Thursday, June 9, 2016

Mobile Health AppNo matter what you want to do, there’s an app for that, and health is no exception. With more than 165,000 health-related apps available, mobile health apps, called mHealth apps by some, are already a huge part of the digital market and are poised to grow even more abundant. According to reporting from Forbes, 79% of Americans would be willing to use a wearable device to manage their health, and significant numbers are already using health and fitness apps for smart phones and tablets (Elias, 2015). This market is growing as health care organizations race to catch up with Silicon Valley. According to reporting from CNBC, 70% of health care organizations are planning to invest in mobile health apps, wearables like watches and activity trackers, and devices and software for remote health monitoring and “virtual care” by 2018 (Kharpal, 2016). This blog post will take a look at mobile health apps, their potential, and their uses for improving child health and community health.

An app a day keeps the doctor connected. With a quick download and sign-up, you can use a smart phone to track steps, count calories, log your mood, record medications, monitor your fertility, prompt you to stand if you’ve been sitting too long, and document your sleep. While there has been relatively little research on the efficacy of these apps, there is a move to legitimize this self-recorded personal health data by linking it to your personal health record, which is accessible by your physician. EMIS Health, a medical software company, has created the Patient Access application, which allows patients to securely transfer the personal health data collected by Apple Health to EMIS Web, a prominent electronic health record system in the United Kingdom. Other electronic health systems and health care organizations are looking to follow suit to give doctors access to this potentially rich patient data.

Given the relative newness of the field, it’s not surprising that research on the effectiveness of mHealth apps is difficult to find. A review by the Commonwealth Fund of “patient-facing” apps—apps used by the consumer—for people self-monitoring a variety of chronic illnesses, found that the majority of these apps were unlikely to be useful in engaging patients due to being outdated, having poor reviews, or not being interactive (Singh et al., 2016). A review of ten free maternal and child health apps found that only four had been developed with the involvement of health professionals and only three had adequate security to protect user data (Scott, Gome, Richards, & Caldwell, 2015). However, a systematic review of literature on mHealth adoption found that healthcare professionals felt that these applications can improve patient communication and care and help patients gain better knowledge of themselves (Gagnon, Ngangue, Payne-Gagnon & Desmartis, 2016). Remote monitoring technologies—enabling patients to self-report their illnesses—have potential to decrease medical costs for chronic diseases by helping patients get treatment more quickly and reminding them to take medicine on time (West, 2012).

Health apps for children. While most personal health apps are aimed at adult users, there is a selection of child health apps on the market. Healthychildren.org, which is supported by the American Academy of Pediatrics, publishes a series of apps that cover topics such as medical advice on minor childhood illness and injuries, an app to ensure the proper installation and use of car seats, and health trackers for general health and attention deficit and hyperactivity disorder (ADHD) behaviors. Other child-focused apps include 5-2-1-0 Kids!, a healthy lifestyle app developed by Henry Ford LiveWell; Kurbo, a mobile adaptation of the Stanford Lucile Packard Children’s Hospital pediatric obesity program; and mobile versions of “exergaming” programs that encourage children to move while playing with the device. As with the adult apps, there is little data on the effectiveness of child-focused apps and users would be wise to select apps that have been developed by reputable health care or child health organizations.

White coat, stethoscope, and smart phone. While the main focus of the market is on personal health apps, there is a growing market of apps for medical professionals themselves. There were more than 97,000 physician or medical care provider-facing apps available in spring 2013 and that number has certainly grown (Frisch, 2013). The most common kinds of medical professional apps are those that provide information access, such as apps that allow physicians to view electrocardiograms and other types of medical imaging, or to access treatment decision-trees (West, 2012). Community health workers (CHW), particularly in developing areas, have been a focus of mobile app development. A systematic review found that mobile technology is a promising tool for these workers and that there is evidence that access to mobile information improves the quality of care, efficiency of services, and program monitoring. Mobile health apps help CHWs collect high quality data in the field, access education and training that might be otherwise difficult to access, and help CHWs maintain compliance with best practices and standards (Braun, Catalani, Wimbush, & Israelski, 2013; West, 2012).

Medical professional-facing apps have one advantage over personal health apps: stronger regulation. The Food and Drug Administration (FDA) recognizes “the potential benefits and risks to public health represented by these apps” and has begun to issue guidance for mobile medical apps that are either a) used as an accessory to a regulated medical device or b) transform a mobile device into a regulated medical device (FDA, 2015, p. 4). This includes apps that perform functions like controlling blood pressure cuffs, displaying medical images during active patient monitoring, interfacing with blood glucose meters or electrocardiographs, or creating drug or radiation dosage plans. This does not cover many of the most common kinds of medical apps that would be used by the general population, such as apps that help patients with disease self-management, track health information, or interact with personal health records or electronic health records.

