digital healthcare and mhealth apps: promoters or barriers ... · 1. digital healthcare and mhealth...

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Yorkshire Centre for Health Informatics Digital healthcare and mHealth apps: promoters or barriers to integrated care ? Jeremy Wyatt DM FRCP ACMI Fellow Leadership chair in eHealth research, University of Leeds Clinical Adviser on New Technologies, Royal College of Physicians, London [email protected]

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Page 1: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Yorkshire Centre for

Health Informatics

Digital healthcare and mHealth apps:

promoters or barriers to integrated

care ?

Jeremy Wyatt DM FRCP ACMI Fellow

Leadership chair in eHealth research, University of Leeds

Clinical Adviser on New Technologies, Royal College of Physicians, London

[email protected]

Page 2: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Digital healthcare

“Supplementing or substituting interactive digital tools for

clinical, self management or health promotion activities”

Primary users can be health professionals, patients or

members of the public

Secondary users: those analysing the data captured for CQI,

research & other purposes

Page 3: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Why digital ?

• Convenience – the 24hr society – fix your

symptoms any time, any place

• The promise of unified health records [access

digital information anywhere]

• Opportunity for automated analysis, audit, decision

support, case finding, reminders…

• Never lose your records – on the cloud

• Efficiency of the digital channel…

£8.60

£5.00

£2.83

£0.15 £0

£1

£2

£3

£4

£5

£6

£7

£8

£9

£10

Face to face Letter Telephone Digital

Co

st

in £

per

en

co

un

ter

Mean public sector cost per completed encounter across 120 councils

Source: Cabinet Office Digital efficiency report, 2013

Page 4: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

The wide range of digital

healthcare tools

Tools for professionals:

• Electronic health records, ePrescribing...

• Tablets and apps to support bedside / mobile working

Tools for patients with LTCs:

• Skype consultations, txt msgs for reminders & test results…

• Apps, home monitoring, websites, social media etc. for self

management

Tools for the public:

• Phone / online triage tools for acute illness

• Apps, serious games etc. for health promotion…

Page 5: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Potential drawbacks of digital

• Equity of access – “cyberdivide”

• Getting people to use it

• Safety issues:

– Bad programming inside: miscoded algorithms / risk

scores

– Bad programming on the human interface

– Leakage of confidential clinical data

– Failure to share clinical data, leading to fragmented

records

• So, does it actually reduce resource use & save

money ?

Page 6: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Impact of pt. access to their record

on healthcare resource use

US cohort study comparing office visits per month in those who

did and did not take up online access to their records

Results: a significant increase in:

• The number of office visits (0.7 per member pa.)

• Phone calls (0.3 per member pa.)

• OOH visits (19 per 1000 members pa)

• ER visits (11 per 1000 members pa.)

• Hospitalisations (20 per 1000 members pa.)

Source: Palen, JAMA 2012

Page 7: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

What does “Integrated care”

require ?

Integration across specialist services within same

organisation:

• Unique pt. identifier

• Coordination & sharing of data definitions, data capture &

data access

• Trust of users in data, software etc.

Integration across organisations:

• Exchange of pt. data, clinical protocols, service information

across organisational boundaries

• Even greater trust in “foreign” data, software, care protocols

Page 8: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Case study:

Building trust in mHealth apps

Page 9: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Apps: supportive evidence

Recent randomised trials of apps themselves:

• Self management by people with diabetes [Kirwan, JMIR 2013]

• “My Meal Mate” for reducing BMI [Carter, JMIR 2013]

Systematic reviews of mHealth in general:

• Computer based self-management in diabetes

[Pal, CDSR 2013]

• mHealth for HIV Treatment & Prevention

[Catalani, Open AIDS J 2013]

• mHealth technologies for service delivery

[Free, PloS Med 2013]

Page 10: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

The variable quality of health apps

Developers publish apps: • with no named source of content (95%)

• after no apparent clinical contact (86%)

• with no evaluation to support their claims (100%)

