosh, co-founder and CEO of WellApps. Shamosh, a sufferer of ulcerative colitis, created the GI Monitor as a better way to log his symptoms and more effectively partner with his physician to manage his condition. The tool includes interactive features and simple graphics that enable patients and their providers to explore correlations between their symptoms, diet, and medication. Most users print out summary reports to bring with them to their office visits.
"We work closely with physicians to compile the GI Monitor reports in a format they want to see," says Shamosh. "Doctors get worried about being inundated with too much data, so we give them a summary view of symptoms that can then make the office visit discussion more efficient—and allow for a more holistic discussion of what doctors can offer to improve patients' well-being."
Incorporating Social Networking Into Clinical Care
Increasingly, developers are incorporating social networking functions into disease management apps, enabling users to connect with others who have the same conditions so they can compare symptoms and treatments, and offer empathy and encouragement. "Online health communities and health apps can give patients measurement tools to characterize and understand their illness, both individually and in the context of everyone else," says Ben Heywood, co-founder and president of PatientsLikeMe, a site on which members discuss their conditions and pool their collective experiences to spur knowledge and research into effective treatments. "When you have MS and you have some leg spasticity, you may not know if this is normal. But hearing from others that they are experiencing this too is therapeutic in itself."
In a recent online exchange via the social media component of GI Monitor, a patient described her worsening symptoms after her physician reduced her prednisone from 40 mg to 10 mg. This post prompted several responses from users about similar experiences, including one who commented that this seemed to be "a really quick drop" for that drug. Prompted to call her physician, the patient discovered that there had been a breakdown of communication and she was supposed to be tapering down prednisone 10 mg at a time—not from 40 mg to 10 mg as she had done.
Disease management apps and other mobile tools can also play a key role in facilitating collaboration among groups of providers caring for patients—helping to create the communication networks necessary for accountable care organizations and other integrated care models. "Mobile health tools provide the opportunity to better coordinate care," says Jean-Luc Neptune, M.D., M.B.A., senior vice president of Health 2.0, a private company that sponsors innovation competitions to come up with apps that take advantage of government and other sources of health care data. "Hospitals can identify patients at risk for readmission, track them with a mobile device, and share their health information among their providers."
Challenges Remain
While there is much excitement over health care apps among patient advocates, as well as industry experts and providers, several challenges stand in the way of fulfilling their potential to improve quality and reduce costs through better care management and coordination.
Notably, since use of mobile apps is being driven by consumers and individual providers, there is a danger of leaving some people behind—particularly patients who may not be able to afford smartphones or have the technical savvy to use them. There are, however, some ways to get around the digital divide. For example, Beacon communities are using a simple text message–based campaign to reach those who may be at risk for diabetes; studies show that nearly everyone has access to a cell phone with the ability to send and receive texts, and there have been notable successes with this approach in programs such as Text4Baby. A pilot will launch this fall in three Beacon communities—Detroit, New Orleans, and Cincinnati—using text messages to motivate people to assess their risk for diabetes and connect with local health and wellness resources.
Another hurdle is reimbursement: providers generally cannot bill for time they spend outside of face-to-face visits checking up on patients, whether it be through e-mail, phone calls, or by reviewing health information submitted to them via mobile apps. Thus, even if health care apps save time, there may not be incentives to use them under fee-for-service models. "The more and more tracking of patients mobile apps enable us to do, the more we need to be cognizant that physicians need to be reimbursed for their time," says Iltifat Husain, M.D., the founder of imedicalapps.com, a site where medical professionals review health care apps.
Still, if apps are shown to improve care and reduce costs—by avoiding complications and the need for in-person visits for instance—then they may be adopted by those who benefit from greater efficiency, including providers working in accountable care organizations or under capitated reimbursement models. Health plans and integrated delivery systems that rely on such care management tools to reduce costs may also benefit. Husain points to Seattle's Group Health, a nonprofit health insurance co-op, as an example of a business model that capitalizes on the benefits of mobile health: salaried physicians can earn bonuses by consulting with their patients by telephone or e-mail, rather than visits. Group Health recently launched a mobile medical app through which its members can schedule appointments, access their medical records and test results, receive care reminders, and directly e-mail their physicians.
There's the matter of regulation as well. The growing popularity of health care apps has caught the attention of the U.S. Food and Drug Administration, which announced in July that it may start regulating apps that connect to medical devices or sensors and those that provide clinical decision support. Some worry that regulation will slow the pace of innovation, but Neptune of Health 2.0 sees this as a positive step. "The fact that the government is providing guidance this early is good news," he says. "It will help the industry organize itself if it knows what the rules are."
As health care apps continue to evolve, it will be important for developers to reach out to both patients and providers in order to create tools that address clear clinical needs and can be easily integrated into providers' workflow and patients' lives. It also will be crucial to consider whether an app will help providers meet evolving requirements—for example, to demonstrate meaningful use of electronic health records. Several hospitals have already created mobile app versions of their proprietary EHR systems.
With support from a federal grant, researchers at Children's Hospital Boston and Harvard Medical School are working to create an EHR platform akin to the iPhone—which relies on published software that allows any developer to build applications for it. This is expected to encourage flexibility and innovation in the creation of health care apps. Such a platform could potentially enable clinicians to avoid being "locked in" to one type of health IT solution, instead choosing from the prescribing, decision support, and laboratory apps that are best suited to their needs.
As with other forms of health information technology, the effects of health care apps will ultimately depend on how people use them. To the extent that they can make information available at the point of care—and encourage people to actively manage their care and partner with their providers—they have enormous potential to bring health care beyond the walls of the examining room and into people's lives.
"Mobile for me is about communication—24/7 access to data and most importantly to people," says Shamosh of WellApps. "New devices like smartphones that have ears and eyes, that understand time and location, really help you take advantage of this."
1 Health care providers' growing use of health care apps is part of a larger trend toward mobile health care delivery, in which providers rely on wireless Internet connections, portable computers, portable medical devices, and other mobile tools to communicate with patients and other providers and to deliver care.
2 Nineteen percent of physicians use a tablet personal computer in their work, while 69 percent said they are likely to do so in the next few years. Only 5 percent of the U.S. population owns a tablet. In contrast to the 80 percent of physicians who own smartphones, only about 28 percent of the U.S. population has one.
3 Observations of daily living have been defined as the patterns and features of daily life such as diet, physical activity, quality and quantity of sleep, pain episodes, and mood. See http://www.projecthealthdesign.org/home.