How to integrate health apps at the point of care

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They track caloric intake, sleep, and daily steps. They educate patients about their conditions and medications. They coach patients to self-manage their anxiety, depression, diabetes, and pain … and so much more. We’re talking about the thousands of consumer health apps available on app stores today. 

Experts agree that these apps foster consumer empowerment that may even translate to better outcomes and lower costs, both of which can help physicians gain points under the Merit-based Incentive Payment System (MIPS). Some apps-those that capture physiologic data-may also help physicians generate revenue for reviewing the data that’s captured.

Another reason to keep these apps on the radar? Consumers want them. A September 2018  report from the consulting firm PwC found that 54 percent of surveyed consumers would be open to trying an FDA-approved digital app or online tool to treat their medical condition.

This raises an important question: Should physicians recommend these apps to their patients, particularly in an era of value-based reimbursement? 

Definitely, says Niko Skievaski, co-founder and president of Redox, a healthcare data standardization company in Madison, Wisc. “Providers need to be the ones saying that one app is better for patients than another in the same way they’d say one medication is better than another,” he adds. “They need to think about apps as therapeutic interventions.”

Frederic S. Goldstein, president and founder of Accountable Health, LLC, a population health management company in Jacksonville, Fla. agrees. “The time between office visits is where the action happens,” he says, adding that many consumer health and wellness apps help fill these gaps using reminders, prompts, and coaching. “These are all intervention efforts to potentially correct a behavior before it gets bad enough to require treatment.”

Consumer health and wellness apps are also important because they enable data-informed conversations between patients and physicians, says Jan Oldenburg, principal at Participatory Health, a patient engagement consulting company in Richmond, Va. “This data can help physicians and patients make more of an impact during the limited time they have during face-to-face visits,” she adds.

Physician adoption on the rise

Given the benefits, are physicians starting to recommend these apps at the point of care? Yes, according to the PwC report. Fifty-six percent of physicians said they’ve initiated discussion about an app or digital program during a conversation with a patient. Twenty-six percent said a patient initiated the discussion.

More physicians don’t initiate these conversations because the quality of the apps varies tremendously, says Yauheni Solad, MD, internist and medical director of digital health and telemedicine at Yale New Haven Health System in New Haven, Conn. “We want to make sure that when clinicians recommend these apps during the clinical encounter, they have a clear understanding of the app’s effectiveness,” he says. “Physicians should avoid apps with low-quality content and inappropriate data handling, and we need to guide them in making this choice,” he adds. 

Yale New Haven pays for access to a digital platform that allows physicians to prescribe apps that have been clinically validated and assessed for their value to the patient. Patients receive a text message with a URL link to download the app. The platform also includes a physician-facing dashboard that aggregates data from all apps into a single view for each patient, making it easier to manage individuals using different apps to manage multiple chronic conditions.

However, this type of platform may be cost-prohibitive for small independent practices, meaning these physicians often must sort through the endless sea of apps on their own trying to identify which ones are clinically effective and worthwhile. There are also other challenges, most notably that many apps are not integrated with EHRs, meaning it may be difficult to glean useful information from the data that’s collected.

Using and recommending consumer health apps

Fortunately, there are several steps physicians can take to make the task of selecting, recommending, and using apps at the point of care less daunting. Consider these seven steps.

1/Narrow the list of potential apps.

 Experts share these questions to consider:

• What behavior do you want to change? Are there any apps that can help? For example, do you have a lot of patients with diabetes who need help managing their diet, exercise, or medications? There are many apps available to help patients with each of these tasks, one of which is provided by the American Diabetes Association. Other associations may provide similar apps targeting a chronic condition.

• What information do you typically ask patients to track and share? Is there an app that captures this information digitally?

• What MIPS quality measures do you report? What quality metrics are included in your value-based payer contracts? What apps are available to target these conditions?

• What apps are your colleagues and larger health systems using? Have any of these apps helped patients achieve better outcomes?

2/ Assess the efficacy of the app.

Did the app developer solicit physician input, and can you rely on the accuracy of the content? Physicians should download the app first to get a sense of whether it’s clinically sound and something patients will use, says Ashish Atreja, MD, MPH, FACP, chief strategy officer at Rx.Health, a platform for prescribing curated apps and digital therapeutics. Is it easy to set up an account? And read user feedback and reviews. Do patients find the app valuable, and does it help them improve their health?  

“A lot of these app developers are small companies looking to gain traction,” says Skievaski. “They’re very approachable. Email them or call them, and ask them to convince you that it’s going to work for your patients.” He also suggests that physicians look to see whether any medical journals have published clinical studies about the app, he adds.

