chronic diseases: an app a day

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Managing Chronic Diseases: An App a Day? Iris Thiele Isip Tan MD, MSc @endocrine_witch #HealthXPh Chief, University of the Philippines Medical Informatics Unit Associate Professor, University of the Philippines College of Medicine Tuesday, May 6, 14

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Presentation at the World Congress on Cardiology in Melbourne, Australia

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Page 1: Chronic Diseases: An App A Day

Managing Chronic Diseases: An App a Day?Iris Thiele Isip Tan MD, MSc @endocrine_witch #HealthXPh Chief, University of the Philippines Medical Informatics UnitAssociate Professor, University of the Philippines College of Medicine

Tuesday, May 6, 14

Page 2: Chronic Diseases: An App A Day

Disclosure Statement of Financial InterestI, Iris Thiele Isip Tan DO NOT have a financial interest/arrangement or affiliation with any healthcare related companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Tuesday, May 6, 14

Page 3: Chronic Diseases: An App A Day

“Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the leading causes of mortality in the world, representing 60% of all deaths.

These diseases are preventable.

Up to 80% of heart disease, stroke and type 2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors, mainly tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol.

World Health Organization

Tuesday, May 6, 14

Page 4: Chronic Diseases: An App A Day

There’s an app for that!

Which app?

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Apps (un)regulated

The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8

App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt

Tuesday, May 6, 14

Page 5: Chronic Diseases: An App A Day

There’s an app for that!

Which app?

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Apps (un)regulated

The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8

App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt

Tuesday, May 6, 14

Page 6: Chronic Diseases: An App A Day

Clinical uses for a medical

app

REFERENCE

Clinician centered

Patient centered

EDUCATION

Disease reference

Clinical reference

Drug reference

Medical literature

EHR & electronic

prescribing

Productivity

Communication

Medical calculator

Health promotion

Patient communication

Health tracking

Medication reminder

General medical education

Specialistmedical education

Formal continuing

medical education

Patienteducation

Fig 1 from Aungst TD et al. Int J Clin Pract 2014;68:141-2.

Tuesday, May 6, 14

Page 7: Chronic Diseases: An App A Day

There’s an App for That: Content Analysis of Paid Health and Fitness AppsWest JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett JJ Med Internet Res 2012;14(3):e72

n = 5430Apps: Health and Fitness category

n = 1324Free apps(Excluded)

n = 338Non-English apps(Excluded)

n = 432Miscategorized into Health & Fitness category(Excluded)

n = 3336Final study sample

1

2

3

Assess credibility vs price

Categorize content according to Health Education Curriculum Analysis Tool (HECAT)

Categorize content according to Precede-Proceed Model (PPM)

Tuesday, May 6, 14

Page 8: Chronic Diseases: An App A Day

Predisposing FactorsAntecedents to behavior, such as knowledge, attitude, beliefs, values, and confidence or motivation.

Enabling FactorsAntecedents to facilitate behavior change such as teaching skills, providing a service, or tracking progress.

Reinforcing FactorsFactors that provide a reward or feedback for behavior, such as interaction with family, friends (social networks), or health professionals (trainer).

Specific behavior by individuals

Health

Fig 1 from West JH et al. J Med Internet Res 2012;14(3):e72Adapted from Precede-Proceed Model for health promotion planning and evaluation by Green & Kautner

Causal relationship of Precede-Proceed Model

factors influencing behavior and health

APPScan address one or more of these factors

Tuesday, May 6, 14

Page 9: Chronic Diseases: An App A Day

App credibility by priceWest JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett JJ Med Internet Res 2012;14(3):e72

This is an app intended to promote health or prevent disease

This app is credible or trustworthy

As a health care professional, I would use this app for my personal use or recommend it for use by one of my clients

0 500 1000 1500 2000

$0.99>$0.99

No. of apps

*

*

*

* p <0.001

Tuesday, May 6, 14

Page 10: Chronic Diseases: An App A Day

Apps by HECAT content areaApps could be coded in multiple categories

West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett JJ Med Internet Res 2012;14(3):e72

Physical ActivityPersonal health & wellness

Healthy eatingMental & emotional health

Sexual & reproductive healthAlcohol, tobacco & other drugs

Violence prevention & safety0 200 400 600 800 1000 1200

No. of apps

33.2%

28.8%

19.5%

12.4%

7.3%

3.9%

2.9%

Tuesday, May 6, 14

Page 11: Chronic Diseases: An App A Day

Apps by HECAT content areaApps could be coded in multiple categories

West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett JJ Med Internet Res 2012;14(3):e72

0

300

600

900

1200

Physical Activity

No.

