GeriTech

In Search of Technology that Improves Geriatric Care

technology adoption

When Foundation-Approved Apps Founder

[This post was first published on The Health Care Blog on 9/6/13. Dr. Mike Painter of RWJF was kind enough to post a thoughtful response in the comments section there.]

What does it mean when an app wins a major foundation’s developer challenge, and then isn’t updated for two and a half years?

Today, as I was doing a little background research on task management apps for caregivers, I came across a 2012 post listing Pain Care as a handy app for caregivers.
Pain is certainly something that comes up a lot when it comes to geriatrics and supporting caregivers, so I decided to learn a little more about this app.
“The Pain Care app won the “Project HealthDesign” challenge by the Robert Wood Johnson Foundation and California HealthCare Foundation,” reads the descriptive text in the Google Play Store. 
Well well well! RWJF and CHCF are big respectable players in my world, so I was impressed.
But then as I looked at the user reviews, I noticed something odd. Namely, that the most recent one seems to be from April 2012, which is like 2-3 generations ago when it comes to apps.
And furthermore, the app itself was last updated in February 2011. This is like a lifetime ago when it comes to apps. 
I decided to download the app and give it a whirl. It’s ok. Seems to be an app for journaling and documenting pain episodes, along with associated triggers. Really looks like something developed by doctors: one of the options for describing the type of pain is “lancinating,” and in a list of “side-effects” (side effects of what? the pain medication one may have just taken?) there is the option to check “sexual dysfunction.” Or you could check “Difficulty with breathing.” (In case you just overdosed on your opiates, perhaps.)
The app does connect to a browser-based account where I was able to view a summary of the pain episode I’d documented. It looked like something that one should print and give to a doctor, and in truth, it would probably be helpful.
Setting snarky comments about the vocabulary aside: this app actually looks like a good start for a pain journal. But it needs improvement and refining, in order to improve usability and quality. Also, although I don’t know much about app development and maintenance, I assume that apps should be periodically upgraded to maintain good performance as the operating systems of iPhones and Android phones evolve.
What does it mean, that this app was blessed by RWJF but then has been left to founder? A quick look at the developer’s news feed reveals that the app maker, Ringful Health, has racked up an impressive array of research contracts and prestigious partnerships: NIH, CMS, Consumer Reports.
Will these alliances lead to more lasting (read: supported and improved in an ongoing fashion) products and apps that can benefit patients and caregivers? What is the measure of a successful app, from the perspective of public health authorities, and of foundations?
Clearly, this is partly about issues related to business case and funding. To maintain an app, you need money. (If you get money from active users, then you definitely need to work on keeping them happy.)
Who will pay to maintain the apps that foundations, government agencies, and public-interest agencies help start?
And what does happen to most of these apps and tech projects that win foundation awards? Would be interesting to learn more about the natural history of such apps…

Sleep, Stress, and Sustaining Behavior Change

If you are interested in the non-pharmacological treatment of insomnia, an interesting item ran in the NY Times this week: “How Exercise Can Help Us Sleep Better.”

This particularly caught my eye for a few reasons. The main one is that sleep problems are a common complaint among older adults. And exercise is something that I’ve often recommended as part of an approach to improving sleep, whether the patient was a sixty-some year old caregiver, or a more elderly person with dementia.
Plus, as I’ve mentioned in a prior post, I myself have had frequent struggles with insomnia, and have sometimes applied to patients what I’ve learned from myself.
The thing is, it didn’t really seem that I slept much better on days when I got more exercise. Still, I’ve continued to recommend exercise to caregivers and frailer elders alike, given how beneficial exercise is over all. (It’s linked to better strength, better function, better mood, better health outcomes, better glucose control, etc.)
Do most of them manage to increase their exercise? Well, no. At least, not as far as I could tell, and determining how much people’s exercise levels have changed is a challenge because so far, I’ve mostly had to rely on people’s self-report, during a visit. (I’m still waiting to have a patient or caregiver use a Fitbit or other activity tracker.)
And does exercise in fact improve sleep? The Times article describes a fascinating new research study addressing this topic. 

