The State of Mobile Health in Today's Practice

February 20, 2018

More practices are adopting mHealth technologies in different ways, but the lack of evidence surrounding these apps has some concerned.

Three out of four Physicians Practice readers agree: mobile devices are a mainstay in today's medical practice.

No, this isn't some lame commercial pitch, but the reality of our readership's day-to-day operations based on the results of a new survey from Physicians Practice. In the 2018 Mobile Health Survey (187 total respondents), 75.9 percent say they use mobile health (mHealth) in their practice on a weekly basis.

As recently as two years ago, an

doctors were excited about the prospect of using mHealth in daily practice, but a far smaller number were actually doing so. Make no mistake about it, restraint over using mHealth in day-to-day practice is still a prevalent feeling. The majority of practices using mHealth regularly are only doing so 0-5 hours per week, according to the 2018 Mobile Health Survey.

Yet, it's clear there has been a shift in the way physicians and practices view mHealth in the practice. Some of this is due to a shift in technological capabilities, with one reason being the EHR.

"[With my EHR platform], I can access pretty much all of my patients' information on a mobile phone or a tablet and it's quite convenient," says Joe Kvedar, MD, founder and vice president of Connected Health, an initiative from Partners HealthCare system in Boston.

Greg Kuhnen, senior director of research at The Advisory Board, a Washington D.C.-based consulting group, also emphasizes this convenience factor - in and out of the office. The mobile apps allow physicians to look up lab results, get context on a patient, and answer a question, all with a few swipes, he says. "It's definitely a lifestyle improvement," he says.

Dr. Kvedar mentions consumer expectations of mHealth usage have only gone up in recent years. "Some of the organizations we would have not thought of as competition, like CVS, Walgreens, or payers, Teladoc - who have created opportunities to interact with a clinician outside of traditional areas - have created a fear of missing out among [clinician organizations and administrators]...people are starting to adopt [mHealth technologies] more because they feel they'll be left out if they don't."

Uses of mHealth

The Physicians Practice 2018 Mobile Health Survey shows a variety of uses for mobile technology in the practice setting. The most common, according to nearly 70 percent of respondents using mHealth, is for communication between staff members. The second most common is using the mobile EHR application (51.1 percent of respondents), third is communication with providers (50 percent), and right behind that is education on clinical issues (46.6 percent of respondents). This jives with what Kuhnen has observed at Advisory Board.

"We see a couple of applications that we're expecting to be pretty ubiquitous quickly. We've seen pretty broad adoption. The first of those is unified communications…Skype-like systems that bring together calling, texting, paging, screen sharing, video chats…The reason they've been popular is because they improve productivity and cut down on communication errors," he says.

Communication is how ProHealth Care, a health system in the Waukesha, Wisc. area, uses mHealth. According to Bill Bailey, enterprise architect at ProHealth, the app his organization uses helps nurses on the care team communicate, through secure voice and texting capabilities. Bailey says the app has a robust directory, meaning nurses can not only communicate with each other and get on the same page, but also add members of the patient's care team who need to be contacted. 

Linda Girgis, MD, family medicine physician in South River, N.J., uses mobile for communicating with patients. She says she sometimes Skypes with patients, and also uses the patient portals and telemedicine.

"The area where I practice was classified as a PCP crisis shortage area by the American Academy of Family Physicians. A doctor near us who had been in practice for decades recently retired. There are just not enough doctors who practice primary care in my area. Using mobile apps allows us to be able to treat more patients," she says, adding that not only do these mobile communications allow her to be more productive, but they are convenient for the patient. "We have some patients who travel long distances to come to our practice. Some routine follow-ups [done through mobile] cut that commute."

Telemedicine, Girgis says, has yet to catch on with patients. The 2018 Mobile Health Survey confirms this, as only 4.8 percent of mHealth-using practices say they engage patients through telemedicine. This compares to 41 percent who say they use secure text messaging and 38.6 percent who use the patient portal.

Xcertia

The number of practices using mHealth has grown exponentially, in part because the number of mHealth apps has grown. In the 2018 Mobile Health Survey, practices listed a number of apps they use on a daily basis (see the survey results for a more complete list) including Epocrates, Quantia MD, Doximity, UptoDate, and many more.

According to Research 2 Guidance, a research firm, there were 325,000 mHealth apps available in 2017, representing a 25 percent growth from 2016. This growth could potentially mean mHealth apps that haven't been thoroughly vetted are being used by patients and clinicians alike. The Food and Drug Administration (FDA) monitors mHealth medical apps in the same capacity it does for medical devices. However, there is still uncertainty around how the FDA defines an app that meets this criteria. Moreover, there is absence of evaluation of these apps from a clinical usage perspective.

For this reason, a number of health care stakeholder groups, led by the AMA, American Heart Association, HIMSS, and others, started a collaborative initiative called Xcertia. It is developing a set of guidelines that will give clinicians the ability to judge mHealth apps based on content, privacy, operability, and security.

"There is an overwhelming number of apps in the mobile health space with no real sense of which ones are up to snuff from a clinical perspective," says Kvedar, who is a founding board member of Xcertia. He says the guidelines should give clinicians the seal of approval to use or recommend a particular app. "The vision is clinicians will see this and feel more comfortable offering that to patients."

Kvedar adds that a number of physicians say they want to recommend mHealth apps and use them more frequently, but have trepidation in doing so. Currently Xcertia is evaluating the first draft proposal of its guidelines. Once those guidelines are finalized the organization will look to find a certifying body, which will evaluate apps based on the criteria.

Wearables
One area of mobile that might need more thorough evaluation is wearables. Currently, the use of wearables by practices is much lower than average mHealth apps, with only 14.5 percent of respondents to the 2018 Mobile Health Survey saying they accept data from these devices. The most common reason why, according to 61.1 percent of respondents, is that the data doesn't integrate into the EHR.

Kuhnen says another factor in slowing down the adoption of wearables in a practice setting is the lack of financial incentives. "Physicians are seeing so much data currently, there is a bit of a data overload. You're going to have to see more of a move towards value-based payments to get them to use [wearable data]," he notes. Putting physicians on the hook for the cost of care in a fully capitated model, he notes, would give them more reason to ensure their patients are being more active. Kvedar agrees that compensation is a big question regarding tracking and using wearables data, as well as how it can be integrated into a physician's work flow.

Steve Ommen, associate dean and medical director of connected care at Mayo Clinic, says the data around the technology needs to develop as well. "The wearable devices have largely focused on simple biometrics to date, that we didn't previously have a large archive of data that we knew was a true signal of someone's health. Now that more people are using them and there are large databanks of biometric data, the big data [crowd] can develop algorithms to predict [health behaviors]," he says.

Ommen adds that the sensors that drive these wearable devices are evolving into more specific uses for the patients who need this kind of tracking the most. "I think wearables are coming, but there is a lot of work to be done."

Advice

Whether it's mobile apps, wearables, or something else, there are still practices afraid to take the plunge. For those who are airing on the side of caution, Girgis has some simple advice: "Don't be afraid to try new things." She adds that it's important to ask advice of those who have already gone ahead and adopted the technology. 

It's important for mHealth novice practices to start small and make sure they understand an app's value before using it, advises Kuhnen. Another important piece of advice, he says, is to make sure you consider the patient's feelings.

"If you're not careful on how you roll [a mHealth app] out, there can be negative feelings on patient side. If a patient sees a staff member tapping on away at their phone, they may assume they're on Facebook or a social network. Having an explicit communication or marketing strategy on how you roll these things out is important," he says.

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