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Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
Chronic Diseases: An App A Day
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Chronic Diseases: An App A Day

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Presentation at the World Congress on Cardiology in Melbourne, Australia

Presentation at the World Congress on Cardiology in Melbourne, Australia

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  • 1. Managing Chronic Diseases: An App a Day? Iris Thiele Isip Tan MD, MSc @endocrine_witch #HealthXPh Chief, University of the Philippines Medical Informatics Unit Associate Professor, University of the Philippines College of Medicine Tuesday, May 6, 14
  • 2. Disclosure Statement of Financial Interest I, 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
  • 3. “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
  • 4. 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
  • 5. 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
  • 6. 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 Specialist medical education Formal continuing medical education Patient education Fig 1 from Aungst TD et al. Int J Clin Pract 2014;68:141-2. Tuesday, May 6, 14
  • 7. There’s an App for That: Content Analysis of Paid Health and Fitness Apps West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett J J Med Internet Res 2012;14(3):e72 n = 5430 Apps: Health and Fitness category n = 1324 Free apps (Excluded) n = 338 Non-English apps (Excluded) n = 432 Miscategorized into Health & Fitness category (Excluded) n = 3336 Final 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
  • 8. Predisposing Factors Antecedents to behavior, such as knowledge, attitude, beliefs, values, and confidence or motivation. Enabling Factors Antecedents to facilitate behavior change such as teaching skills, providing a service, or tracking progress. Reinforcing Factors Factors 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):e72 Adapted 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
  • 9. App credibility by price West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett J J 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
  • 10. Apps by HECAT content area Apps could be coded in multiple categories West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett J J Med Internet Res 2012;14(3):e72 Physical Activity Personal health & wellness Healthy eating Mental & emotional health Sexual & reproductive health Alcohol, tobacco & other drugs Violence prevention & safety 0 200 400 600 800 1000 1200 No. of apps 33.2% 28.8% 19.5% 12.4% 7.3% 3.9% 2.9% Tuesday, May 6, 14
  • 11. Apps by HECAT content area Apps could be coded in multiple categories West JH, Cougar Hall P, Hanson CL, Barnes MD, Giraud-Carrier C, Barrett J J 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
  • 12. Apps by Precede-Proceed Model Apps 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
  • 13. 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
  • 14. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013 n = 43,689 apps Healthcare & Fitness or Medical n = 20,007 Miscategorized or only loosely health related n = 23,682 Genuine healthcare related 1 2 3 App categorization IMS Health functionality scoring system Apps placement on the patient journey n = 16,275 Consumer oriented n = 7,407 Healthcare professional oriented Tuesday, May 6, 14
  • 15. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013 App categorization by functionality INFORM Provide information in a variety of formats (text, photo, video) INSTRUCT Provide instructions to user RECORD Capture user entered data DISPLAY Graphically display user entered data/output user entered data GUIDE Provide guidance based on user entered information; recommend consult REMIND/ ALERT Provide reminders to the user COMMUNICATE Provide communication with HCP/patients; provide links to social networks Tuesday, May 6, 14
  • 16. Inform Instruct Record Display Guide Remind/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
  • 17. Patient Apps for Improved Healthcare IMS 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 Intervene Tuesday, May 6, 14
  • 18. Patient Apps for Improved Healthcare IMS Institute for Healthcare Informatics Oct 2013 Number of apps Functionality score 25 individual criteria Weights specific to category of app Maximum score: 100 More than 90% of apps scored 40 or less Tuesday, May 6, 14
  • 19. 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 regimens Understanding physician instructions Ensuring polypharmacy is appropriately managed Medication compliance or adherence to physician instructions Tuesday, May 6, 14
  • 20. 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 referrals Second opinions Diagnosis/ Education Medical information, condition management information, emotional support post- diagnosis Filling prescription Finding a pharmacy, availability, price and insurance coverage Compliance Persistence, compliance n = 304 n = 931 n = 562 n = 200 n = 225 Therapy Area Specific: 1,980 Demography Specific: 1,440 Tuesday, May 6, 14
  • 21. 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
  • 22. “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
  • 23. 38% to track exercise 31% to monitor diet 12% to manage weight Others: 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
  • 24. Yap yap yap! by davdibiase http://www.freeimages.com/photo/160538 More likely to download an app Women Under 50 Better educated Annual household income over $75,000 Significant health change in last 12 months Mobile Health 2012 Pew Internet Survey Tuesday, May 6, 14
  • 25. Patients facing multiple chronic diseases typically over age 65 Lowest smartphone penetration 18% of US adults >65 y vs 55% of those aged 45-54 y Tuesday, May 6, 14
  • 26. 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
  • 27. Hyperwall by Florian Plag https://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 Aitken Executive Director IMS Institute for Healthcare Informatics Tuesday, May 6, 14
  • 28. 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 media Search mobile app store Research 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 NO NO 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 practice Tuesday, May 6, 14
  • 29. 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 Clinical decision making Medical publisher Regularly updated Properly referenced Authors listed Feedback Recommended For health professionals ???Tuesday, May 6, 14
  • 30. 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 privacy Does 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
  • 31. 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
  • 32. “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
  • 33. 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
  • 34. 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 Paskavitz Editor-in-Chief, Quantia Inc. Tuesday, May 6, 14
  • 35. Drug questions by Ano Lobo, https://flic.kr/p/8Rvugs QuantiaMD Poll n = 1500 37% of physicians have prescribed an app to their patients. Press release 24 Feb 2014 http://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
  • 36. QuantiaMD Poll n = 250 Press release 24 Feb 2014 http://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
  • 37. 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
  • 38. “ 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
  • 39. Runkeeper and health on iPhone by Jason Howie, https://flic.kr/p/e5CBwN Mobile medical app to be used as an accessory to a regulated medical device; or to transform a mobile platform into a regulated medical device FDA guidance, Sept 2013 Tuesday, May 6, 14
  • 40. “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.2014.2564Caledos runner by Nicola, https://flic.kr/p/fP18Jx Tuesday, May 6, 14
  • 41. 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
  • 42. 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_witch Tuesday, May 6, 14

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