“Patient-centeredness”….will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it.” — Don Berwick, Former Administrator of CMS.
There are a ton of health-related mobile apps on the market and in development. Some of them engage patients without involving doctors and some are aimed at doctors and not at patients. In order to be considered an app that supports the patient-centered medical home, I believe that it is crucial that the app strengthen the connection between the patient and the doctor and/or the care team.
Optimally, patient-centered mobile apps should have a number of functions:
• Provide evidence-based information about the clinical condition to the patient (or caregiver)
• Collect self-reported data from the patient (or caregiver)
• Have tracking, reminder, and “nudging” functions
• Be customizable
• Have a mechanism to easily provide actionable self-reported data to the doctor (preferably via integration into the EHR)
• Be low-cost or free
• Work on a variety of mobile devices
• Have significant offline functionality so it can accessed anytime, anyplace – even if wireless is not available
These are apps that physicians will want tell their patients about (and vice versa). And, they are apps that doctors and patients will want to discuss routinely as a part of the care process (“So, Mrs. Smith, let’s talk about last month’s headache pattern that you sent me via your iHeadacheApp” “Let’s start our visit today, Mr. Jones, by talking about your interaction with your WellDoc DiabetesManager®…is it helping you manage your glucose better?” “I see from your Asthmapolis report that you seem to trigger your asthma whenever you are at your Grandmother’s house on 4th and Vine. Can we talk about that?”)
Mobile apps, plus or minus sensors, provide patients with new and powerful tools for self-management and self-awareness. They provide clinicians with new and probably more reliable insights into the behavior of their patients with chronic illness, including adherence with treatment, impact of diet, exercise, and other environmental factors. Early studies suggest that use of these tools by patients favorably impacts clinical outcomes (see below), however, it remains to be seen if physician/care team reinforcement of the use of these technologies will be able to improve them even further.
Three chronic illness apps
So, let’s take a look at three chronic illness apps that I think will one day be a part of every Patient-Centered Medical Home:
WellDoc is the granddaddy of all chronic illness mobile companies. It was founded in 2005 by a sister (board certified endocrinologist Suzanne Sysko Clough, MD) and her entrepreneur brother, Ryan Sysko. I will focus here on their first product, DiabetesManager®; other products, such as Oncology Manager, are in development.
DiabetesManager® is a “full service” diabetes support tool providing patients with personalized real-time coaching, glucose testing and medication reminders, alerts when results are too high or too low and follow-up inquiries to be sure the high/low alert was appropriately treated. The tool can be configured so that family and caregivers can also receive alerts. The platform also supports docs manage individual diabetic patients and/or their entire population of diabetics (AKA “disease management”). The WellDoc Automated Expert Analytic System bumps patient data against evidence based guidelines or goals specific to the individual patient. Given space limitations of this blog, the best way to learn more about the multiple integrated features of DiabetesManager® is to view this video:
Because the company incorporated clinical trials of the effectiveness of their platform/app into their business development plan right from the start, there is good data, including a cluster-randomized controlled trial published in the September 2011 issue of Diabetes Care, to document the effectiveness of the technology. This study found a mean decline of 1.9% in A1C levels in the group that used mobile phone-based DiabetesManager® compared to the group that received “usual care.” This improvement in A1C was found whether the patients entered the trial with a high or a low A1C.
iHeadache is one of several apps developed by Better Quality of Life, Inc., a Texas-based organization with the stated mission of providing “practical web-enabled resources and tools to improve patient outcomes – and clinician and staff satisfaction – while creating an efficient and sustainable clinical office practice.” The organization is led by Brian Loftus, MD, a neurologist specializing in pain and headache (as well as multiple sclerosis).
iHeadache is available for the iPhone, iPod touch, and the Blackberry. There is no Android version yet, but I bet they are probably working on this. There are both free (ad-supported) and paid versions (a one-time fee of $4.99 on iTunes). [I downloaded the free version and was bothered by the instrusiveness of the ads – a full screen pop-up ad for Cambia with a link to the Cambia website – I personally would be willing to pay the five bucks to avoid these ads.]
