A guest post by Ahmed Awada (*)
Introduction
Considering the technological era that we live in, it should be no surprise that mobile apps are an integral part of the future. Almost every aspect of our lives is affected by mobile apps, from entertainment, to mobile ordering, to ride sharing, and so much more. We’ve seen every industry begin to use mobile apps in some way, and the trend continues as the majority of time spent online is now on mobile apps. This can be said about the Health IT field, and the way that it has evolved to increasingly become more mobile app focused.
The mobile health app market has grown over the years and completely transformed the healthcare industry which has been known to be more slow-paced and less dynamic. The smartphone transformed the way that patients access their medical information, interact with providers, and even request appointments or medications. There are now 318,000 medical health apps worldwide, double the number of apps available in 2005.
What’s driving this massive rise in the use of mobile health apps, and apps in the healthcare field? For one thing, the ease of use and accessibility has benefited both patients and providers. The relationship between the two is very important, and mobile health apps have transformed the way communication is conducted. Waiting weeks or months for a follow-up appointment is no longer as common as before since this can all be done virtually. Many Electronic Medical Record applications now have the capability of doing electronic visits where the user might take pictures of certain conditions, such as a rash, and send it to their provider for updates or checkups. This not only saves the patient time of having to physically go to the clinic, but also the provider who can quickly review all the information and photos and give a diagnosis to the patient within a short time. This is especially helpful if a patient wants to communicate with a provider who may be in a different state. On top of this, the convenience of managing health on the go is great for patients who don’t really have the time to make appointments or sit for long periods of time in clinics.
With this comes the encouragement of healthier behavior, and apps like the ones found in the Fitbit and Apple Watch help correlate personal decisions with better health outcomes. On the flip side, these health apps do have their drawbacks; data privacy is a big deal for patients who want to keep their Patient Health Information (PHI) private and secure. The fear of hackers who want to steal patient information and sell it is very real, and this turns away many patients from using these apps. Another negative of these health apps is the fact that they may not always be accurate. There is the risk of getting a false diagnosis, or end up getting prescribed a medication that isn’t needed. While this is an extreme case, one has to look at the fact that many apps claim to be able to measure a user’s health rate or stress level using the phone’s sensor. There have been instances of patients sending pictures of conditions and photos not being clear enough, raising the potential for an inaccurate diagnosis. With all this being said, mobile health apps have transformed the health and healthcare field, changing the way patients and providers interact and fulfill their roles.
Patient and Provider Relationship Enhanced By the Use of Mobile Health Apps
Known as mHealth, this is the use of mobile technology, such as smartphones, in a healthcare setting (Aitken & Lyle, 2015). Now with better access to this information, providers and patients have much better communication, helping to better manage chronic health conditions. This increased engagement makes it much easier for both sides to setup more frequent appointments and help spot abnormalities much quicker. This reduces the annoyance of having to create more appointments and the patient having to waste time to physically travel to a clinic.
For providers, this allows for better utilization of their time to address patients much quicker and give a diagnosis or prescription in a reasonable amount of time. This is especially true for patients who have chronic health conditions depends on the adoption of specific behavioral change techniques, defined as “observable, replicable and irreducible component of an intervention designed to alter or redirect causal processes that regulate behavior” (Michie et al., 2013, p. 82). Self management for the patient is crucial to ensuring that these conditions do not worsen, and by having your provider on the device that you use everywhere, it makes it very simple and convenient to maintain this regimen and ensure successful self-management. To be more specific, the average patient may interact with a myriad of providers such as physicians, nurses, nurse practitioners, pharmacists, health educators, dietitians, and physical and occupational therapists. Together, any of these providers and patients can utilize mobile apps and create action plans to tackle their medical conditions. By recording and sharing real-time biometric measurements, this has the potential to put a patients providers all in one place.
Many mHealth apps have been created to manage patients who regularly visit multiple providers, or have numerous prescriptions. This can get very difficult to track and many patients can get overwhelmed with the sheer amount of information they have to keep track of. By having all of this in a convenient app with notifications and reminders, patients can regularly check to ensure they are up-to-date on check-ups and whether or not they need refills for medications they are taking. Upon looking at this further, we can look a the IBCT model, developed by Glasgow and colleagues, which focuses on the use of computer-based tools and devices to assist with health behavior changes. By using this model, we can analyze the inclusion of the healthcare provider, patient, and technology techniques, and understand the functions that each one plays.
