A Renaissance in Mobile Computing – It was only seven years ago when Apple released its first iPhone. Little did we know that Apple’s product launch would catalyze a renaissance in mobile computing, transform how we conduct business, impact our everyday lives and even alter the way we deliver health care. Now it’s all happening, and happening fast. With Apple’s recent announcement of “HealthKit,” developers can employ a single platform to allow health and fitness applications (apps) to exchange data with each other and with electronic health records (EHRs). Advances like HealthKit and Google’s “Fit” will further accelerate development of mobile health (mHealth) apps, both for GI patients and beyond.
Current State of mHealth Apps – As of late 2013, there was a dizzying array of more than 44,000 mHealth apps available on the Apple iTunes store.1 Most of these apps fall within the “health and wellness” category, allowing users to monitor mood, diet, sleep, energy levels and other quality of life attributes. Some apps allow patients to find doctors, others offer health information, and still others attempt to make diagnoses.
For a consumer reviewing the mHealth marketplace, there is little guidance regarding which of these apps are best, which are supported by data or which provide true value. The IMS Institute for Healthcare Informatics evaluated each of the apps on the market and concluded that well over 90 percent were of low quality.1 Within the limited group of quality apps, only a small sub-group was supported by peer-reviewed data of any kind, much less randomized controlled trials. In short, although enthusiasm for mHealth is boiling over, the level of evidence does not match the level of excitement.
A multinational working group recently published recommendations for how to move the mHealth field from mere curiosity to serious science.2 The group emphasized that before mHealth apps can truly impact population health, developers must address the high attrition rate of users, the persistent “digital divide” between younger versus older patients, and the reality that an app is unlikely, unto itself, to alter health behavior in a sustained and clinically meaningful way without clinical support and tailored guidance. The Agency for Healthcare Research and Quality (AHRQ) also published guidance on how to develop mHealth apps.3 AHRQ emphasizes that apps should be developed by multidisciplinary experts in cognitive science, computer science and social science; be continuously tested in partnership with patients; and fit specific needs of end users — not perceived needs presupposed by developers and academicians. All too often, teams unaware of the conceptual frameworks underlying app development hastily develop their products and rush to market. Sometimes academicians predetermine what patients want without first checking, or create user experiences without diligently consulting the users themselves. This “just get it out” mentality has undermined the field.
Examples of High Quality mHealth Apps – In its landscape review of mHealth, IMS identified several apps that met its predefined criteria for high quality.1 In the category of diagnostic apps, IMS points to iTriage as a model for evaluation. iTriage collects signs and symptoms, crunches the input through algorithms, yields a differential diagnosis, and suggests an action plan and list of appropriate local providers. “Virtual visit” apps like HealthTap, Teladoc, American Well and MDLive go a step further by offering patients direct and immediate access to a physician through their smartphone or tablet device. For $49 on average, physicians can conduct a virtual face-to-face interview, make a diagnosis and even send prescriptions. The app “Pager” goes yet a step further. Founded by the team that developed Uber — the wildly successful car service app — Pager allows patients to select among a panel of doctors and obtain rapid house calls for $199. Insurance is now starting to cover some of the virtual visits and app-generated house calls. These disruptive e-consult apps physically disintermediate patients and providers, allowing care to occur outside the physical walls of health-care facilities. Now we need rigorous data to learn whether these apps improve outcomes, reduce cost and ultimately provide value.
GI mHealth Apps – Despite the high prevalence of GI disorders, there are relatively few mHealth apps to support our patients. Most of the available GI apps offer information or symptom tracking, such as the “GI Buddy” by the Crohn’s and Colitis Foundation of America, “GI Bodyguard” from the Canadian Digestive Health Foundation, “Gut Tracker” by the Digestive Disorder Foundation, or the International Foundation for Functional GI Disorders mobile app, among others. Our teams at Cedars-Sinai partnered with the University of Michigan to develop an app called “MyGiHealth”4 that allows patients to rate their own symptoms using e-scores we developed for NIH,5 ties the scores to a tailored online “education prescription,” and allows patients to convert their symptoms into a full narrative history of presenting illness (HPI)6 that can be uploaded to an EHR. We are now collaborating with EHR vendors to evaluate how the app might integrate with health records to improve processes and outcomes of care, and are conducting an NIH-supported trial of the app in GI clinics.
Conclusions – Although mHealth apps are pervasive and here to stay, there remains substantial work to determine which apps to use, how to use them and whether they will truly impact outcomes of care in GI and beyond. To advance the field, we need rigorous research, partnership with patients and multidisciplinary teamwork. GI societies should fund this work to expand the offerings for our patients while ensuring high-quality products. Time will tell whether the current enthusiasm is justified, or whether this “e-wave of the future” has crashed.
– Commentary by Dr. Brennan Spiegel