Patients are asked to use the app to track the frequency and duration of their headaches over time as well as to record severity, associated symptoms, disability, medications (and response), and triggers. All the information is collected by picking from lists (or in the case of time, spinning a wheel until the time interval appears). The only time you have to type is if you want to add comments in the notes section.
A symptom list is built in so that answering the questions (e.g., Is your headache preceded by an aura? Is it primarily one-sided, etc.) leads to a presumptive diagnosis of headache type (migraine vs tension).
Reports for the physician can be customized. The report can be set to capture different time periods (e.g., 28 days, 7 days) and the clinician can choose what is included (headache type, medication taken, disability, triggers, or notes. The report can be emailed or printed out and brought by the patient to the visit.
There is a quick start guide and manual as well as video tutorials (although the site is pretty intuitive and most patients (and doctors) should be able to use it without consulting those materials.
The average rating for all versions (269 customers) on iTunes is 3.5/5 stars. The main complaints were about the ability to report more than one headache/day (they seem to have fixed it as it let me report on several headaches in one day) and duration (limited to 24 hours, although the website says for multiday headaches should be reported each day for as long as it lasts).
The Asthmapolis tool is both a sensor, a mobile app, and a website. The sensor, called the Spiroscout, is a device that contains a GPS unit that can be easily attached to most asthma inhalers. It tracks the frequency and location of use of the inhaler. Data from the device is uploaded into the Asthmapolis mobile tracking app and onto the Asthmapolis website.
Users can also manually enter additional information, such symptoms (cough, wheezing, shortness of breath) and triggers (cold, wind, smoke). Because the tracking tool is on the always available mobile phone, information about the event is more likely to be captured in “real time,” thus avoiding the problem of faulty recall.
The data can be accessed from any internet connected device and patients can send the data to their doctors via the website. Patients and their doctors can use this information to determine if any particular locations or other manually entered triggers are correlated with the asthma exacerbations. Medication usage data can be referenced as docs work with their patients on issues related to medication adherence. Clinicians also have their own set of tools, including clinical dashboards, so that they can view the information about all of the asthmatics in their panel and identify and outreach to those who are not doing well.
Practices with an EHR should be able to embed a link to the Asthmapolis website so that the information is easily accessed. In the near future, patients will be able to use the Asthmapolis website to set up text messages, including reminders to notify them if their controller medication has not been used as prescribed.
The results of one small (N=40) CDC funded trial, submitted for publication in a peer-reviewed journal were very good. Half of uncontrolled asthmatics were in control after using the device for three months and 70% of patients improved their level of control. Other, larger studies, are in process including one in collaboration with the Dignity Health System near Sacramento, California.
Asthmapolis has also been partnering with public health agencies and epidemiologists to improve scientific understanding of disease triggers and progression, thus, hopefully, improving our overall understanding of the disease and its relationship to environmental factors. The Asthmapolis sensor and corresponding software applications have not been cleared for use by the United States Food and Drug Administration. However, you are interested in learning about investigational pilot studies or personal use of the system in the future, please contact Asthmapolis at http://asthmapolis.com/contact/
Take home message
mHealth has the potential to transform the care of chronically ill patients from the traditional episodic, office-visit based delivery model to one that is both more responsive and more continuously available to patients. Mobile-powered self-management combined with active clinician engagement in the self-management process has the potential to improve clinical outcomes that have been stubbornly resistant in the absence of such tools.
Further, mHealth applications, such as the ones described above, also provide tools to help manage the health of populations (AKA “disease management”). I predict that a mHealth strategy, customized to the practice’s panel, will one day – soon – be an important part of every patient-centered medical home.
It is a great time to be in healthcare.
This post was first published in Medical Home News, May 2012. The author has no professional or financial relationship with any of the three apps (although she wishes she did!)
Editor note: Asthmapolis was rebranded as Propeller Health in 2013.