Question

Chapter 7, Fong et al. (2011) discusses various methods with which technology can assist personal health and exercise, including pedometers and GPS technology. There are also a wide variety of cell phone health apps that can assist in tracking distance run, heart rate, and caloric intake, among other health measures. Conduct your own research to identify a health app available on cell phones.

· Describe the purpose of the app. What benefits does it bring to the user? What are some potential disadvantages or risks of using this app

Answer 1

Smartphones, the most common “personal computer” today, have revolutionised the communication landscape. Almost ‘always on’ and highly portable (carried by their users everywhere they go), smartphones provide real-time, on-demand communication, while their rich multimedia touch-displays operate with increasing speeds, delivering data services and computing power to document and improve the networked lives of their owners

Health apps are application programs that offer health-related services for smartphones and tablet PCs.

Communication via smartphones is personalised: smartphones store and exchange large amounts of personal information and users are able to customise their phones to suit their personal preferences and needs. A smartphone can record a large number of details about its user’s current status and whereabouts. It can relay appropriate social support and enable real-time and asynchronous exchanges with other users via social networks and other forms of mobile communications. The latter include text messaging (Short Message Service—SMS), photography (still and video), location and other sensors (global positioning system [GPS], accelerometers, ambient light sensor, etc.), built-in applications or apps (e-mail, contacts, calendar, document readers and video players, etc.) and wireless data service. (‘App’, short for ‘application (program)’, refers to a self-contained piece of software coded for a specific purpose and usually optimised to run on a mobile device.)

Because they’re accessible to patients both at home and on-the-go, health apps are a part of the movement towards mobile health (mHealth) programs in health care. There are many varieties of health apps available for purchase from app stores. Some are designed to help consumers make healthier choices in their everyday life by offering advice about fitness or nutrition. Others help doctors and patients communicate from afar, like apps for diabetics that automatically sent glucose readings to their primary care physicians. Some apps are aimed at physicians themselves—many apps combine mHealth with electronic medical records (EMR), allowing doctors to keep accurate records that are easily accessible.

The mobile revolution is offering an unprecedented opportunity to provide medical support when and where people need it. Large numbers and varieties of medical and health-related apps exist on the market today.

Apps for medical providers
Many apps are developed for a target audience of healthcare workers, including physicians, nurses and assistants. These apps are generally more sophisticated, with medical terminology and functions, and not easily navigable by non-health professionals. The top apps were drug-reference guides such as ‘Epocrates’ (Epocrates, Inc.) and ‘Lexicomp’ (Wolters Kluwer), as well as clinical decision-support reference tools such as ‘UpToDate’ (Wolters Kluwer) and ‘Medscape’ (WebMD LLC).

Specialty or disease-specific apps

Though some apps cover a broad spectrum of general medical knowledge, others may be tailored to specific specialties such as colorectal disease-themed apps in gastroenterology or goniometer apps in orthopaedics. The ‘Eye Handbook’ (developed at the University of Missouri Kansas City, USA) is a free ophthalmology-themed app offering mobile diagnostic visual tests, a user directory of eye-care professionals, ophthalmology specific calculations, ICD-9 codes and an atlas of common ophthalmic conditions. The field of infectious disease may particularly benefit from the rapid updates of apps which provide news and updates in real time. ‘Outbreaks Near Me’ (developed at Boston Children’s Hospital, USA) utilises news media reports, medical e-mail list services and alerts from official national and international organisations to monitor global infectious diseases via the ‘HealthMap’ database.