The provider’s role is obviously the most complex, as they must obtain the patient, analyze it, and make recommendations or setup goals that the patient must then follow. The patient must take all of this and make the decision on how to approach the guidelines that are given. The technology, in this case mHealth apps, acts as the bridge between patients and providers. While the provider has the largest role in this model, it’s not described in depth how the patient and the technology can further the relationship between all sides. We can infer based on looking into apps that are designed for EMR companions that the patient has the ability to input their symptoms, with pictures which act like an in-clinic visit (also known as an e-visit).
So what can providers, such as informatics nurses, do what better enhance this relationship between provider, patient, and the technology that binds them? During the app development process, these nurses and speak with patients and providers to better understand each side, and what might be lacking in these apps. The goal would be to ensure mHealth apps incorporate elements to enhance communication, motivation, bond/legitimacy, and accountability between the patient and the provider via the mHealth app. An example could be that the informatics nurse could encourage the use of email (or intramail), which allows the patient to readily have a way to contact their provider at various times of the day. This allows for a constant connection between the patient and provider, and ensures that nothing is missed by either party. This would prove to be a positive outcome because the key to making these mHealth apps is for patients and providers to keep the line of communication open, especially when the disease is chronic and needs constant check-ups.
Encouraging Healthy Behavior and Increasing Education for Patients
When analyzing the usage of mHealth apps do encourage healthy behavior, we can look at non-healthcare related apps such as the ones that could include fitness apps as well. The top free health and fitness apps for iPhones include MyFitnessPal, FitBit Activity Counter, Pacer, and Period Tracker Lite. With a wide variety of options for these apps, it’s interesting to see that there are so many uses for them. Period Tracker Lite is a menstrual-cycle tracker that has greatly helped women. Other apps include an HIV risk calculator, a self-described self-test for erectile dysfunction, and another proposes home remedies for cold sores, colitis, conjunctivitis, and constipation.
The benefits from these apps are endless, with another benefit being education that makes it easier than ever to learn more about potential symptoms and why a patient may be experiencing them. For example, using one of these apps to analyze why a patient may be feeling nauseous, could prove to be helpful in saving a trip to the clinic if it is something very minor. By understanding how to regularly maintain health and fitness, a patient holds themself accountable and improves their awareness of how to better prevent illness. For many patients that have heart issues or don’t regularly get enough exercise throughout the day, apps such as MyFitnessPal maintain steps and how many calories have been burned throughout the day. This eventually becomes a routine for the patient, and by the time that check-ups come around with a provider, the patient has the ability to pull up this information and present it. It makes the process very easy so that an action plan is created to increase a patient’s physical activity to meet a certain goal. For other apps such as the one for erectile dysfunction, this provides a small stepping stone for a patient to gain a small understanding of the condition, and later present this to their provider in a clinic visit. By knowing what the symptoms are, this helps minimize unnecessary visits that could be based on suspicions. It also allows the patient to have a much better understanding of what certain symptoms mean and how to handle them.
Do Health and Fitness Apps Really Benefit the Patient?
While these health and fitness apps have many benefits as discussed above, there is the argument that they do not provide any real health value to consumers who are already “healthy,” and could stoke unneeded anxiety among those who are worried about their health. We could look at many health tracking apps as unnecessary for those that are already healthy and don’t need to record their normal activities and vital signs. For some people, this adds another level of anxiety where there is a constant expectation to improve and do better. There is also the fear that these health and fitness apps are pushing deceptive claims.
With patients increasingly using these apps to measure their health and self-diagnose themselves, this runs the risk of a misdiagnosis and further complicates a medical issue. In 2011, the Federal Trade Commission accused the developers of two acne apps of falsely claiming they could treat acne by shining colored light onto users’ skin. This preys on the anxiety for many patients who may want answers or to rid themselves of a particular disease. Patients could also go out and use the self-diagnosis to purchase medications that don’t need a prescription, and ended up ingesting something that isn’t necessary for their condition. “If an app claims to treat, diagnose or prevent a disease or a health condition, it needs to have serious evidence to back up those claims,” Mary K. Engle, associate director of the F.T.C.’s division of advertising practices. There is a hope that the creators of these health apps will do their research and ensure that the proper standards are in place to make it a safe experience for not only the patient, but also the provider who is giving their own advice and recommendations. It’s important that these two recommendations from different sources do not conflict and harm the patient in the end.
