mHealth Not App-ropriate for Some Patients

There it was, in black and white, a bold proclamation of ingenuity and innovation.

“Instant Blood Pressure,” blared a banner title in the Health & Fitness section of Apple’s voluminous app store. “Monitor Blood Pressure Using Only Your iPhone.”

Iltifat Husain, M.D., could hardly contain his intrigue. Eight years ago, while still a medical student, Husain founded iMedicalApps.com, an online publication for medical professionals interested in mobile medtech and healthcare-related apps, and co-founded iPrescribeApps.com, a platform that will eventually enable providers to prescribe health apps to patients. He currently juggles his role as iMedicalApps’ editor-in-chief with his duties as a mobile medical apps speaker and CEO of Decision Point Informatics LLC, developer of mobile, point-of-care evidence-based decision support to clinicians. Before assuming the top post at DPI, Husain was an assistant professor of emergency medicine and director of mobile app curriculum for two years at Wake Forest University School of Medicine.

Suffice to say, Husain knows a thing or two about medical apps.

Obviously, Husain was drawn to the app for its futuristic-sounding technological capability (think “Star Trek” medical tricorder). But he was also curious about its placement in the online store, as it was prominently displayed in both the top 10 “Paid” and “Top Grossing” sections.

Husain immediately downloaded the app, aiming to satisfy his curiosity and discover whether the program’s pie-in-the-sky promise was based in science fact or fiction. It proved to be the latter—it was an app created solely for entertainment rather than clinical purposes.

“How does an app make it into the top 10 paid section, competing among the likes of ‘Fitness Buddy,’ ‘7 minute workout challenge’—and apps that even Apple has pushed from a fitness standpoint—all while explaining it will measure your blood pressure in a few paragraphs, and then at the end, give a line saying it’s ‘for entertainment purposes?’ ” Husain asked metaphorically in a July 2014 iMedicalApps review. “When I first saw this app, I was terrified. I practice medicine in the Emergency Room. I see what poor blood pressure management does on a daily basis. Blood pressure management is not a game. This is real life. This is not ‘entertainment.’ My formal recommendation is for this app to be removed from the iTunes store. If [an] app…can’t do what the title states it can do—then it shouldn’t be available to download.”

Perhaps not, but the instant blood pressure app is hardly the only mobile health program to overstate its purpose. A recent study published late last year in Health Affairs concluded that many mHealth apps fail to help their intended audience. The study was based on a comprehensive review of 137 highly rated or often-recommended mHealth apps in the Apple or Google stores that target chronic conditions like asthma, arthritis, diabetes, hypertension, depression, lung disease, liver disease, kidney disease, heart failure, and addiction to drugs, alcohol, or tobacco. Researchers also scrutinized apps designed for stroke and cancer survivors, dementia/memory loss patients, chronic pain sufferers, and obese folks.

“Clearly there is a large-scale proliferation of apps happening related to health, and people have made the switch over to smartphones,” noted Karandeep Singh, M.D., an assistant professor of learning health sciences at the University of Michigan Medical School who teamed with Brigham and Women’s Hospital investigators for the study. “But the question is, to what extent are apps serving the needs of patients with chronic diseases, and their caregivers, as opposed to generally healthy people seeking help with wellness?”

Not very well, according to the study results. Only half of the apps designed for asthma, stroke, and elderly patients responded appropriately to dangerous levels entered by users, researchers reported. Also, nearly all the apps critiqued (121) allowed people to input data about their daily health (i.e., blood sugar levels, blood pressure, suicidal thoughts) but only 28 of the programs responded appropriately to dangerous values such as high blood pressure readings, low blood sugar levels, or suicidal moods.

Other key findings of the study:

• Many apps offer tracking functions, education, reminders, and alerts that are useful to high-need, high-cost patients, who often face social and economic barriers to healthcare, and have complex medical needs. But few mHealth programs provide tailored guidance based on the data users provide to the tracking interface, or offer ongoing engagement that rewards “good” results.
• There are a wide range of apps available for some conditions (diabetics and depression), but very few for others (chronic pain and arthritis). Puzzling, considering there are more than 165,000 mHealth applications available to smartphone users.
• App store ratings, supplied by other users, are not always a reliable guide, even with highly rated apps. Researchers found that doctors and others on their evaluation team often rated apps much higher, or lower, than the online store ratings based on the apps’ usability or patient usefulness.

“We found that the consumer-generated rating on the app store is a very poor marker of how usable an app is, and whether a physician would recommend it. Clearly, the work is not done once consumers have rated an app,” Singh said. “Going forward, we need to evaluate apps on the basis of what it would take for physicians, and organizations that issue clinical guidelines, to start recommending them to patients.”