A clinical study of sleep and exercise

To summarize: the study randomized 11 sedentary women (avg age 61 years old) with insomnia to a program of exercise 3x/wk versus no change. 
After four months, the women who were exercising regularly did have better sleep, and were sleeping on average 45-60 minutes longer every night.
But here’s the kicker: it took literally months of exercising before sleep got better. And on a day-to-day basis, most participants did not sleep better on days when they exercised. 
According to the Times article (the study’s author was interviewed), this is at odds with most research & the experience of many people, which is that exercise = better sleep that night.
However, Dr. Baron, the study’s lead author, notes that many studies of how exercise affects sleep used people who didn’t have insomnia at baseline. She goes on to explain that people with insomnia may be “neurologically different,” and have a “hyper-arousal of the stress system.” But if they maintain an exercise program, after a few months they do start to sleep better, which Dr. Baron attributes to a dampening of the stress response.
The study also found that participants exercised less on days after sleeping poorly, so in the short-term it seemed that sleep had more of an effect on exercise than vice-versa. 
The Times article concludes with Dr. Baron advising readers with chronic insomnia to start exercising regularly if they aren’t already doing so, but to bear in mind that improvements in sleep probably won’t be immediate and could very well take months.

Implications for the practice of geriatrics and general medicine

Would one find similar results if one studied a group of 85 year old women with poor sleep? And what if they had dementia? No one knows, and it’s quite possible that the results would be different since both aging and cognitive impairment are known to modify sleep patterns.
Still, these results are very important to the practice of geriatrics, because the study group sounded very similar to a population that we often work with: family caregivers.
Chronically stressed? Not enough time to exercise? Can’t sleep well at night?
Sound like anyone you know? Actually, it sounds a bit like me and other working mothers who have too much on their plate, but it also sounds like the women I see bringing their elderly loved ones to see the doctor, frazzled by the strains of worrying about a parent and taking on more and more caregiving duties.
And, the chronic stress of family caregivers is a very serious public health problem. It affects the health, wellbeing, and even workplace productivity of the caregivers themselves. Plus it often has a direct bearing on the health and wellbeing of the elderly person being cared for.
In general, stress is a huge and thorny problem in healthcare and for society. As a physician, I’ve often diagnosed stress as an important contributor to some significant health problem we’re trying to manage. But it’s very difficult to help people reduce their stress.
This study sheds some light on why: reducing one’s internal reactivity to stress takes time. A behavior change meant to reduce stress may need to be sustained for months. 
This is a tough challenge for all involved. Tired and stressed caregivers want relief now, and don’t have a lot of energy and bandwidth to stick with a behavior change for months. Clinicians want to help (and if they’ve kept up with best practices, want to help the patient minimize the use of pills for sleep or anxiety), but it’s hard to find a way to get patients to sustain behavior changes.

What tech solutions might help?

It’s not hard to envision how technology solutions might help. For those caregivers who have a smartphone or can access technology, it should be possible to
  • Log sleep and exercise. Ideally, with as little hassle as possible. Collecting this data can be helpful to clinician and caregiver when they meet to follow-up on a plan to increase exercise, decrease stress, and improve sleep. 
    • In some cases following data in real-time might help people maintain a behavior or technique (such as in biofeedback). 
    • Whether caregivers would find it helpful on a daily basis to see how much they’d slept every night is unclear to me; it could potentially be stressful to not see sleep improving as quickly as one wants it to.
  • Provide reminders and support to help caregivers maintain the exercise habit. There must be some way to leverage technology to help caregivers (or any patient/person) maintain an exercise habit, but I’m not sure which would work the best for the caregivers I work with. 
    • In fact, the multiple options available (there are so many apps/services available to help people meet fitness goals!) is a problem: making a choice is difficult!
    • Caregivers and patients would probably appreciate and value a recommendation from clinicians, but it might be hard for clinicians to make a recommendation unless it’s a product the clinician has already tried for him/herself.
      • We may also see companies aggressively market themselves to doctors, in hopes that their fitness app will be “prescribed.” I have mixed feelings about this since historically when business markets to doctors, the patients are not always well-served by the results.

