nguyen slides - information anywhere - 2017 omed · the presenter does not recommend one mobile app...

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This project has been funded in whole or in part with Federal funds from the National Library of Medicine (NLM), National Institutes of Health (NIH), under cooperative agreement No. UG4LM012340 with the University of Maryland, Baltimore. The content is solely the responsibility of the authors and does not

necessarily represent the official views of the National Institutes of Health.

Information Anywhere:Evidence‐based Mobile Apps and Resources

Tony Nguyen, MLIS, AHIP

Technology and Communications Coordinator

Objectives

• Identify authoritative evidence‐based mobile apps and resources for practitioners

• Utilize mobile optimized websites to locate evidence‐based resources

• Select and appraise mobile apps utilizing evaluation tools

Please Note

The presenter does not recommend one mobile app over another.

Apps mentioned in this presentation are intended as examples.

New apps are developed and released often and may reflect new advancements in medical technology and delivery of information.

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Background Where are we with Mobile Devices and Healthcare?

PubMed Article Search

29 Citations on Mobile Applications

731,298 English Language Journal Articles

346: Allergy, Immunology, and Transplantation Journals

Article Citations: https://www.ncbi.nlm.nih.gov/sites/myncbi/14YigAeurPbkU/collections/53109548/public/

Why Mobile Now?

Raine L & Perrin A. 10 facts about smartphones as the iPhone turns 10. Pew Research Center. June 28, 2017. Available at: http://www.pewresearch.org/fact‐tank/2017/06/28/10‐facts‐about‐smartphones/

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Device Ownership Trends

Mobile Fact Sheet. Pew Research Center. January 12, 2017. Available at: http://www.pewinternet.org/fact‐sheet/mobile/

U.S. Device Ownership78% Desktop 77% Smartphone51% Tablet 22% E‐Reader

Tablet/Mobile Operating Systems

Net Marketshare. Mobile/Tablet Operating System Market Share. Available at: http://marketshare.hitslink.com/operating‐system‐market‐share.aspx?qprid=8&qpcustomd=1

Why Mobile in Healthcare?

• Combine functions of pagers, cell phones, and PDAs

• Combines computing and communications

• Ease of access and use at point of care

• Advanced features • Web searching

• GPS • High‐quality cameras

• Sound recorders

Cook VE, Ellis AK, Hildebrand KJ. Mobile health applications in clinical practice: pearls, pitfalls, and key considerations. Ann Allergy Asthma Immunol. 2016 Aug;117(2):143‐9. doi: 10.1016/j.anai.2016.01.012. Review.

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Physician Adoption

“This is not ‘nice to have stuff’ anymore, this is life saving stuff now.”

Eric Yablonka, CIO

University of Chicago

Benefits to Mobile Device Use

• Communication: Voice, Video, Text, E‐mail

• Hospital Information Systems: EHR, EMR, CDSS, PACSs, LISs

• Informational Resources: Textbooks, Guidelines, Medical Literature, Drug Reference

• Clinical Software Applications: Disease Diagnosis Aids, Medical Calculators

• 35% used apps to make clinical decisions.

The Connected Medical Professional

• 87% use a smartphone or tablet in the workplace.

• 54% use a tablet in practice

• 2:1 use online resources vs print to make clinical decisions

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Mobile Healthcare

• 1/3 Physicians recommend mobile health (mhealth) apps

• 40% agree apps could improve patient outcomes

• 1.5 billion mobile users use a mhealth app

• Healthcare Apps are a $26 billion dollar market


What are Mobile Apps?

• Software intended for a mobile device.

• Works on specific Operating System (OS)

• May work with or without internet

What is mHealth?

• Practice of medicine and public health, supported by mobile devices, for health services and information.

• Use of mobile devices to support health related monitoring and self‐help activities.

