Download - 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
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
“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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
“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
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
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
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
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
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
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
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
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
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
“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
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
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
Drug questions by Ano Lobo,https://flic.kr/p/8Rvugs
QuantiaMD Polln = 1500
37% of physicians have prescribed an app to their patients.
Press 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
Tuesday, May 6, 14
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
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
“ 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
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
“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
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
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