Data Risks Associated with mHealth Apps
A major concern that both patients and providers share is the security of health data that is shared among the apps that have been discussed. The security of Patient Health Information (PHI) is a top priority for many apps, with a majority of them taking the necessary precautions to ensure that this information is not compromised. Apps which accompany EHR and EMR software contain records of past visits and conditions, which patients want to remain private. Not only this, but crucial health information could be compromised in the event of an attack. While analyzing health and fitness apps found in app stores, this risk also applies since many of these apps require access to similar data.
In 2013, Privacy Rights Clearinghouse, a nonprofit advocacy organization in San Francisco, analyzed 43 free and paid apps, finding that 72 percent of them exposed personal information such as dates of birth, email addresses, and medical information. Only half of the apps linked to a privacy policy, which typically explains what personal information is gathered and if data is shared with or sold to third parties and why. With a lot of mHealth apps, accessing past medical records and medications is as easy as ordering takeout food, and this could be the cause for concern. With easier accessibility, comes the risk of making it easier for hackers to find their way past security and stealing precious patient data. Not only this, but many medical organizations are warning that these patient data-sharing apps could facilitate invasions of privacy.
The question begs, do these third party companies have access to too much patient data? A battle is brewing by prominent medical organizations to ensure that patient data is accessible, but also safe and secure. One of the big pushes being made is to require health providers to send medical information to third-party apps, like Apple’s Healthy Records, after a patient has authorized the data exchange. While pushes like this have kept third parties in check to not have more access than they should, groups such as the American Medical Association, warned regulators that there is the potential for data abuse if the consumer apps are authorized to retrieve their medical records. If there are no federal regulations in place to keep these third party apps in check, this could lead to sensitive details, such as prescription drug history, to be put in jeopardy.
As major companies such as Amazon, Apple, Google, and Microsoft are now racing to capitalize on health data, it’s a race for slice of the healthcare market now that it is moving towards being mobile app centric. With these companies trying to make accessing health records easier and more convenient for their customers, it opens the door for many possibilities, and concerns. Dr. Don Rucker, the federal health department’s national coordinator for health information technology, says that by allowing patients to access their medical data through these apps, it helps to give them second opinions and understand medical costs. People have the ability to shop for doctors and insurance companies through their phone, and this makes the entire experience much more fluid. With the ability to make appointments and pay bills, it’s a complete process from start to finish. But with all of the progress, Rucker says that there is a major drawback with security. Physicians’ organizations have said that the rules failed to give people granular control over their data. This means that there are very small clauses and agreements to utilize these apps, and this means consumers are unknowingly giving access to large amounts of data. Dr. Rucker has said that “that current information-sharing standards could not accommodate granular data controls and that privacy concerns needed to be balanced against the benefits of improved patient access to their medical information (10).” The problem is that many people are comfortable giving this information away willingly. For fitness apps, a majority of them collect their heart rate data and store it. This is something that isn’t covered by federal protections. While patients have to choose whether to use these apps and give up this data to third party companies, many trust the big brand names in the same way that they don’t let financial data go out randomly to unknown banks. With the big companies like Apple and Google making it very accessible with their integrated ecosystems, it makes it hard for consumers to avoid using them since it’s so appealing.
Hackers and Mobile Health Apps
So why do hackers love health apps? What could they possibly use that data for? Well if your medical information is accessible on your phone, it opens the door for hackers to take your doctor’s name, and possibly even your home address.
When stealing a credit card number, hackers realize that they can be cancelled, something you can’t do with medical health records. This includes the home address and social security number that could put a person’s security and identity at risk. About one-fifth of mobile devices in the United States have a health app installed on their smartphone. A study in the March issue of the Journal of the American Medical Association in March showed the following: “of 271 apps studied, 81 percent did not have privacy policies. Of the 19 percent (41 apps) that did have privacy policies, only four specified that they would seek permission before sharing data with third parties.” This is very concerning because health apps are not subject to privacy and security regulations in the Health Insurance Portability and Accountability Act (HIPAA).
