[This post originally appeared on The Health Care Blog on 3/13/13.]
Should
I be prescribing apps, and if so, which ones?
I be prescribing apps, and if so, which ones?
I
recently came across this
video of Happtique’s CEO Ben Chodor
describing his company to Health 2.0’s Matthew Holt. In it, the CEO explains
that Happtique is creating a safe and organized space, to make it easy for
doctors to prescribe apps and otherwise “engage with patients.”
recently came across this
video of Happtique’s CEO Ben Chodor
describing his company to Health 2.0’s Matthew Holt. In it, the CEO explains
that Happtique is creating a safe and organized space, to make it easy for
doctors to prescribe apps and otherwise “engage with patients.”
Because,
he says “we believe that the day is going to come that doctors, and care
managers, are going to prescribe apps. It’s going to be part of going to the
doctor. He’s going to prescribe you Lipitor, and he’s going to give you a
cholesterol adherence app.”
he says “we believe that the day is going to come that doctors, and care
managers, are going to prescribe apps. It’s going to be part of going to the
doctor. He’s going to prescribe you Lipitor, and he’s going to give you a
cholesterol adherence app.”
He
goes on to say that they have a special process to make sure apps are “safe”
and says this could be like the good housekeeping seal of approval for apps.
goes on to say that they have a special process to make sure apps are “safe”
and says this could be like the good housekeeping seal of approval for apps.
Hmm.
I have to admit that I really can’t imagine myself ever prescribing a
“cholesterol adherence” app. (More on why below; also found myself wondering
what it exactly meant for Happtique to say an app was safe. What would an
unsafe cholesterol app look like?)
I have to admit that I really can’t imagine myself ever prescribing a
“cholesterol adherence” app. (More on why below; also found myself wondering
what it exactly meant for Happtique to say an app was safe. What would an
unsafe cholesterol app look like?)
Happtique,
of course, is not alone in hoping that clinicians will be prescribing apps to
patients in the near future. Many digital health enthusiasts expect that apps
will become a routinely used tool in healthcare, especially if clinicians
encourage patients to use them.
of course, is not alone in hoping that clinicians will be prescribing apps to
patients in the near future. Many digital health enthusiasts expect that apps
will become a routinely used tool in healthcare, especially if clinicians
encourage patients to use them.
But under what circumstances will
clinicians want to prescribe apps, and what would make it easier for them to do
so?
clinicians want to prescribe apps, and what would make it easier for them to do
so?
Right
now, my best guess would be that clinicians will mainly be motivated to
prescribe apps in the same way that they’ve historically prescribed drugs:
now, my best guess would be that clinicians will mainly be motivated to
prescribe apps in the same way that they’ve historically prescribed drugs:
- Because
they’ll get marketed to,
mainly by companies with financial interests in clinicians prescribing
certain apps. This leads to clinicians both having an awareness of the app
and having a feeling that prescribing the app is a good thing at some
level (whether or not this is true by other objective evaluations).
- Because
someone will make it very easy for them to recommend an app to
patients. This could be a platform such as Happtique becoming dominant
enough – and usable enough – such that it becomes very easy for a
clinician to prescribe an app, just as Amazon has made it very easy to buy
on their site. Or it could be a major medical system integrating links to
a smaller curated set of apps into their e-prescribing or patient
recommendation system. (Happtique is working on this, too.) There are lots
of ways to make it fairly easy for clinicians to take certain actions,
especially if someone stands to make money as a result.
- Because
patients and families might request an app. Just as
direct-to-consumer marketing of drugs can affect prescribing,
direct-to-consumer marketing of apps could influence clinicians. This
could be a general request: “Can you recommend an app to help me with this
health problem?” Or it might be a request that a clinician endorse a specific
app: “I’ve seen ads for a Beer’s
Criteria app. Would you recommend I use it, to help me spot
medications that could potentially harm older adults?” (In which case I’d
likely answer a resounding YES; a geriatrician can dream, no?)
Ok,
now let’s step back a bit and think about what the above approach has overall
brought us when used by the pharma industry:
now let’s step back a bit and think about what the above approach has overall
brought us when used by the pharma industry:
- Lots of prescribing of drugs, whether or not
drugs were the optimal approach to managing a given problem - Lots of prescribing of certain well-marketed
drugs, whether or not those specific drugs were the likely to be the best
choice based on available evidence - Lots of profit for certain companies
- High pill burden for many patients
- Substantial medication-related expenses, both
out-of-pocket and for payers - Harm related to medication side-effects and
interactions
Hmm.