Studies published in medical journals hold more weight than those published by the app developers themselves, says Atreja. That’s because developer-sponsored studies rarely use randomized controlled trials, and tend to focus on small sample sizes of individuals who are already healthy, he says. A January 2019 study  published in Health Affairs found this to be true as well.

3/Determine whether the app will integrate with your EHR.

Integration allows providers to make use of continuous monitoring and predictive analytics, says Solad. Although EHR vendors are increasingly working with app developers to enable interfaces that allow for seamless data transmission, the majority of apps currently do not integrate, he adds. However, if a physician is passionate about using a particular app, Solad suggests asking the developer whether it would consider working with the EHR vendor to enable integration. Developers may be willing to do so if it means they can expand their user base, Soldad says. 

Integration may also present revenue opportunities for certain apps-particularly those that measure physiologic data and are FDA-approved. When using these apps, providers may be able to report CPT code 99091, for which Medicare pays approximately $59. However, providers should find out whether their local Medicare and Medicaid administrative contractors and commercial payers will pay this code for the review of consumer app-derived physiologic data before they try to bill it, says Michael Warner, DO, CPC, a national advisory board member of AAPC, a training and credentialing organization for the business of healthcare in Salt Lake City, Utah. CPT code 99091 is reportable once per patient every 30 days provided that the physician reviews appropriate data every 30 days and spends at least 30 minutes reviewing, interpreting, and responding to the data, says Warner.

Even if the app doesn’t have an interface with your EHR, it may have a dashboard that aggregates and presents the data in a meaningful way-and this may be as useful as integration in some cases, says Oldenburg. “In fact, it’s really important that the app aggregates information and presents trends visually because it helps both patients and physicians see trends and harvest learnings,” she adds.

Physicians should also keep in mind that not every app may be well-suited for integration, says Steven E. Waldren, MD, MS, vice president and chief medical informatics officer at the American Academy of Family Physicians. For example, physicians may want to integrate an app that’s tied to an FDA-approved glucometer but not necessarily one that simply tracks exercise. Glucometer readings can inform medical decision-making when tied to specific alerts for data that falls outside of set parameters, he adds. Exercise data, on the other hand, wouldn’t necessarily trigger a clinical intervention.

4/ Determine whether there’s a cost for using the app. 

Keep in mind that patient adoption may be lower for apps that aren’t free to use, says Atreja.

5/ Review the developer’s data handling policy. 

Does it even have a policy? “There are unfortunately malicious entities out there who are putting applications together just to collect name, date of birth, and other information,” says Waldren. “These details are pretty valuable on the black market.” Look for answers to these questions: What data can the app access after patients download it? Some apps may be able to access phone and email contacts, call logs, calendar data, data about the device’s location, and more. What will the developer do with that data? This information can often be found in the “app permissions” under the details, or in the apps privacy policies.

6/ Engage patients to use the apps. 

Oldenburg suggests starting with a handful of patients who already use apps. “Tell them, ‘I’m using this app, and I’d love to see what you think of it. I’d like you to send me a note in a couple of weeks to let me know how it’s going,’” she says. As these individuals see positive results, share their stories with other patients to motivate them, she adds.

Ask medical assistants to help patients download the app while they’re still in the care setting, says Skievaski. This helps ensure follow through, and it demonstrates that the physician values the app because they’re willing to devote resources to help ensure patients’ success.

7/ Integrate the app into the clinical workflow. 

There are several ways in which physicians can integrate a consumer health app into their workflow. If the app doesn’t already integrate with the EHR, consider asking patients to simply open the app on their mobile device at the time of the visit, says Solad. A nurse or medical assistant can review the most recent data (or look at the dashboard if the app includes one) before the physician enters the exam room and then enter that data into the EHR, says Atreja. Another idea is to review the data when care coordinators contact patients receiving chronic care management services. 

Think outside the box

Although validation is important, it shouldn’t necessarily preclude physicians from trying the app with their patients to achieve better outcomes, she adds. “You don’t need to be super scientific,” she says. Start recommending an app, and then track the results of the people who are using the app versus those who aren’t. Are you starting to see some results?”

Remember to gather feedback from ^­patients. Do patients like the app? Do they use it consistently? Does it help them manage their condition? “The app development community is very iterative,” says Skievaski. “It releases something and then relies on feedback from users and providers. This is where physicians can actually make a difference so these products provide value back to patients.”