Workouts, tips, ideas

Monitors, measurement of workouts, logs, automatic recordings

0

300

600

900

1200

Personal health & wellness

Complementary & alternative medicine

Sleep

Remedies/medications/prescriptions

Disease/illness specific information

0

300

600

900

1200

Healthy eating

Nutritional breakdown of food

Calorie counters, journals, logs

Healthy diet – specific information

Healthy recipes & cooking tips

Tuesday, May 6, 14

Page 12: Chronic Diseases: An App A Day

Apps by Precede-Proceed ModelApps could be coded in multiple categories

West JH et al J Med Internet Res 2012;14(3):e72

0

1000

2000

3000

Predisposing

No.

Informative

Knowledge or awareness

0

1000

2000

3000

Enabling

Provide a service or sell something

0

1000

2000

3000

Reinforcing

Interfacing with social networking sites for encouragement

Beliefs, values, attitudes

Confidence or motivation

Track/record behavior

Teach a skill

Evaluation based upon self-monitoring

Encouragement, trainer support, coach

Predisposing + Enabling + Reinforcing n = 62

n = 1776 n = 2181 n = 222

Tuesday, May 6, 14

Page 13: Chronic Diseases: An App A Day

40,000+ healthcare apps on US Apple iTunes app store

Mostly diet and exercise apps

Skew in download volume>50% of apps achieving < 500 downloads

5 apps account for 15% of all downloads

Tuesday, May 6, 14

Page 14: Chronic Diseases: An App A Day

Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013

n = 43,689 appsHealthcare & Fitness or Medical

n = 20,007Miscategorized or only loosely health related

n = 23,682Genuine healthcare related

1

2

3

App categorization

IMS Health functionality scoring system

Apps placement on the patient journey

n = 16,275Consumer oriented

n = 7,407Healthcare professional oriented

Tuesday, May 6, 14

Page 15: Chronic Diseases: An App A Day

Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013

App categorization by functionality

INFORMProvide

information in a variety of formats (text, photo, video)

INSTRUCTProvide

instructions to user

RECORDCapture user entered data

DISPLAYGraphically display user

entered data/output user entered data

GUIDEProvide guidance

based on user entered information; recommend consult

REMIND/ALERTProvide

reminders to the user

COMMUNICATEProvide

communication with HCP/patients;

provide links to social networks

Tuesday, May 6, 14

Page 16: Chronic Diseases: An App A Day

InformInstructRecordDisplay

GuideRemind/alert

Communicate

Individual Functionality Multi-functionality

Less than 1/2 of apps which provide information also provide instructions

Approx 1/5 of apps which provide information also track/capture user data

Information Inform + Instruct

Information Inform + Record

Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013

Tuesday, May 6, 14

Page 17: Chronic Diseases: An App A Day

Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013

159 apps link to sensors<50 apps relate to actual condition management; provide tools and calculators for users to measure their vitals

Mostly fitness and weight apps: monitor pulse rates when exercising & measure body weight and BMI

Patient uses app to collect health data either by choice or on physician recommendation

Patient can transmit data to physician or take phone along to appt to show physician

Patient and physician together evaluate the data

Necessary interventions made; behavioral or medication changes

Collect data Share data Evaluate data InterveneTuesday, May 6, 14

Page 18: Chronic Diseases: An App A Day

Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013

Number of apps

Functionality score

25 individual criteriaWeights specific to category of app

Maximum score: 100

More than 90% of apps scored 40 or less

Tuesday, May 6, 14

Page 19: Chronic Diseases: An App A Day

App Placement Along Patient Journey Patient Apps for Improved Healthcare (IMS Institute for Healthcare Informatics Oct 2013)

A bowl of salad by kuwashima,http://www.freeimages.com/photo/1401249

Dumb Bells2 by GlennPeb,http://www.freeimages.com/photo/986735

Planning my week by tinpalace,http://www.freeimages.com/photo/586475

You are ill 2 by lusi,http://www.freeimages.com/photo/1157469

1

2

Change consumer/patient behavior (exercise & diet)

Improve implementation of prescribed treatment regimensUnderstanding physician instructionsEnsuring polypharmacy is appropriately managedMedication compliance or adherence to physician instructions

Tuesday, May 6, 14

Page 20: Chronic Diseases: An App A Day

App Placement Along Patient Journey Patient Apps for Improved Healthcare (IMS Institute for Healthcare Informatics Oct 2013)