Can health apps create healthier communities? Enterprising researchers have begun to tap the potential of the large amounts of data gathered by these devices to improve community health (Cha, 2016). The Healthy Communities Institute’s HCI Platform collects mapping and data visualization tools and displays indicators such as teen pregnancy rates, mortality data, average incomes, and educational attainment on a dashboard-like website. While not strictly an app in the mobile sense, the HCI Platform allows stakeholders like hospitals, public health agencies, and community coalitions to develop targeted interventions in their communities. Collecting and displaying this data is one half of the healthy communities equation, and personal health apps have the potential to improve the other half: data collection.

One path is to use the data collected by apps and devices to conduct large-scale research projects on individual health. ResearchKit, developed by Apple, is a flexible software platform that allows researchers to draw on the large number of iPhone users around the world to recruit participants for large studies. With input from iPhone users, researchers have access to frequent data updates at relatively low cost. Researchers using this platform are currently recruiting participants for studies on asthma management, concussion outcomes, risk factors for chronic obstructive pulmonary disease (COPD), and diabetes treatment compliance, among others. The Asthma Mobile Health Study, developed by the Icahn School of Medicine at Mount Sinai, has recruited more than 8,600 participants to track their asthma symptoms and triggers. Users’ self-reported symptoms are matched using location data with local weather, pollution, and allergen counts. The PRIDE study from the University of California, San Francisco is the first national longitudinal cohort study of the lesbian, gay, bisexual and transgender (LGBT) population. It collects self-reported demographic and health data to examine health and healthcare inequalities.

Another path is to utilize data from smart phone users to gather information on the healthiness of the community environment itself. The Asthma Mobile Health Study described above has the potential to pinpoint specific air quality hazards in communities and to link those hazards to asthma symptoms on a scale that would have been difficult without massive user input. There are apps that guide users to healthier choices, such as healthy restaurants, that can be used to both inform users and to collect data on the prevalence of food deserts (Levere, 2014).

Even apps that do not initially look like research tools can be used to gather community health data. A recent study on food deserts mined publically-available food-related posts from the photo-sharing service Instagram to examine the types of foods consumed in food deserts (De Choudhury, Sharma, and Kiciman, 2016). Strava is an app that uses GPS to track distance, speed, and elapsed time primarily for cycling and running activities. Users capture this data either with their phones or with compatible tracking wearables and compete for bragging rights as the software records and displays personal bests and overall bests for given segments of a trail or road. With more than 170 million recorded trips, Strava has developed a Global Heatmap showing the most popular routes to run or ride. A close-up of a given city or neighborhood quickly shows which areas are frequented by cyclists and runners, exposing possible gaps and disparities in safe infrastructure. Recognizing the strength of this data, Strava partners with departments of transportation and city planning groups to improve walk and bike infrastructure (Strava Metro, n.d.).

While these apps are not child and youth focused, it is not difficult to see how they might be used to improve child health. The Asthma Mobile Health Study focuses on adults, but findings about the links between environmental triggers and asthma symptoms could be helpful in developing interventions and risk factor assessments for children at risk of developing asthma. Although Strava users are adults, the data on walkable, bikeable communities could be used to see where a Walking School Bus or a Bike to School Day route would be more feasible, and to pinpoint communities where there are not safe routes to school.

Improving health in schools and out of school time. One underdeveloped area for health apps is in child health. As noted above, there are personal health trackers and exergaming-related apps for children and youth, but there are very few apps that address the environments where children spend most of their days: in schools, day cares, and out of school time. The most common types of child care app are closely related to personal health trackers. These allow parents, sitters, day care workers, or others to track child-related data point, such as nursing times and duration, nap and sleep times, weight, diaper changes, and others. An example of this type of app is Baby Connect. For older children, apps like Daily Connect or HiMama allow day cares to share daily activity reports.

Apps exist for day care and out-of-school time workers as well, but most are mobile variants of administrative software, like Kinderlime and ChildWatch. These are more oriented towards the business side of child care and provide staffing reports, attendance and registration software, and billing tracking. Some aspects of quality care and licensure compliance such as child/staff ratios and Child and Adult Care Food Program (CACFP) meal and attendance tracking are included in some of these apps.