Study of 112 chronic pain apps for public use: Rosser & Eccleston 2011

So, apps: 1. Raise privacy issues (10% of 600 popular health apps had privacy policy)

2. Can be expensive for clinician, consumer & health system

3. Give bad advice (eg. opioid drug dose converter - Haffey 2013;

melanoma risk tools - Wolf 2013; Leeds study on cardiovascular risk

apps)

Page 11: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Leeds study of CVD risk apps

19 cardiovascular risk prediction iPhone

apps (paid or free) for public use

15 scenarios, true 10 year risk varied from

1% to 75%

Results:

• Some apps limited age to 74, ignored diabetes

• Estimated risk on scenario with correct risk of

75% varied from 19% to 137% !

Heart Health App With Hannah Cullumbine & Sophie

Moriarty, Leeds medical students

Page 12: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Study on App privacy risks

All Apps ask for “permissions” at

installation:

• Some are legitimate, eg. access to

internet

• Many are not: access to contacts,

phone calls, browsing history…

Median of 4 privacy risks for lifestyle

Apps, 1 for medical Apps (p<0.001)

Heart rate App –

Cardiograph

With Hannah Panayiotou & Anam Noel,

Leeds medical students

Page 13: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

How to promote higher quality Apps ?

Traditional strategies:

• Expert reviews by eg. iMedicalApps.com

• NHS review & branding

• Self-certification using eg. Health on the Net criteria

• User ratings and reviews (“wisdom of the crowd”)

• Regulation by MHRA, FDA etc.

New strategy: develop & promote app quality

criteria based on Donabedian’s model

Avedis Donabedian, Lebanese

physician, 1919-2000

Page 14: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

User ratings: app display rank versus

adherence to evidence

Study of 47

smoking

cessation

apps (Abroms

et al, 2013)

Page 15: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Regulation of medical apps by FDA, FCC

If classified as a medical device by FDA a product must

demonstrate efficacy, but:

• Only 100 apps so far classified as a medical device

• Decision to exercise “enforcement discretion” on most medical apps

• So, FDA has not actually banned any apps, yet

However, the Federal Communication Commission has

banned some apps with misleading claims, eg. “Acne Cure”

(no evidence of claimed benefit of iPhone screen backlight)

Sharpe, New England Center for Investigative Reporting, Many health apps are based on

flimsy science at best, and often do not work. Washington Post, November 12th 2012

Page 16: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

We need to think differently…

Old think New Think Paternalism: we know & determine what

is best for users

Self determination: users decide what is

best for them

Regulation will eliminate harmful Apps

after release

Prevent bad Apps - help App developers

understand safety & quality

The NHS must control Apps, apply rules

and safety checks

Self regulation by developer community

Consumer choice informed by truth in

labelling

App developers are in control Aristotle’s civil society* is in control

Quality is best achieved by laws and

regulations

Quality is best achieved by consensus

and culture change

The aim of Apps is innovation

(sometimes above other considerations)

App innovation must balance benefits

and risks

An Apps market driven by viral

campaigns, unfounded claims of benefit

An Apps market driven by fitness for

purpose (ISO) & evidence of benefit

• The elements that make up a democratic society, such as freedom of speech, an independent

judiciary, collaborating for common wellbeing

Page 17: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Our draft quality criteria for apps

based on Donabedian 1966

Structure = the app development team, the

evidence base, use of an appropriate CPD / health

promotion etc. model…

Processes = app functions: usability, accuracy etc.

Outcomes = app impacts on users (knowledge,

problem solving…), patient outcomes, NHS

resource use

Wyatt JC, Curtis K, Brown K, Michie S,. Submitted to Lancet

Page 18: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Summary for apps

3. The Royal College of Physicians, NHS

Trusts, BSI and other bodies are

exploring this approach, eg.

“Patients, health professionals and

system developers would benefit from

publication of an agreed set of quality

criteria for clinical and health promotion

systems and for apps.”