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mHealth App Benefits

• Accessible & Convenient• Better clinical‐decision making

• Increased efficiency• Enhanced productivity• Facilitate patient control of health information

• Reduce burden and cost associated in healthcare delivery• Support behavioral change in patients • Potential link to mHealth apps with EMR/EHR


mHealth in Action

mHealth HospitalMobile connectivity for:

• EHR• Clinical Resources• Charting• Patient Education• Patient Communication

• Discharge Instructions• Home Health Monitoring

• Financials

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Clinical Use of

Mobile Apps

Aungst TD, Clauson KA, Misra S, Lewis TL, Husain I. How to identify, assessand utilise mobile medical applications in clinical practice. Int J Clin Pract.2014 Feb;68(2):155‐62. doi: 10.1111/ijcp.12375.

Clinical Use Barriers

• Wireless access in the hospital or clinic

• Knowing what resources are available• Understanding how to use the resources• Technology problems

• Complicated installation process

• Do not have permission to install software

• Lack or Time

• Other

Wiechmann W, Kwan D, Bokarius A, Toohey SL. There's an App for That? Highlighting the Difficulty in Finding Clinically

Relevant Smartphone Applications. West J Emerg Med. 2016 Mar;17(2):191‐4. doi: 10.5811/westjem.2015.12.28781.

Epub 2016 Mar 2. Review. PubMed PMID: 26973750; PubMed Central PMCID: PMC4786244.

Locating Medical AppsMedical Apps for the Healthcare Professional

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Finding Apps

https://www.apple.com/itunes/ https://play.google.com/store/apps

mHealth Apps


Classification

Apple and Google have no interest in making sure “medical” apps and “health” apps are classified appropriately.

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App Store “Medical”

Apps Considered

Wiechmann W, Kwan D, Bokarius A, Toohey SL. There's an App for That? Highlighting the Difficulty in Finding Clinically Relevant

Smartphone Applications. West J Emerg Med. 2016 Mar;17(2):191‐4. doi: 10.5811/westjem.2015.12.28781. Epub 2016 Mar 2.

Review. PubMed PMID: 26973750; PubMed Central PMCID: PMC4786244.

Apple Suggestions

Top Paid Health Apps

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Top Free Health Apps

Issues with App Store Medical Apps

• Security

• Frequency of updates

• No “peer‐review”

• What makes the medical app store good also makes it bad (low barrier of entry)

Medical App Problems

• Variation in quality, testing, and evaluation

• Design and function over EBM

• Uncertain long‐term care effectiveness

• Lack of regulatory supervision

• Privacy and security concerns

Armstrong S. Which app should I use? BMJ. 2015 Sep 9;351:h4597. doi: 10.1136/bmj.h4597. Review. PubMed

PMID: 26353800.

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TIP: Search with Purpose

• Can’t enter “medical students” or “residents” when in an app store.

• Focus on key subsections (examples include):• Histology• Anatomy

• Pathology

• The more defined, the better.

Where to StartMedical Society and Government Organization Mobile Apps

Medical Society Apps

• Often medical and health professionals aren’t aware of these apps.

• Easy recommendations

• Often apps are free

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Emergency Medicine Resident Association

• https://www.emra.org/publications/mobile‐applications/

• 6 Apps

American Academy of Orthopedic Surgeons

• http://aaos.webauthor.com/go/auc/

• 9 Apps


American Society of Regional Anesthesia and Pain Medicine

• https://www.asra.com/page/150/asra‐apps

• 4 Apps

American Academy of Pediatrics

• https://www.aap.org/en‐us/Pages/Get‐the‐AAP‐Mobile‐App.aspx

• 15 Apps

American College of Cardiology

• Notable apps: ASCVD Risk Estimator, ACC Guideline Clinical App, Statin Intolerance

• Outdated ones too: CardioSmart

• http://www.acc.org/tools‐and‐practice‐support/mobile‐resources

• 16 apps

American College of Cardiology. Mobile Apps. Available at: http://www.acc.org/tools‐and‐practice‐support/mobile‐resources

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Government Apps

Centers for Disease Control and Prevention • https://www.cdc.gov/mobile/mobileapp.html• 27 Apps (14 for Healthcare Providers)