Obviously many have also benefited from the prescription of pharmaceuticals,
but still, especially when one considers the med lists of elderly patients, it
becomes clear that there’ve been downsides to the way clinicians have been
historically been encouraged and enabled to prescribe.
Obviously many have also benefited from the prescription of pharmaceuticals,
but still, especially when one considers the med lists of elderly patients, it
becomes clear that there’ve been downsides to the way clinicians have been
historically been encouraged and enabled to prescribe.
Will
we do better when it comes to apps?
we do better when it comes to apps?
Why should a clinician recommend an app?
If
I were asked “Why should a clinician prescribe an app?” I would answer as
follows:
I were asked “Why should a clinician prescribe an app?” I would answer as
follows:
Because it’s likely to help the patient
reach his or her most important health goals, and is a good fit within an
over-arching medical management plan.
reach his or her most important health goals, and is a good fit within an
over-arching medical management plan.
In
other words, if the goal is to provide sensible medical assistance to patients
and families, the use of an app should be likely to:
other words, if the goal is to provide sensible medical assistance to patients
and families, the use of an app should be likely to:
- Help a
patient work towards the most important medical goals. - This means clinician and patient
should’ve discussed goals overall, and prioritized which issues are most
important for the time being. Since I take care of complex older
patients, prioritizing issues is really a must, and then we can set
certain goals for the issues we’ve decided to focus on.
- Be likely
to provide benefit or otherwise be clinically useful. - This doesn’t mean we always need
peer-reviewed studies demonstrating that use of this particular app
provided a health benefit. But there should be some reason to believe
using an app will be clinically useful. - This could be because the app
facilitates collection of data needed to revise the treatment plan, i.e.
documents pain, incontinence, sleep patterns, as-needed medication use, etc. - Or it could be that the app
digitally guides patients through an intervention previously found to be
beneficial, such as a home exercise plan. - As with the prescription of a
drug, recommending an app should include guidance as to what benefit the
patient can expect, as well as a plan for ensuring that the app is delivering
benefit as expected.
- Be a good,
feasible fit within an overall management plan. - Just as I don’t prescribe a
medication in isolation, without considering the patient’s other medical
conditions and other prescriptions, I wouldn’t recommend an app in
isolation. - I find that most patients and
families have only so much bandwidth available for daily healthcare
management tasks. So in considering an app I’d also try to be mindful of
how many other apps have been recommended, and I’d try to work out an overall
plan that was going to be manageable for the patient. After all, there is
only so much futzing with
devices that one can do in a given day.
Since
my patients are older adults with multiple medical problems, I expect that I
wouldn’t very often suggest apps that are narrowly focused on something like
cholesterol. I don’t need patients to “adhere” (a problematic word for many
reasons) to their statin and learn all about which diet is best for lowering
cholesterol.
my patients are older adults with multiple medical problems, I expect that I
wouldn’t very often suggest apps that are narrowly focused on something like
cholesterol. I don’t need patients to “adhere” (a problematic word for many
reasons) to their statin and learn all about which diet is best for lowering
cholesterol.
What
I do need is for patients to be supported in taking several meds that we’ve
decided on, and then I need them perhaps to have support in remembering
whatever combination of diet tips we decided was a reasonable fit for their
preferences and combination of medical conditions. (For example, in some cases
I *do* advise the family of a frail elderly diabetic to loosen up and let the
patient have a doughnut.)
I do need is for patients to be supported in taking several meds that we’ve
decided on, and then I need them perhaps to have support in remembering
whatever combination of diet tips we decided was a reasonable fit for their
preferences and combination of medical conditions. (For example, in some cases
I *do* advise the family of a frail elderly diabetic to loosen up and let the
patient have a doughnut.)
Also,
it would be burdensome if every specialist my patient saw decided to prescribe
their own pet app for “adherence” to whatever condition the specialist was
concerned about. Just as Boyd et al demonstrated in their 2005 JAMA
paper that attempting to implement all guideline-recommended care for nine
commonly co-existing chronic conditions led to an unmanageable plan of care,
prescribing an app for every little thing on an older patient’s problem list
will definitely lead to app overload for the patient’s care circle.
it would be burdensome if every specialist my patient saw decided to prescribe
their own pet app for “adherence” to whatever condition the specialist was
concerned about. Just as Boyd et al demonstrated in their 2005 JAMA
paper that attempting to implement all guideline-recommended care for nine
commonly co-existing chronic conditions led to an unmanageable plan of care,
prescribing an app for every little thing on an older patient’s problem list
will definitely lead to app overload for the patient’s care circle.