Mobile health apps pose a major risk because of the fact that there is no buffer between the user and the information. In this case, security is compromised since there are no regulations in check to ensure that there is a barrier to prevent hacking. “Patient privacy should be well addressed. The selling of this information should be more transparent,” said Diane Johnson, director of the Strategic Regulatory at Johnson & Johnson, a multinational medical products and services provider that offers a number of mHealth apps. There is some hope though: data that is saved on an individual’s phone, is safer than being saved to the cloud. Having the encrypted information in your hands gives better control than the lack of barriers found in the cloud.
The Future of Mobile Health Apps
So what does the future of mobile health apps look like? We’re already seeing wearable devices take over in the past few years to help us monitor our health, diet, sleep, and well-being. More and more apps are being created each day that make it easier than ever to maintain a healthy lifestyle. With the emergence of wearable devices like Google Glass, this adds a whole new level of added visibility into a consumer’s health lifestyle with unique apps integrated that function as an Augmented Reality evolution. With the eventual rise of Virtual Reality, e-visits are taken to the next step with providers and patients being able to see themselves face-to-face as if they were in the same room.
While this evolution in technology has proven that mobile health apps will continue to dominate the smartphone in the next few years, there is also the worry that security will always lack, and third party companies or hackers will prey on patient data. But just as EHR/EMR medical information in hospitals and clinics has become more secure against attacks, this could also be true for mobile health apps. Regulations are also in sight to ensure that patient data isn’t exploited by big companies such as Apple and Google. With the expansion of the patient-provider relationship looking to be stronger than ever with the help of mobile health apps, the future is very bright for these apps in the next decade of technological app advancement.
References
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- Dignityhealth.org. (2020). Dignity Health | The Pros and Cons of Mobile Health Apps. [online] Available at: https://www.dignityhealth.org/articles/the-pros-and-cons-of-mobile-health-apps [Accessed 1 Mar. 2020].
- Singer, Natasha. “Report Questions Whether Health Apps Benefit Healthy People.” Bits Blog, 15 Apr. 2015, https://bits.blogs.nytimes.com/2015/04/14/report-questions-whether-health-apps-benefit-healthy-people/?_r=0
- Aitken M, & Lyle J (2015). Patient adoption of mHealth: Use, evidence and remaining barriers to mainstream acceptance. Parsippany, NJ: IMS Institute for Health care Informatics.
- Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W,… Wood CE (2013). The behavior change technique taxonomy (vl) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46(1), 81–95. doi: 10.1007/S12160-013-9486-6
- “Utilization of Mobile Applications in Collaborative Patient-Provider Monitoring of Chronic Health Conditions.” An Examination of Three Theoretical Frameworks to Guide Practice, 7 Mar. 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6555616.
- Glasgow RE, Bull SS, Piette JD, & Steiner JF, (2004). Interactive behavior change technology: A partial solution to the competing demands of primary care. American Journal of Preventive Medicine, 27(2), 80–87. doi:10.1016/j.amepre.2004.04.026
- “‘Acne Cure’ Mobile App Marketers Will Drop Baseless Claims Under FTC.” Federal Trade Commission, 1 Mar. 2019, https://www.ftc.gov/news-events/press-releases/2011/09/acne-cure-mobile-app-marketers-will-drop-baseless-claims-under.
- “When Apps Get Your Medical Data, Your Privacy May Go With It.” Https://Www.Nytimes.Com/#publisher, 3 Sept. 2019, https://www.nytimes.com/2019/09/03/technology/smartphone-medical-records.html
- Ouyang, Xuanyan. “Why Hackers Love Health Apps.” PCWorld, 26 July 2016, https://www.pcworld.com/article/3099004/why-hackers-love-health-apps.html.
(*) This blog post initially appeared as an essay for one of my courses at Florida Atlantic University. It is being shared here as a guest blog post with the author’s consent.
All views and opinions expressed in this post are those of the authors and do not necessarily reflect my opinion or the official policy or position of any agency, organization, or company.
Featured image: photo by Alexander Sinn on Unsplash