Prevention/Healthy Lifestyles Healthy living, diet & exercise, addiction quitting, stress, relaxation & sleep

n = 8,786

Self-diagnosis Symptom checker and self diagnosis

Finding a HC profession or facility Doctor reviews and referralsSecond opinions

Diagnosis/Education Medical information, condition management information, emotional support post-diagnosis

Filling prescriptionFinding a pharmacy, availability, price and insurance coverage

CompliancePersistence, compliance

n = 304 n = 931 n = 562 n = 200 n = 225

Therapy Area Specific: 1,980Demography Specific: 1,440

Tuesday, May 6, 14

Page 21: Chronic Diseases: An App A Day

There’s an app for that!

Which app?

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Apps (un)regulated

The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8

App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt

Tuesday, May 6, 14

Page 22: Chronic Diseases: An App A Day

“45% of all American adults own a smartphone.

19% have downloaded an app specifically to track or manage health.

Nationwide telephone survey N = 3,104 US adults

7 Aug-6 Sept 2012

Tuesday, May 6, 14

Page 23: Chronic Diseases: An App A Day

38% to track exercise31% to monitor diet

12% to manage weightOthers: BP, menstrual cycles, pregnancy, diabetes, medication etc.

Mobile Health 2012 Pew Internet Survey

Exercise, diet and weight apps most popular downloads

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Tuesday, May 6, 14

Page 24: Chronic Diseases: An App A Day

Yap yap yap! by davdibiasehttp://www.freeimages.com/photo/160538

More likely to download an appWomen

Under 50Better educated

Annual household income over $75,000Significant health change in last 12 months

Mobile Health 2012Pew Internet Survey

Tuesday, May 6, 14

Page 25: Chronic Diseases: An App A Day

Patients facing multiple chronic diseases

typically over age 65

Lowest smartphone penetration18% of US adults >65 y

vs 55% of those aged 45-54 y

Tuesday, May 6, 14

Page 26: Chronic Diseases: An App A Day

Patients face a dizzying array of healthcare apps to choose from, with

little guidance on quality or support from their doctors.

Some efforts are underway to help provide professional healthcare guidance in

both the US and the UK but these are limited in scope and impact to date.

Tuesday, May 6, 14

Page 27: Chronic Diseases: An App A Day

Hyperwall by Florian Plaghttps://flic.kr/p/8aro3Y

“It’s the Wild West out there. It’s hard to sort through them all and there’s little evidence about which ones really work.

Murray AitkenExecutive Director

IMS Institute for Healthcare Informatics

Tuesday, May 6, 14

Page 28: Chronic Diseases: An App A Day

What clinical tools do you currently use in practice?

Do you want to replace the tool

with an app?

Does an app currently exist for

the reference?

Locate app via website link or

through app store

Begin search for substitution app

Can the reference be replaced if not exact duplicate?

Continue current practice

Inquire for app: word-of-mouth or

social mediaSearch mobile

app storeResearch apps

through blogs or websites

Search for published

literature on apps

Critically evaluate app

Perform new search or maintain

current practice

Is the app useful for utilization in

clinical practice?

Incorporate app into daily practice

YES YES

YES

YES

NONO

NO

Evaluate app based upon vital domains to ensure efficacy, safety,

accuracy and continual support in use[ ]

Fig 2 from Aungst TD et al Int J Clin Pract 2014;68:141-2.

Screening apps for use in practiceTuesday, May 6, 14

Page 29: Chronic Diseases: An App A Day

Found a clue by Morgan https://flic.kr/p/6WMk48

Questions to ask before downloading an appVisser BJ & Bouman J. Student BMJ 2012;20:e2161

Clinical decision making

Medical publisherRegularly updatedProperly referencedAuthors listedFeedbackRecommendedFor health professionals ???

Tuesday, May 6, 14

Page 30: Chronic Diseases: An App A Day

Found a clue by Morgan https://flic.kr/p/6WMk48

Questions to ask before downloading an app

Visser BJ & Bouman J. Student BMJ 2012;20:e2161

Patient’s privacyDoes the app require you to input

patient specific data, and could this compromise patients’ privacy?

?Conflicts of interest

Do you know where the app is from? By a drug company or a

non-commercial organization?

Tuesday, May 6, 14

Page 31: Chronic Diseases: An App A Day

Mapping mHealth Research: A Decade of Evolution Fiordelli M, Diviani N, Schulz PJ. J Med Internet Res 2013;15(5):e95

Copyright ©Maddalena Fiordelli, Nicola Diviani, Peter J. Schulz. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.05.2013.