Medical education and teaching
The younger generation of technologically capable medical professionals in training, such as students and residents, harness the power of innovative apps to improve learning. The mobility of a smartphone or tablet allows students to carry a plethora of clinical resources in a convenient and searchable package. The flexibility of the mobile platform provides interactivity in teaching and a more personalised education. Given the high rate of mobile technology adoption among young clinicians, mobile applications display great potential to augment traditional training. ‘Bump’ (Bump Technologies, Inc.), a mobile app that transfers information between two mobile devices when put in very close proximity together, demonstrated enhancement of pharmacy student learning and communication in patient simulation scenarios. For new trainee doctors, a mobile app, which functioned as a portable electronic library, provided a wealth of information when senior or attending physicians were not available and thus enhanced patient care. German physicians adapted the German College of General Practitioners and Family Physicians practice guidelines into an easily accessible app for physicians and medical students. Flashcard and subject review applications, such as ‘Microbiology and Immunology Wiz’ (Current Clinical Strategies Publishing) or ‘Lange Microbiology & Infectious Diseases Flash Cards’ (Modality Inc.), allow for portable and customisable education for medical students. When provided with access to smartphones, physicians effectively utilised several point-of-care mobile applications in delivering healthcare in a resource-limited setting.

Apps for patients and the general public (including health and fitness apps)
On the other end of the spectrum, there are patient-centred apps capable of performing an equally wide array of functions. Current apps aid patients in managing chronic disease, lifestyle management, smoking cessation and even self-diagnosis.

The diabetes mellitus epidemic is reflected in the number of apps geared towards diabetic patients. On the Android platform alone, over 80 diabetes apps offer a variety of functions, including self-monitoring blood glucose recording, medication or insulin logs, and prandial insulin dose calculators. Another diabetes intervention app integrated communication between patients and a healthcare provider. The patient would log fasting blood sugars, daily eating behaviours, medication compliance, physical activity and emotions into a mobile online diary. A remote therapist with access to these diaries would then formulate personalised feedback to the patient.

The most number of apps belong to the exercise and weight loss category. The built-in camera, standard in smartphones today, allows users to record a photo diary of daily food and drink. These photos may be transferred to a server, which identifies and quantifies the food portion. A weight loss trial utilised a mobile app to monitor dietary intake, body weight and objectively-measured physical activity (obtained from a Bluetooth-enabled accelerometer) of its participants.

Apps are also developed for smoking cessation and alcohol addiction. At least 47 iPhone apps for smoking cessation are available. ‘A-CHESS’ (Alcohol Comprehensive Health Enhancement Support System), a smartphone-based intervention for preventing relapse in alcoholic dependency harnesses mobile technology to improve treatment and motivation.

In patients with chronic disease characterised by life-threatening flares, apps may allow them to track and even report symptoms. The app ‘m.Carat’ was developed at Faculdade de Medicina da Universidade do Porto, Portugal, for asthmatic and allergic rhinitis patients to record their exacerbations, triggers, symptoms, medications, lung function tests and visits to the doctor or the hospital. Users can also receive disease education, medication information, task notifications, and synchronise records with an online database to better control their symptoms.

Psychiatric patients benefit from ambulatory monitoring through an app that randomly prompts the patient to self-report psychotic symptoms multiple times throughout the day. Another app for sickle cell disease patients allows them to access an online diary to record pain and other symptoms. Monitoring symptoms in patients with COPD (chronic obstructive pulmonary disease) through a mobile app alerts patients and providers to suspected disease exacerbations, thereby facilitating prompt intervention.

An app developed for patients with dementia, ‘iWander’, assists patients with daily living by providing audible prompts offering to direct the patient home, sending notifications and GPS coordinates to caretakers, or by calling local emergency services.

Patients may even use apps to attempt self-diagnosis without a medical visit. Patients with a camera-enabled smartphone can use apps to take photographs of skin lesions and send these to a remote server for computer analysis and/or review by a board certified dermatologist. Such apps are not without their pitfalls and this will be discussed in detail later in this paper.

Apps may empower non-medical professionals to provide basic triage at the scene of trauma such as on the sidelines of a sporting event. An app development team with a neurosurgeon among its members created ‘Concussion Test’, which follows the standardised and validated Sport Concussion Assessment Tool 2 (SCAT2). Five similar concussion apps exist for purchase as well.