RCP Future Hospital Commission report 2013, p. 93

1. App rating, self-certification and regulation are not enough

2. To reduce “apptimism”, we must evaluate apps against

quality criteria & label them

Page 19: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Semantic interoperability

Disclaimer:

I am not omnipotent, just a doctor

Page 20: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

mHealth as both challenge and

opportunity

Challenges:

• Patchwork of incompatible, small scale apps from cottage

industry of developers

• Silos of data

• Much software is not reusable (some OS apps)

• Poor IG: only 10% of 600 most popular H&LS apps had

privacy policy – recent US/ German study

Opportunities:

• Little NHS investment so far in infrastructure

• Shake down coming once EU DP Regulation agreed

• Open mHealth initiative

Page 21: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Open mHealth initiative

Reusable health

data &

knowledge

services

Analysis, feedback

Processing

Data storage

Data transport

Data capture

Apple’s

Healthkit ?

App1 App2 App3 Based on Estrin & Sim, Science 2012

Stovepipe model Open model

Page 22: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

We have the necessary standards

in the NHS

• Patient identity standards – NHS number

• Health-specific syntactic and semantic data

standards – SNOMED CT, HL-7, CDA…

• Data stores that enable selective, patient-controlled

sharing - eg. MyDex, Patients Know Best…

• Core data processing functions eg. feature

extraction and analytics - ??

So, let’s do NHS Open mHealth !

Page 23: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Conclusions

1. Digital healthcare and mHealth apps have much

to offer the NHS and global health

2. However, they could be barriers to integrated care

3. Integrated care requires both human trust and

technical standards

a) Agreed quality criteria for eg. apps will help build trust

b) Approaches like Open mHealth will help address

technical / data exchange issues

4. The NHS is very well placed to adopt both these

approaches

Page 24: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers
Page 25: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Transforming health care

Old model of care New model

Focus on acute conditions Focus on long term conditions

Reactive management Prevention & continuing care

Hospital centred Embedded in homes & communities

Disjointed episodes Integrated with people’s lives

Doctor dependent Team based, shared record

Patient as passive recipient Patient as partner

Self care infrequent Self care encouraged & supported

Use of ICT rare Dependent on ICT & devices

Page 26: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

The potential of mobile health

apps

Apps offer clinicians just-in-time knowledge & reminders;

patients personalised support for self-management

Once developed, they are easy to disseminate (“massively

scalable”)

Smart phones can help NHS access hard-to-reach populations

Apps technology allows:

• Tailoring to user profile and location (via GPS, wifi zones, scanned QR

codes on patient label, equipment, hospital walls…)

• Linkage to large knowledge bases (eg. ePrescribing tool, Map of

Medicine, My Meal Mate details of 60k foods)

• Access to data held securely on remote EPR, not device

Powell et al. In search of a few good apps. JAMA 2014

Page 27: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Expert reviews: iMedicalApps process

Acquire App

Review existing literature

Use App in simulated

environment

Use App in clinical practice

Draft assessment according to

template

Further peer review by senior

editorial staff

Slide from Tom Lewis,

Warwick Uni / iMedicalApps

Page 28: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

Self-certification of web sites using

Health on Net criteria

The process:

1. Check “Health on the Net” criteria www.hon.ch:

• Authoritative, attributed material; date of revision

• Website states: purpose, intended user; if for patients, that

it is no substitute for medical advice

• Policy on confidentiality of patient data

• Justification of claims with scientific evidence

• Contact details, funding sources, advertising policy

2. Download HON logo & attach to site

No sanctions for misuse of HON logo:

Page 29: Digital healthcare and mHealth apps: promoters or barriers ... · 1. Digital healthcare and mHealth apps have much to offer the NHS and global health 2. However, they could be barriers

NHS Health Apps library criteria

• Relevant to people living in England

• Complies with data protection laws

• Complies with trusted sources of information, such

as NHS Choices.

• Could it potentially cause harm to a person’s health

or condition. “Eg. is it limited to providing

information from a trusted source – or might it go

on to provide personalised medical

recommendations or treatment options?”

http://apps.nhs.uk/review-process/#transcript