National Library of Medicine • http://www.nlm.nih.gov/mobile/• 13 Apps

AHRQ• https://epss.ahrq.gov/PDA/index.jsp

Specialty Apps

MedShr

https://itunes.apple.com/us/app/medshr‐discover‐share‐medical/id1006385131?mt=8&ign‐mpt=uo%3D2https://play.google.com/store/apps/details?id=net.medshr.android

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Clearpath

https://itunes.apple.com/us/app/clearpath/id540260769?mt=8

Lab Tests Online ‐ M

https://itunes.apple.com/us/app/lab‐tests‐online‐m/id447858911?mt=8https://play.google.com/store/apps/details?id=com.livewirekiosk.lwk.labtestsonline

PathLead

https://play.google.com/store/apps/details?id=com.leicamicrosystemsinc.leica

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VisualDX

https://itunes.apple.com/us/app/visualdx/id348177521?mt=8https://play.google.com/store/apps/details?id=com.visualdx.android

Essential Anatomy 3

https://itunes.apple.com/us/app/essential‐anatomy‐2/id596684220?mt=8&ign‐mpt=uo%3D2https://play.google.com/store/apps/details?id=com.the3d4medical.EssentialAnatomy

Human Anatomy Atlas

https://itunes.apple.com/us/app/human‐anatomy‐atlas‐3d‐anatomical/id446207961https://play.google.com/store/apps/details?id=com.argosy.vbandroid

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Information Management

• Write and dictate notes

• Record audio

• Take photographs

• Organize information and images

• Use e‐book reader

• Access cloud services

Time Management

• Schedule appointments

• Schedule meetings

• Record call‐schedule

Health Record Maintenance and Access

• Access EHRs and EMRs

• Access images and scans

• Electronic prescribing

• Coding and billing

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Communications and Consulting

• Voice calling

• Video calling

• Texting

• E‐mail

• Multimedia messaging

• Video conferencing

• Social networking

Reference and Information Gathering

• Medical textbooks

• Medical journals

• Medical literature

• Literature search portals

• Drug reference guides

• Medical news

Clinical Decision Making

• Clinical decision support systems

• Clinical treatment guidelines

• Disease diagnosis aids

• Differential diagnosis aids

• Medical calculators

• Laboratory test ordering

• Laboratory test interpretation

• Medical exams

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Patient Monitoring

• Monitor patient health

• Monitor patient location

• Monitor patient rehabilitation

• Collect clinical data

• Monitor heart function

Medical Education & Training

• Continuing Medical Education

• Knowledge Assessment Tests

• Board Exam Preparation

• Case Studies

• E‐learning and Teaching

• Surgical Simulation

• Skill Assessment Tests

iMedicalApps

Available at: http://www.imedicalapps.com/

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MDLinx Mobile App Reviews

Available at: https://www.mdlinx.com/internal‐medicine/mobile‐app‐center/

Consumer Health Apps

• Wellness Management

• Disease Management

• Self‐diagnosis

• Medication Reminder

• Electronic Patient Portal

• Physical Medicine and Rehabilitation

Happtique

http://www.happtique.com/

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What Apps Do You Use?

Mobile Friendly WebsitesThere’s not always an app for that.

Mobile Apps vs. Mobile Sites

Mobile Apps

• Program designed to run on a specific OS.

• Programming for each OS is necessary.

• Provides user interaction by integrating with existing tablet or smartphone features.

• Might not rely on internet connection.

• Can push alerts.

• Pre‐installed or downloaded from an application directory.

Mobile Sites• Free to access

• Mobile friendly version of website.

• Responsive design helps create mobile version.

• HTML Programming

• Cannot push alerts to users.

• Internet Connection Required

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Patient Care – On Demand Search

http://pubmedhh.nlm.nih.gov/

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Evaluating Mobile Apps

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Considerations: Content

• mHealth app authors may have a conflict of interest that influences content.