In search of tech tools to try

Ok, so now let’s play a fun game called “Help-a-Doc.”
I am willing to try an app or service in the next few months to log my own sleep and exercise, and also to help me start and maintain a 3x/wk exercise habit. (And let’s see if it improves my sleep, which could stand to get better.)
If you have a recommendation to meet any of the needs above (sleep tracking, exercise tracking, and behavior change support), please post in the comments below, or drop me a line.
I’d like to eventually have some specific tools to suggest to caregivers and other non-frail adults who are struggling with sleep, exercise, and stress.

Why We Can’t Leave It to Business to Educate Us

[This post was first published on The Health Care Blog on 4/5/13.]

Recently I came across yet another media article with suggestions as to how digital health products can gain more widespread adoption. The writer notes that “we can learn a lot from the pharma and healthcare industries,” and goes on to discuss the importance of engaging the doctor.

This article, like many I read, doesn’t acknowledge the downsides of using pharma’s tactics.

I have to assume that this is because from a business perspective, there aren’t a lot of downsides to pharma’s tactics. Pharma, along with many other healthcare industry players (hospitals, insurance companies, device manufacturers) has overall been extremely successful from a business standpoint.

So if the intent is to help digital health companies succeed as businesses, then by all means one should encourage them to copy pharma’s tactics.

But as we know, what works for business has often not worked well for serving the needs of individual patients, or to society from a health services and public health perspective.

This despite the fact that pretty much all businesses in healthcare proclaim that they are there to serve patients and society. Of course they will say this. This isn’t surprising at all.

What I have found a bit surprising, though, is the extent to which most of the media coverage of digital health is business-oriented and business-boosting. (I suppose this is because tech has always had a very close relationship with business and consumerism.)

Now, I do firmly believe that digital health innovations are absolutely essential to solving the country’s most pressing healthcare problems. I also believe that dynamic entrepreneurial energy is generally better at developing these innovations than are academic institutions or government entities.

But I worry about the extent to which business and entrepreneurs are directing the conversation on which innovations and approaches will best serve individual patients, and society. Business’ track record in this respect is really bad. Which makes sense: once a company has invested time and resources in bringing a product or service to market, they are going to try to sell it to the rest of us, whether or not it’s good for us.

In other words, although we need business innovations to help drive much-needed change in healthcare, I’m leery of letting business dominate the outreach to clinicians and society.

So, here are some related issues that I’ve been pondering lately:

  • How to encourage the media coverage of digital health to include a little more “in the interest of patients and the public” perspective?
  • How to help clinicians, academics, and health services experts learn about digital health, in a less marketing-directed way? (I’ve been informally polling my colleagues recently: most have never heard of e-patients and know very little about digital health. This means we have hardly anyone without financial ties to industry who can talk to tech journalists or others.)
  • How to foster more constructive interchanges between the digital health entrepreneurs, who have terrific new ideas, and health experts, who should be critiquing these new ideas and providing feedback on how the implications of adopting these products at scale, and how these products might be viewed in a broader health context?

For all these questions, it seems we would need to start by providing clinicians and healthcare experts with a way to keep current with digital health trends and technologies. And this way should not be unduly influenced by marketing efforts or entrepreneurial enthusiasm.

How should clinicians, academics, and non-profit experts learn about digital health?

It’s normal for the providers of these new technologies to volunteer to do the job (as pharma has historically done when it comes to new drugs), but we need viable alternatives that have fewer financial stakes in the education effort.