In
short, I can envision apps helping patients and families manage a medical care
plan. But I worry that we’ll end up making the same mistakes with apps as we’ve
often made with the prescription of medications: recommendations based on
marketing rather than thoughtful assessment of expected value, and prescription
of apps for every little medical condition rather than choosing a few
high-yield apps based on a whole-person approach to managing healthcare.
short, I can envision apps helping patients and families manage a medical care
plan. But I worry that we’ll end up making the same mistakes with apps as we’ve
often made with the prescription of medications: recommendations based on
marketing rather than thoughtful assessment of expected value, and prescription
of apps for every little medical condition rather than choosing a few
high-yield apps based on a whole-person approach to managing healthcare.
Ensuring thoughtful clinical app use
How
to ensure that the clinical recommendation of apps is thoughtful and
person-centered? I’m not sure, but in general I think there would be value to
clinicians and patients doing the following:
to ensure that the clinical recommendation of apps is thoughtful and
person-centered? I’m not sure, but in general I think there would be value to
clinicians and patients doing the following:
- Review use of the app in the context of the
overall big picture of the person’s health, and the overall goals of
medical care - Be explicit about the purpose of the app and
expected benefit - Plan a future time to review use of the app and
assess whether the benefit justifies continued use. - Periodically consider winnowing down the number
of apps being used, especially if the patient or care circle report any
app fatigue.
You
might notice that the above looks an awful lot like what we should be doing –
but often don’t – with patients’ chronic medication lists.
might notice that the above looks an awful lot like what we should be doing –
but often don’t – with patients’ chronic medication lists.
Summing it up
Apps,
like pharmaceuticals, can in principle help patients and families meet their
healthcare goals. Many would like clinicians to embrace apps and begin
recommending them to their patients.
like pharmaceuticals, can in principle help patients and families meet their
healthcare goals. Many would like clinicians to embrace apps and begin
recommending them to their patients.
It
would be easy for clinicians to end up making the same mistakes with apps as
we’ve often made with the prescription of medications: recommendations based on
marketing rather than more considered assessments of expected value, and
prescription of apps for every little medical condition rather than choosing a
few high-yield apps based on a whole-person approach to managing healthcare.
would be easy for clinicians to end up making the same mistakes with apps as
we’ve often made with the prescription of medications: recommendations based on
marketing rather than more considered assessments of expected value, and
prescription of apps for every little medical condition rather than choosing a
few high-yield apps based on a whole-person approach to managing healthcare.
To
ensure more thoughtful recommending of apps, especially for medically complex
patients, we could consider strategies that can be helpful in managing multiple
medications. These include reviewing the use of a proposed app within the context
of the patient’s overall health issues and goals of care, being explicit about
the purpose of the app and expected benefit, and periodically reviewing and
adjusting app use. The recommendation of apps for every single medical
diagnosis affecting an older person could easily lead to app overload, and
should be avoided.
ensure more thoughtful recommending of apps, especially for medically complex
patients, we could consider strategies that can be helpful in managing multiple
medications. These include reviewing the use of a proposed app within the context
of the patient’s overall health issues and goals of care, being explicit about
the purpose of the app and expected benefit, and periodically reviewing and
adjusting app use. The recommendation of apps for every single medical
diagnosis affecting an older person could easily lead to app overload, and
should be avoided.
Missing from your thoughtful app recommendatios are a few things I consider very important. I am a retired nurse who specialized in pain management, oncology, palliative care, and health literacy. I also fall into the older adult catagory. First, do the have a smart phone and/or computer/tablet. In our age group not everyone can afford the fees for internet access, etc. How health literate are they; can they read. Maybe because we are rural in Maine, we still see people who cannot read and if it is both the husband and wife-it gets tricky. What is the app's health literacy level? I have actually had a surgeon say she wouldn't do the procedure if they weren't capable of reading the hand-out (which was at a 12 grade level). Also be sure the information is correct and helpful. I also have persistent post crainiotomy pain and two apps I checked out were deleted quickly (because persistent (chronic) pain is so many different things (causes and presentation) you cannot do one sized fits all. One site said "instead of going to your medicine cabnet when you have breakthrough pain, go to the park and exercise". That would make my pain worse and another older adult who is not so well informed would feel guilty if the advice "did not fit". The other site gave too much mis-information. Thanks.
hi Janice,
Excellent points, thank you for sharing. I think smartphones & tablets will keep becoming more affordable and widespread, but the health literacy concerns are indeed very important and will always be an issue.