Wrestling with Recommendations on Mobile Health Apps

You know the scenario. A patient walks into your office, announces the arrival of their new smart phone, and asks, “What healthcare app should I download?” Or, “My FitBit shows I’m not sleeping well at 3 a.m. What does that mean?”

Before you answer, consider the dichotomy raised by Morgan Reed, executive director of ACT—The App Association, which represents more than 5,000 software companies in the mobile ecosystem.

“Wellness apps don’t get into the HIPAA area,” Reed explains. “And it becomes a question of reimbursement. How do I make a recommendation, and how do I get reimbursed for it?”

It is indeed a conundrum for physicians.

Exploding Area

If you’ve wrestled with the above questions, you’re not alone. According to a Manhattan Research survey, while many physicians recognize the potential of mobile health apps to improve patient care, they’re also uncertain as to which ones to recommend.

“This has been a fascinating and high-speed moving area,” Reed says.

But, where physician decisions are concerned, maybe not fast enough. Physicians responding to the Manhattan Research survey indicated a dearth of published evidence of the clinical effectiveness of mobile health apps as part of the hesitancy to recommend one app over another.

“The problem has been this odd mix of examples and anecdotes, and the speed at which these things are being used,” Reed says. “But you haven’t seen the kind of lengthy double-blind studies you might need. Plus, the reality is the apps themselves change pretty quickly. The bad news of that is it’s hard to do a good study when the application might iterate 5 times during the study.”

Alex Kutikov, MD, FACS, a urologic surgeon with Fox Chase Cancer Center, has experienced this first hand. Kutikov is involved with Visible Health, which produces apps for physicians to use at the point of care to simplify complex concepts to patients.

“We’ve discussed trials,” Kutikov says. “But there are such challenges to small companies trying to make it in the digital health space, and doing a trial and study doesn’t get them where they want to go. When there’s a clear benefit and it just helps somebody communicate something to a patient, then there’s less incentive to do a trial.”

Liability Issues

Imagine you’ve recommended a mobile health app to a patient, and part of the app’s regimen for maintaining health and fitness is for patients to walk, or take a specific number of steps every day. But if you’ve neglected to note that this patient has a hip problem by decreasing the number of steps recommended by the app, are you responsible for any injury that might occur?

“Am I liable if I don’t look at reams and reams of information about how many footsteps Mrs. Jones took?” Reed questions. “Questions like that arise where the physician may want to recommend an app, believe it has good use for their patient, but can’t imagine devoting the time to read through all the information.”

Kutikov says, at least to some extent, it’s an issue of content fidelity; making sure the content on an app is up to date. “You can write an explanation of a disease process, and then a study comes out and everything you wrote last month is obsolete. That happens in medicine every day.” And staying current is likely to become more challenging.

“Patients are using more of these devices, more wearables, and the sensors that are part of these devices are only going to get more sophisticated and more accomplished,” Reed says.

Tackling the Challenges

Reed suggests that in considering what health apps to recommend to patients, physicians need to look beyond the iTunes store and consider the recommendations of other physicians. In addition, if you recommend an app, take the time to make certain it has a privacy policy that’s easily understandable.

“Even though it doesn’t need to deal with HIPAA, it’s a good idea to know what kind of information that app is collecting on your patient,” he says.

Next consider the data that the app is compiling. Is it a good, visual representation of what you need to know? And perhaps most importantly, think of your patient and the apps usability.

“Just as you have compliance issues with medications, you could have compliance issues with apps,” Reed says. “Ones that confusing or hard to use, don’t gravitate toward one just because it’s medical. Your patients won’t use it. User interface is almost more critical in this space than anywhere else.”

Kutikov seconds those thoughts.

“The app store is a graveyard of sophisticated and sometimes well-intentioned apps that just didn’t get clinical traction,” he says. “If it makes a physician’s job harder, nobody is going to use it.”