The problem, of course, is that our usual sources of more-objective-information-in-true-service-of-healthcare seem really unsuited to helping us understand emerging digital health technologies. For instance, by the time any high-quality peer-reviewed research is published, the technology studied is likely to be hopelessly outdated. Likewise, expert guidelines and panels take way too long to digest, process, and present their findings. So clinicians can’t keep current by relying on these time-tested methods of curating information.

Also, there is also a volume of information problem. I’ve been trying to learn about digital health for the past six months and it’s like trying to drink from a firehose.

Hence, I’ve been thinking that what I personally really need is a source of up-to-date commentary and information on digital health that is sensibly curated, and tailored to my clinical interests, i.e. the healthcare of medically complex older adults. To date, I’ve found sites that are related to caregiving, or consumer technology for seniors, or healthy aging, or evaluating assisted living. But none about technology for geriatric healthcare in particular.

So here is my latest idea: I’ve recently been wondering if something like the Journal Watch model could be adapted, to help clinicians keep up with key developments in digital health. (I subscribe to Journal Watch General Medicine.)

What I particularly like about Journal Watch is:

  • They review several key published articles every week, most of which are clinically relevant. (Occasionally there’s something about an exciting new bioscience breakthrough.)
  • They provide a nice concise summary of the research.
  • Each article summary is accompanied by a short comment written by a clinician-editor. The comment is by far the most valuable thing to read, since these editors tend to have an excellent grounding in the pragmatic aspects of clinical work, as well as a good understanding of the health-services implications of the study.

For comparison to the idea above, consider something like iHealthBeat.org. It is fantastic that the California Healthcare Foundation provides this service. And yet, I unsubscribed a while back.

Why? The snippets are too varied – nobody has selected items of special interest to clinicians and academics focused on medical care for older adults. Plus, the snippets themselves don’t feel like they’ve been selected and edited by someone who understands my needs and priorities – unsurprising since they aren’t chosen or commented on by another general internist.

Just as Journal Watch is intended to help clinicians keep up with “Medicine that Matters,” we need a Digital Health Watch service for clinicians, tailored for different specialties, to help clinicians and academics keep up with “Digital Health that Matters.”

Journal Watch, of course, isn’t free. But then again, most good sources of information aren’t.

If we had a good method for clinicians to learn about digital health, then we might see more healthcare experts constructively critiquing the efforts of the digital health entrepreneurs.

This might not be great for every company’s business, but could be very good for clinicians, individual patients and society.

Summing it up

It’s understandable that the entrepreneurial digital health community will want to engage and educate clinicians. However, as we’ve seen with pharma and other profit-oriented healthcare industries, there are significant downsides to letting business dominate and direct clinician education.

To date I’ve found that many of my colleagues in academia know little about digital health, or emerging technology innovations. This makes it difficult for medicine’s expert community to thoughtfully engage and critique the ideas of digital health entrepreneurs.

The overall healthcare needs of society would be much better served if clinicians and academics could learn about digital health via sources that have no significant financial conflict of interest. I would love to find a “Digital Health Watch” service similar to Journal Watch.

If you can recommend a high-quality, not-too-business-oriented source of information on digital health for me to follow, please comment or send me an email.

The Tablet Transition

[This post originally appeared on The Health Care Blog on 3/29/13.]

I purchased my first tablet a few weeks ago, and have since been thinking more about tablets for seniors and caregivers. Like many, I’ve assumed that tablet-based tools will eventually make certain aspects of healthcare easier for clinicians, for older adults, and for their caregivers. But so far I’ve found the tablet harder to use than I’d expected.

Actually, technically this is my third tablet purchase. The first was an iPad last summer, which I promptly sent back after realizing that my laptop was much better suited to supporting me in my clinical work (read my full minority report here).

The second was a Nexus 7 which I purchased as a holiday gift for my 62 year old step-father, a structural engineer. (As he’s mildly uncomfortable figuring out new-fangled technology, I set up his device and helped get him started using it.)

