While smartphones, sensors, and the ubiquitous Internet continue to transform industries like finance and retail, perhaps there is no area of greater potential or interest than chronic disease management. The concept is simple. Smartphones and sensors provide real-time monitoring of biomarkers and behavior, machine learning and big data analytics uncover personal health insights from this data, and then digital devices offer immediate feedback or interventions leading to improved health.
For example, a smartphone app could, with permission, monitor a person’s location and analyze that data to determine the person has not left the house today. The app could then suggest the person take a walk outside in order to improve their mood and reduce risk of a stroke. The number of use cases seems almost unlimited – as reflected in over 250,000 health-related smartphone apps on the commercial marketplace.
When Investment Rhymes with Canada
Canada has a proud history of achievement in the areas of science and technology, and the field of biomanufacturing and life sciences is no exception.
But something is not working and global health disparities continue to expand. Despite the potential for smartphones to detect and facilitate treatment of depression and even to provide early warning signs of suicidal thoughts, neither depression nor suicide rates have decreased. Despite the potential for wearable sensors to motivate exercise and apps to promote dietary improvement, obesity rates across the globe continue to expand.
A decade ago it was simple to understand why digital technologies had not advanced health outcomes – few people in 2008 actually owned or had access to these devices. But in the ten years since the iPhone was released this has changed. Now over 80 percent of the US population and over 2 billion people around the world own a smartphone. The world population, especially those in developed countries, own the devices, we have capacity to detect pathology and deliver interventions on these devices – so what is missing?
Perhaps the right question is not what is missing, but who is missing. The digital divide is rapidly closing such that access to technology is ceasing to be a barrier, but ownership does not equal engagement. Imagine that everyone in the world was given membership to a gym – no one would expect that everyone in the world would go to the gym regularly. The same goes for smartphones and health. Simply having the smartphone is a necessary first step, but creating programs that can engage users over the long term and motivate change is the real challenge.
But what exactly drives uptake of health apps? There are many answers to this question, but here we propose a few.
Health apps must be interesting and easy to use
This one seems unbearably obvious, but as a field we have a long way to progress on this front. Most health apps today continue to work primarily through offering triggered messages and/or patient education. They do not capitalize on the opportunity to be more interactive or individualized. A 2015 study found a leading reason consumers stopped using a health app was loss of interest. This clearly does not bode well for wide-scale implementation.
On top of being sub-optimally engaging, existing health apps are often difficult to use. A recent study asked those with chronic illness like diabetes and depression to try to enter and retrieve their own data from popular tracking apps. The results were similar for both conditions – those with chronic illness found even popular apps to be difficult and frustrating to use.
Patients are not the only ones struggling with usability – clinicians are in the same boat. Clinicians often find accessing the information their patients collect via an app difficult since apps often sequester data on unique portals that are not integrated with electronic medical records. For clinicians this means another set of login credentials, another interface that requires loading time, and another program they have to become familiar with. Taken together, this translates into greater administrative responsibilities and, consequently, less time with patients.
Health apps must be integrated into the healthcare system and covered by insurance.
While consumers may be able to pay for a number of apps, they still report that cost is a barrier to use. Perhaps more importantly, patients tend to rely largely on medical professionals to guide their health improvement efforts. And both healthcare professionals and hospital systems still rely on reimbursement from payers for their livelihood.
Optimal integration of health apps into the healthcare system would involve clinicians recommending apps, spending time discussing this treatment option with patients, and then following patient data to determine when more intensive care or follow-up visits are needed. This would require that clinicians know of apps that are effective and trustworthy, have access to data entered via those apps, and have a way of billing for time spent discussing health apps and following patient progress via clinician interfaces.
There are many requirements for such integration, but payer coverage of health apps is a big one. On a practical level, it makes use of health apps in treatment plans feasible. On a more abstract level, it symbolizes acceptance of health apps as valid healthcare tools that, just like services and medications, can produce reliable effects.
Health apps must connect with their users emotionally
Therapeutic alliance or the strength of the connection between intervention agent (traditionally a clinician) and patient has time and time again been found to be a key driver of outcomes in behavioral health. In clinical practice, is why our patients come back week after week even when we ask them to do things that feel like hard work in service of their health – be that behavioral activation, medication adherence or dietary changes. Unfortunately, convenience, omnipresence and even efficacy for those who stick with an app, do not necessarily mean consumers have a connection with health apps.
Apps need to cultivate this connection. Patients need to feel that their apps “get” them. It is this alliance that will keep users interested after the novelty and initial motivation wears off and that hard work (i.e., changing behaviors contributing to chronic illness) sets in. Without a connection to the app –interest is likely to short-lived.
What next?
While of course there are examples of apps that have hit key targets in terms of usability, healthcare system integration, and therapeutic alliance – these remain the minority. That said, the examples of those that do indicate clearly that wide scale engagement of users is not a quixotic quest.
A recent study in Australia featuring an app to prevent suicide in indigenous peoples had low attrition rate of just 3 percent. The secret? Joseph Tighe who led the study had spent many years living and working with the local population, worked with them in the process of designing, building, and even testing the app. The final product was not just an app, but a community engagement project that drew on the experience and expertise of everyone.
Such a collaborative and integrated effort holds lessons for all health app development. We must develop apps iteratively, alongside actual patients and with the guidance of actual providers if we want to see engagement.
Recognizing the crisis in engagement is a first step towards finding solutions. There will always be new app-based interventions and new types of data monitoring and integration tools – but we need to step back and make the current ones we have today work for us all now. Digital health for chronic illness is no longer a technology problem – it’s an implementation problem.