Increase in the number of articles over the past decade (almost doubled from 2007–2008)

Focus on chronic conditions

50% clinical trials; 44% pilot studies

Small sample size (less than 50 people)

Tuesday, May 6, 14

Page 32: Chronic Diseases: An App A Day

“Currently, there are more than 15,000 health-related apps (free and paid) on app stores, but we were not able to find any study assessing any of them.

So what is publicly available has not been evaluated, and what has been evaluated is not publicly available.

Mapping mHealth Research: A Decade of Evolution Fiordelli M, Diviani N, Schulz PJ. J Med Internet Res 2013;15(5):e95

Puzzle 1 by jakubson http://www.freeimages.com/photo/1072527

Tuesday, May 6, 14

Page 33: Chronic Diseases: An App A Day

There’s an app for that!

Which app?

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Apps (un)regulated

The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8

App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt

Tuesday, May 6, 14

Page 34: Chronic Diseases: An App A Day

Apple by VanessaGF,http://www.freeimages.com/photo/1427461

An app a day keeps the doctor away. “ “When a prescription drug goes generic, it has at least

seven years of data about its effectiveness and safety, which gives physicians assurance that patients can use it for self-care.

Medical apps have no history of either effectiveness or safety.

Mike PaskavitzEditor-in-Chief, Quantia Inc.

Tuesday, May 6, 14

Page 36: Chronic Diseases: An App A Day

QuantiaMD Polln = 250Press release 24 Feb 2014http://www.prlog.org/12286663-quantiamd-poll-finds-physicians-are-split-on-use-of-medical-apps-and-42-believe-more-regulation.html

42% won’t prescribe apps because there is no regulatory oversight of them

Dr. Tom saves the day! by Murray Barnes, https://flic.kr/p/4M234v

37% have no idea what apps are out there

21% never recommend apps to patients

21% won’t prescribe apps because there’s no longitudinal data

on apps’ effectiveness

Another 21% won’t prescribe apps because it would generate

an overwhelming amount of patient data

Tuesday, May 6, 14

Page 37: Chronic Diseases: An App A Day

1

2

Two categories of mobile apps

Mobile apps that are NOT medical devices ... will NOT be regulated by FDA

Mobile apps may meet the definition of a medical device but because they pose a lower risk to the public, FDA intends to exercise enforcement discretion

Tuesday, May 6, 14

Page 38: Chronic Diseases: An App A Day

“ Consistent with the FDA’s existing oversight approach that considers functionality rather than platform, the FDA intends to apply its regulatory oversight to only those mobile apps that are medical devices and whose functionality could pose a risk to patient’s safety if the mobile app were to not function as intended.

FDA guidance, Sept 2013

3101 by jmawork,https://flic.kr/p/6dgfs3

Tuesday, May 6, 14

Page 39: Chronic Diseases: An App A Day

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Mobile medical appto be used as an accessory to a regulated medical device; orto transform a mobile platform into a regulated medical device

FDA guidance, Sept 2013

Tuesday, May 6, 14

Page 40: Chronic Diseases: An App A Day

“Although the FDA has focused on safety, it has largely left the review and certification of apps to the marketplace.

The currently available reviews of mHealth apps have largely focused on personal impressions, rather than evidence-based, unbiased assessments of clinical performance and data security.

Powell AC, Landman AB, Bates DW. In Search of a Few Good Apps

JAMA. Published online March 24, 2014, doi:10.001/jama.2014.2564 Caledos runner by Nicola,https://flic.kr/p/fP18Jx

Tuesday, May 6, 14

Page 41: Chronic Diseases: An App A Day

Feedback form: excellent by Dominik Gwarek,http://www.freeimages.com/photo/866529

APPS checklist Verkerk MM, Bargiela D. How to appraise medical apps: a guideline-based framework. BMJ Careers, 22 Oct 2013.

Appliance or platform - Which platform is suitable for the app? Is the information displayed in the most appropriate way?

Purpose - What is the intended use of the app? What influence does it have on clinical decision making? Is there potential for patient harm? Is there a disclaimer?

Person - Whom is the app for (doctors, patients, or others)? Is it designed for local use or wider distribution?

Safety - How reliable are the sources of information? How up to date is the information in the app?

Tuesday, May 6, 14

Page 42: Chronic Diseases: An App A Day

There’s an app for that!

Which app?

Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN

Apps (un)regulated

The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8

App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt

@endocrine_witchTuesday, May 6, 14