Now, I finally have a tablet that I’ll be keeping for myself: a Samsung Galaxy Note 10.1.

The device is slowly growing on me, but it hasn’t been quite the intuitive seamless experience that I’d anticipated. Hence I have a new perspective via which to consider tablets for people who are even less digitally savvy than myself.

Now, I should disclose that my phone is a Blackberry – the only smartphone last summer at Verizon that could be answered by pushing a button rather than swiping – but I had an iPhone from 2008-2009 and an Android phone for a month in 2011. Also, as my husband remains an iPhone devotee, I’ve found myself regularly using his phone regularly to access some app not available on my phone.

So this year I came to try these Android tablets having a little prior Android experience to draw on, as well as some iOS familiarity. Here are some of the hitches I experienced:

  • Disorientation when first getting started. This happened with both the Nexus and the Samsung. Obviously both devices walk the user through some basic setup initially, but I still found myself often perplexed and in “figure-it-out” mode. I struggled with things like figuring out how to switch between apps, decluttering the main screen, copying text, and searching the device. I found myself often turning to Google on my laptop to solve the latest small quandry of the moment.
  • Annoyance with the mobile versions of websites. Tablets are supposed to make it easy to access the web, but I found it annoying to find my usual websites presented in mobile format, especially when using the larger Galaxy Note 10.1, whose screen is not that much smaller than that of my compact Thinkpad. Not only do the mobile versions of websites look different, which takes a little getting used to, but they are often less functional.
  • Too many preloaded apps. The Samsung tablet came with 51 app icons in the app section. I feel a little overwhelmed everytime I look at the app list. I’d like to have less to look at, but I’m not sure what is deletable, or how to hide things. Many apps also seem redundant, such as having both an email app and a Gmail app.
  • But I still needed to install additional apps for functions I considered basic. For my step-father to be able to read library e-books, we had to install an Overdrive app and also a Kindle app, since the library books come in both formats. In order to be able to print to my wireless Brother printer, I had to futz around with my Samsung for well over an hour. I ended up installing a cloud print app and a Brother iPrint app, both of which continue to perplex me and neither of which creates satisfactory print jobs.
  • Difficulty finding the right app for a given need. How to read an e-book in PDF format on my Samsung tablet? The Play Books app preinstalled on the device didn’t seem to do PDFs. (Actually, it seemed to only do books purchased through the Google Play store, and annoyed me by cluttering the screen with recommendations which I couldn’t seem to get rid of.) Realizing that I’d need to add yet another e-reading app to the device, I started looking online to find a good choice. Sigh. Too many choices, hard to know which to get, once an app downloaded have to figure out how it works. Argh…
  • Hard to find a decent manual. The included quick start guides are ok for a quick start, but do not provide a lot of help for those who are lacking a certain amount of tacit knowledge, or past familiarity with the OS. It took me a while digging around on Samsung’s site to find the tablet’s complete user’s manual. Which is basically like a small encyclopedia: ok to search in, but not something that is pleasant to read from start to finish.

So these are my current conclusions about transitioning to Android tablets:

  • A fair amount of tacit knowledge is presumed. Although the included quick start guides do help one get started, they still assume one understands certain basics, like what a widget is. (I’ll admit that I didn’t know what a widget was, and am still unsure of how to use them.)
  • Becoming comfortable with a helpful group of apps takes time. One has to spend time figuring out what are the darn apps already included on the device, one has to spend time identifying additional needed apps, and then one has to learn how to use the apps themselves. This is not a trivial process, especially given the choice fatigue involved in selecting apps to use.
  • It’s an effort to avoid cognitive clutter. From the multitude of preloaded apps to the unavoidable recommended books in the Play Books reader, these tablets seem to bombard the user’s brain with all kinds of tiresome extras. I suppose the manufacturer would tell me these are meant to be helpful, but I’m sure that if one did psychological research, one would find that people have better cognitive performance and feel calmer when there is less to look at.
  • A tablet is not a substitute for a laptop or desktop. In particular, I’ve found the tablets very limiting in two specific aspects. One is web browsing capability: the mobile versions of many websites drive me slightly batty. The other is text entry: even with voice input or Samsung’s Swype-like keyboard feature, entering text still feels painfully clumsy compared to typing on a keyboard. (Yes, I could get a Bluetooth keyboard, but then I might as well use my laptop, right?) 