• Most mHealth apps are created without medical expert involvement.

• Inaccurate medical content within mHealth apps may place patients at risk of harm.

• Monetization practices (inc. advertising) should be considered.


Considerations: Medical Content

• Medical expertise poorly represented – 33%

• Less than half adhere to evidence based resources

• Alternative content prevalent in over 25% apps

• Asthma apps – over 50% from free online resources

• Asthma apps – 25% ad supported


Considerations: Privacy

• Digital information legislation – not applicable to all

• Poor secured information with third party consumers

• Non‐identifiable information can be identified through data triangulation techniques

• 26% free/40% paid apps have no privacy policy


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Considerations: Accessibility

• Barriers: Language, health literacy, computer literacy

• Limited Access – Might not be available on multiple OS

• Cost ‐ less likely to be a barrier to access


Screening Mobile Apps for Utilization and Practice

Aungst TD, Clauson KA, Misra S, Lewis TL, Husain I. How to identify, assess and utilise mobile medical applications in clinical practice. Int J Clin Pract. 2014 Feb;68(2):155‐62. doi: 10.1111/ijcp.12375.

Before Downloading: Updates

When was the app last updated?

• 18 month rule.

• “orphaned” app• If no software update, no content update.

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Before Downloading: Developer

Who is the developer?

• Medical Society

• Physician or healthcare provider• What other apps do they develop? (From games to medical apps?)

Before Downloading: Content

Clear and detailed descriptions and images.

Before Downloading: Troubleshooting

Links to website for troubleshooting support or more information.

• Can’t be just Facebook or Twitter, need to have a landing page.

• Statin Intolerance App does not have this.

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Before Downloading: References

• Links to references when giving clinical recommendations or presenting content.

• (Frequent Issue with most medical apps)

Before Downloading: Contact Info

Ask the Developers!

• Often don’t know they should include obvious information, such as their backgrounds or reference information.

Before Downloading:Ratings and Reviews?

iTunes and Google Play ratings

• Almost always useless

• Not enough of an “n” to have appropriately crowdsourced information.

• Reviews can be bought.

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NHS Apps Digital Assessment

1. Clinical Effectiveness

2. Regulatory Approval

3. Clinical Safety

4. Privacy and Confidentiality

5. Security

6. Usability and Accessibility

7. Interoperability

8. Technical Stability

9. Change Management

NHS. Apps Information for Developers about the Apps Library. Digital Assessment Questions – Beta. https://developer.nhs.uk/digital‐tools/daq/ Accessed 8/22/2017

Final Note Before Downloading

NOT ALL “CRITERIA” WILL BE MET.

mHealth App Guidance

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Privacy RequirementsData Covered Identifying information (identification numbers and physical, physiologic, mental, economic, genetic, social,

medical, or cultural factors relating to the past, present, or future of the patient)

App users must be informed about Identity of those who can access or use personal health information

Reason for collection of health information

Privacy practices of those collecting the information

User right to access and modify data

Contact method for questions or complaints

Data Storage Health information should be kept for the minimum necessary period

Health information must be deleted when use is finished

A clear information storage policy including security should be described

Security Health information must be protected from unauthorized loss, access, or disclosure

Notification in case of breach Users and relevant authorities must be notified in the event that personal health information is breached

In the event of a massive breach, media should be notified

Data Transfer User consent is required before transfer of personal health information to a third party

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Government Regulation

• FDA updated formal guidelines.• mHealth apps are considered software devices

• Classified according to their claims about use and associated risk

• Those that could harm patient safety ‐ regulated • Includes diagnostic assessment and treatment recommendations

• “enforcement discretion”


U.S. Food & Drug Administration. Mobile Medical Applications. Available at: https://www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/default.htm

Cleared Apps

FDA. Establishment Registration & Device Listing. Available at: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRL/rl.cfm

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Examples of Apps

Approved

FDA. Examples of Pre‐Market Submissions that Include MMAs Cleared or Approved by FDA: https://www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/ucm368784.htm

FDA Discretion Advised

• Patients self‐manage conditions w/o specific treatment suggestions

• Provide simple tools to organize and track health information

• Provide easy access to information to health conditions or treatments

• Document, show, or communicate potential medical conditions to healthcare practitioners

• Provide supplemental care to help patients manage their health

Shuren J. The FDA's role in the development of medical mobile applications. Clin Pharmacol Ther. 2014

May;95(5):485‐8. doi: 10.1038/clpt.2014.45. PubMed PMID: 24747239.