Mobile app technology has far-reaching potential in the public health domain as well. Apps may be used to contribute to the care and prevention of sexually transmitted disease (STD).

Text messaging
Text messaging, or Short Message Service (SMS), dates back to the early days of mobile phones, and most applications worked equally well on the simplest mobile phones, the more advanced feature phones, as well as full-fledged smartphones. Text messaging reminder applications are easy to implement with tools such as InSTEDD’s ‘Remindem’ (free and open source). Due to the pervasive nature of the mobile phone, text-messaging applications have the unique opportunity to alert patients directly regardless of location (or availability to take a voice call).

Evaluation of text messaging shows promising results for assisting with clinical monitoring and counselling, keeping medical appointments, smoking cessation, weight loss, chronic disease management (e.g., diabetes care monitoring), or reminding people to use sun protection to prevent sunburns in the near term and skin cancer in the long term. Adherence to therapy and disease control may be improved in psoriasis patients who receive daily educational and motivational text messages. Text message reminders to patients may also improve antibiotic compliance or even prevent recurrent cardiovascular events.

On the one hand, text messaging provides nearly universal user access, particularly in low-resource settings, with decreasing costs, simple interventions to develop and use, customisable content and schedule, and a push-mode delivery that prompts users to read and possibly respond. On the other hand, text messaging offers limited interaction, with often only passive engagement, and does not leverage the latest smartphone computing power.

Electronic health records
Mobile apps may also provide access to electronic health records and patient information. Kharrazi et al. mention 19 apps that allow patients to store personal health records on their mobile devices. ‘HealthVault’ (Microsoft) acts as a platform for personal health data, including data from personal health monitoring and fitness devices, putting consumers in control of their health information, with the ability to securely share it with clinicians, caregivers, family members, or others, as needed. ‘DocbookMD’, an app meeting HIPAA (US Health Insurance Portability and Accountability Act) encryption and security requirements, allows physicians to easily transmit text messages and images to one another.

Telemedicine and telehealthcare
The implementation of telemedicine and telehealthcare (including clinical telemonitoring of patients) through the application of mobile devices is clearly a practical and potentially low-cost choice in the delivery of healthcare, as seen, for example, in the mobile component of the CAALYX/eCAALYX (Complete Ambient Assisted Living Experiment/Enhanced Complete Ambient Assisted Living Experiment) prototype systems.

Several applications have been described that harness mobile devices and apps to increase efficiency and access to care, particularly in emergency situations. When time is of the essence, apps can increase speed and accessibility to critical specialist care in real time, e.g., in stroke or acute trauma.

Pros and Cons
Many frequent users of wellness and fitness apps are becoming increasingly dependent on this technology to give them information on their health. Certain apps echo popular websites like WebMD or Healthline, which offer information about different symptoms and illnesses but aren’t necessarily capable of accurately diagnosing patients — and certainly aren’t as qualified as clinicians. Regardless, many users rely on these websites and apps rather than seeking professional help, which is far from ideal: A 2015 study from Harvard Medical School and the RAND Corporation found that of the top 23 online symptom checkers, correct diagnoses were listed first in only 34% of standardized patient evaluations. Further, these symptom checkers listed the correct diagnosis within the top 20 possible diagnoses in only 58% of standardized patient evaluations.

Despite the drawbacks, health and fitness apps are far from being the worst technology on the market. A 2015 study including 726 participants showed that current users of fitness apps were 27% more likely to self-report being active than participants who did not use fitness apps. Participants who used fitness apps were also more likely to use their leisure time in a health-oriented way and overall had a lower body mass index (BMI) than the other participants. Regardless of whether or not these apps are entirely accurate, they do give users incentive to make positive lifestyle changes.

If patients mention using a health or fitness app, don’t discourage them from doing so — but make sure that they’re aware of its limitations. Should you recommend health apps to your patients? Maybe not yet — the technology is not quite as reliable as it could be, but in a few years, these apps could become the standard first step for diagnosing and monitoring patient health.