How we might make the tablet transition easier

Here’s what I think someone like me – or even my step-father – needed in order to transition more easily to the tablet:

  • Coaching on the basics of using the operating system and the device. Ideally this tutorial is adapted to the type of new user: my step-father and I will have different needs from this kind of tutorial, because even though we are both new, we have different learning styles and comfort levels with new technology. Alternatively, if there had been a Samsung Galaxy Note 10.1 for Dummies book, I would’ve bought it as the Dummies series is usually much more readable and practical than the user’s manual. (I imagine the poor Dummies authors are having trouble keeping up with Android updates and the general pace of tech evolution however.)
  • Needs assessment and recommendations on which apps to use. The dream scenario would be to talk to a capable person about what you’d like to use the device for, and then have good apps recommended (without undue influence from the app makers). Bonus if the apps can be installed and configured for you. This is, of course, the role that many younger adults play for older adults wanting to use a tablet or new digital device. And many of us rely on a tech-savvy friend to recommend apps to us; otherwise the choices easily become overwhelming.
  • Help optimizing frequently-used apps. Even if one is using a well-designed app or program, one often doesn’t get the best use out of it without either making an effort to the learn the ins-and-outs, or getting some guidance from an expert. The ideal scenario is for someone to watch one using the app, and then make a few suggestions as to how to use it more effectively.
  • Help decluttering the tablet. It’s nice to not have too much to look at, and it makes it easier to find the apps that one actually uses. A decluttered tablet would likely be especially helpful to those who are very busy (i.e. caregivers, doctors), very stressed (caregivers, doctors), or cognitively impaired.
  • Access to someone who can answer questions as they come up. So nice to be able to talk to someone when one runs into yet another little hitch. Many of us again will rely on a more tech-savvy friend or family member. Otherwise, online forums can provide some of this functionality, but of course one needs to search them.
  • Remote control and viewing of one’s tablet. I gave my step-father his tablet when he was here in San Francisco visiting us for the holidays, but a week later my parents returned to their home in Arizona. This made it much harder for me to help him with his tablet. I found myself wishing there was a way for me to view and configure his tablet remotely, just as the Lenovo support team remotely controls my laptop when I call them for support.

Summing it up

Tablets and their associated apps can in theory be useful tools, especially for digital health purposes. However, my own recent experience transitioning to an Android tablet was harder than I expected, leaving me to wonder how we might make the process easier for boomer caregivers and for older adults. (And for other practicing clinicians, for that matter).

In particular, I found that using the tablet presumed a fair amount of tacit knowledge, and required me to do a lot of on-the-fly figuring things out. Finding the right apps for my needs and learning to use them was a bit time-consuming. Tablets are very customizable and offer a lot of choices, but all these choices can easily be overwhelming. It also takes a while to learn to use an app efficiently.

In an ideal world, I would’ve like to have access to some tailored coaching on how to use the device efficiently. I would’ve also liked to have a needs assessment and then have apps be recommended, rather than having to spend time and mental energy hashing it all out on my own. In many cases, tech-savvy people provide this kind of orientation, navigation, and troubleshooting to less tech-adept friends and family. Is there a way to provide this kind of assistance more broadly to people transitioning to tablets?

How Should Apps Be Prescribed?

[This post originally appeared on The Health Care Blog on 3/13/13.]

Should
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.”
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
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?)
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.
But under what circumstances will
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:
  • 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:
  • 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.
Will
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:
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.
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:
  • 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.
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.)
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.
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.

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:
  • 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.

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.
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.
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.