More FDA Discretion

• Enable interaction with EHR/EMR system records

• Maintain health weight, sodium, or drug intake/interactions

• Supplement discussions with healthcare provider using video conferencing portal

• Conduct simple calculations like BMI, APGAR scores

• Provide reminders for schedules or medications

Shuren J. The FDA's role in the development of medical mobile applications. Clin Pharmacol

Ther. 2014 May;95(5):485‐8. doi: 10.1038/clpt.2014.45. PubMed PMID: 24747239.

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AMA on mHealth

• Support establishment or continuation of a valid patient‐physician relationship

• Have clinical evidence to support app safety and effectiveness

• Follow EBP guidelines to ensure patient safety, quality of care and positive health outcomes

• Support patient‐centered care delivery to coordinate care and team‐based communication

American Medical Association. AMA Adopts Principles to Promote Safe, Effective mHealth Applications. https://www.ama‐assn.org/ama‐adopts‐principles‐promote‐safe‐effective‐mhealth‐applications. Accessed August 11, 2017

AMA on mHealthcontinued

• Support data portability to promote care coordination through medical home and accountable care models

• Abide by state licensure and medical practice laws and requirements in which the patient receives services facilitated by the app

• Require health practitioners deliver services through the app be licensed in the state where the patient receives services

• Ensure delivery of any services via the app be consistent with state scope of practice laws.

American Medical Association. AMA Adopts Principles to Promote Safe, Effective mHealth Applications. https://www.ama‐assn.org/ama‐adopts‐principles‐promote‐safe‐effective‐mhealth‐applications. Accessed August 11, 2017

Future Directions

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Digital TechnologiesClinical Requirements 2020

Clinical Requirements: The Doctor’s Perspective

• Patient Record

• Digital Interaction between patient and clinician

• Digital Prescribing

• Administrative Functions

• Transfers of Care

• Clinical Governance

Academy of Medical Royal Colleges. Information and Digital Technologies Clinical Requirements 2020. Available at: http://www.aomrc.org.uk/publications/reports‐guidance/information‐digital‐technologies‐clinical‐requirements‐2020/

Integration with EHRs

• Common types of patient‐generated data added

• Reduce provider documentation time

• Issues on large data storage

• Alert clinicians when medical issues arise

• Across EHR accessibility

Cloud‐Based Health Records

• Patient‐centric health record

• Store records across multiple health care networks

• Cross EHR sharing

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App Prescription

• 16% Physicians currently “prescribe” apps

• 46% Physicians expect to “prescribe” apps in 5 years

• 37% Don’t know what apps are out there

• 42% Won’t prescribe apps – re: no regulatory oversight

• 21% Won’t prescribe apps – re: no long‐term data

• 21% Won’t prescribe apps – re: data concerns

• 21% Never recommend apps to patients

Morrissey J. Two big reasons physicians resist mobile health. Hosp

Health Netw. 2014 Jun;88(6):26‐7. PubMed PMID: 25102617.

Prescribing Mobile Apps

• Lack of scientific evidence

• Lack of integration into workflow systems

• Lack of regulatory supervision

• Lack of reimbursement for mHealth from insurance companies

Questions

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Thank you!

Tony Nguyen, MLIS, AHIP

Technology & Communications Coordinator

National Network of Libraries of Medicine, Southeastern/Atlantic Region

[email protected]

410‐706‐2066

nguyen slides - information anywhere - 2017 omed · the presenter does not recommend one mobile app...

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