Apps could help schools and child care centers monitor and improve their health environments, by tracking physical activity time, screen time, meals, and other health metrics. These could provide data on the healthiness of child environments, allow programs to track and promote their quality improvement measures, and help parents select the healthiest programs for their children. Policy to Practice in Youth Programs (P2P) created the Healthy Eating and Physical Activity (HEPA) Mobile app, which is designed for out-of-school time programs to monitor their food and physical activity offerings and environment. Out-of-school time programs are often the target of best practice standards for preventing childhood obesity and promoting healthy lifestyles. Altarum is working with the Michigan Department of Health and Human Services and the State Alliance of Michigan YMCAs to pilot HEPA Mobile in YMCAs across Michigan, to learn whether it is feasible for afterschool providers to collect this data on a regular basis and whether the self-reported data accurately reflects program practices and environments. Another example is an app called Kids Matter from the Child Care Council of Kentucky, which is designed to help parents choose quality child care based on quality improvement metrics. Overall, however, this is an area that remains largely unexplored.

It is clear that the market for health-related apps is only going to grow. As we become more comfortable with tracking and analyzing our health metrics, we should also examine how these rich sources of data could be used to improve and measure community health as well as personal health. However, more research is needed to ensure that the apps used are accurate, supported by evidence, developed with the input of health care stakeholders, and safe to use both from a personal health and a data protection perspective.

Works cited

  1. Braun, R., Catalani, C., Wimbush, J., & Israelski, D. (2013). Community health workers and mobile technology: a systematic review of the literature. Plos One, 8(6), e65772. doi:10.1371/journal.pone.0065772
  2. Cha, A.E. (2016, May 26). “Is 10,000-steps goal more myth than science? Study seeks fitness truths through our phones and more.” To Your Health. The Washington Post [online edition]. Retrieved 5/26/2016 from https://www.washingtonpost.com/news/to-your-health/wp/2016/05/26/is-10000-steps-goal-more-myth-than-science-study-seeks-fitness-truths-through-our-phones-and-more/
  3. De Choudhury, M., Sharma, S.S., and Kiciman, E. (2016). Characterizing dietary choices, nutrtion, and language in food deserts via social media. 19th ACM Conference on Computer-Supported Cooperative Work and Social Computing (CSCW), February 2016. http://research.microsoft.com/apps/pubs/default.aspx?id=257773
  4. Drell, L. (2014). AN APP A DAY KEEPS THE DOCTOR AWAY. Marketing Health Services, 34(2), 20-23.
  5. Elias, J. (2015, December 31). “In 2016, Users Will Trust Health Apps More Than Their Doctors.” Forbes, Tech [online edition]. Retrieved 5/26/2016 from http://www.forbes.com/sites/jenniferelias/2015/12/31/in-2016-users-will-trust-health-apps-more-than-their-doctors/#7e7668412d5f
  6. Food and Drug Administration (FDA). (2015). Mobile medical applications: Guidance for industry and food and drug administration staff. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Retrieved 5/24/2016 from http://www.fda.gov/downloads/MedicalDevices/.../UCM263366.pdf
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  9. Kharpal, A. (2016, May 24). “Tim Cook: Why the Apple Watch is key in the ‘enormous’ health care market.” Tech Transformers: A CNBC Special Report. CNBC [online edition]. Retrieved 5/26/2016 from http://www.cnbc.com/2016/05/24/tim-cook-why-the-apple-watch-is-key-in-the-enormous-health-care-market.html
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  11. Scott, K.M., Gome, G.A., Richards, D., & Caldwell, P.H.Y. (2015). How trustworthy are apps for maternal and child health? Health Technol., 4(4), 329-336.
  12. Singh, K., Bates, D., Dourin, K., Newmark, L.P., Rozenblum, R., Lee, J., Landman, A., Pabo, E., & Klinger, E.V. (2016). Developing a Framework for Evaluating the Patient Engagement, Quality, and Safety of Mobile Health Applications. New York: the Commonwealth Fund. Retrieved 5/24/2016 from http://www.commonwealthfund.org/publications/issue-briefs/2016/feb/evaluating-mobile-health-apps
  13. Strava Metro. (n.d.). Data-driven bicycle and pedestrian planning. San Francisco: Strava. Retrieved 5/24/2016 from http://cdn2.hubspot.net/hubfs/1979139/Strava_Metro___Data-Driven_Planning.pdf
  14. West, D. (2012). How mobile devices are transforming healthcare. Issues in Technology Innovation, No. 18. Washington, DC: Center for Technology Innovation at Brookings. Retrieved 5/24/2016 from http://www.insidepolitics.org/brookingsreports/mobile_health_52212.pdf 

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