Why doctors aren’t prescribing health apps to patients

The BBC had a story recently about general practitioners (GPs) in the UK prescribing health apps to patients. The idea is that prescribed apps would be free to patients, even if they had a cost associated with them, so I’m assuming that the NHS would pick of the tab for such apps.

The story has gotten a lot of attention, and I think with good reason. I’ve written before and believe that physicians need to prescribe health apps, whether they be mobile or web, in order for patients to signup and use them on an ongoing basis.

There are several huge benefits that exist from this approach:

Enhancing, not replacing, the doctor-patient relationship. As eroded as it has become, the doctor-patient relationship is a powerful thing capable of very positive things for our health system. In my utopia, health apps are used to enhance that relationship, providing constant touch points between provider and patient, even if some of the content from the provider is somewhat generic and/or canned. I think that constant contact and accountability for the patient, whether real or perceived, will be a huge driver of ongoing usage. Also, collecting additional data and summarizing it for the provider, potentially with clinical decision support built in, makes the time spent face-to-face that much more valuable.

Minimizing disruption. If the provider can have select apps for each condition or cohort of patients then it makes disruption of clinical flow less for them as they only have to learn to view and act on results from a small subset of apps. Also, if these targeted apps are then integrated into the EMR, even as attached reports, that is less disruption. Or maybe more app developers start making physician apps for viewing patient data. Again, the number of apps has to be limited. If all app makers agree to push data to one platform, such as MS HealthVault or Dossia or whatever, then this problem is solved, but I don’t see the convergence of one storage platform to be very realistic in the near future.

Reducing silos. This relates to disruption above. Reducing the number of apps used by patients reduces the number of silos of data from different app makers. It also filters the huge number of potential apps out there.

Virtually linking patients and providers. If a doc prescribes an app, ideally they could do it with an invite code or QR code or someway for the patient to choose them as part of the app registration process. I realize very few apps do this today but we’re going to be seeing more and more of this coming. Instead of walking out with directions memorized or on printed documents, prescribed apps can pull data into the app and present it a more meaningful way, or maybe automatically add events to a calendar, or create a specific health calendar. This is definitely future-state but has a ton of potential. Linking the two makes access to data easier and also enables messaging between parties, once both patients and providers are ready to message.

Lowering the cost of care. Regardless of provider involvement, I think engaged patients that use health apps on an ongoing basis will be healthier. I think patients feel more accountable if something is prescribed to them and can be tracked. Accountability leads to more active engagement which then leads to better outcomes and lower costs.

With so many benefits, why aren’t physicians prescribing apps? Unfortunately, I believe we are a long ways off from seeing most docs prescribe health apps to patients. The UK has a bit of an advantage because it is a more centralized health system. Systems that are similar in the US, like Mayo, Kaiser, Intermountain, and Geisinger, I could see being some of the first to start having providers prescribe institutionally approved apps.

But, for the vast majority of providers and, by extension, patients, several very large obstacles remain:

The vast majority of providers don’t know anything about health apps. If you’re a provider reading this post, I’m not talking about you. Most practicing physicians don’t have any idea what apps are out there for their patients. Heck, most providers don’t have much of an idea of what apps are out there for themselves (Epocrates and UpToDate excluded, although my wife only knows UpToDate has a mobile app because I installed it on her phone).

Assuming providers knew about apps, they need guidance on what apps are safe. I believe docs are never going to prescribe an app unless a trusted organization confirms its value and accuracy or a trusted colleague tells them about how great it is. Maybe that is where the FDA comes in? But, even with FDA approval, apps don’t fit into nice categories like drugs do (it’s easier to compare two statins than it is to compare two diabetes apps). I’m not sure how this will work exactly but I know there needs to be some higher authority validating, and in essence taking some of the responsibility, from providers. This is what Happtique is trying to do; we’ll just have to see how well it works from a clinical buy-in perspective.

Providers don’t know how it fits into practice. Providers are going to want to know how the apps fit into their practice. Right now I think that’s still unclear. Obviously more data on mood trends as somebody is starting new meds for depression is great, as long as it is presented to the provider in a digestible way. But, what if the patient is suicidal according to the app and there is no feedback mechanism to trigger an alert. If providers are now prescribing patients to enter this additional information, are providers on the hook to assure they know when an immediate response is warranted and then to respond to it?

Lack of payment. Unfortunately this might be the biggest obstacle. In the NHS story references above, the apps were going to be free to patients. In the US, that is not the case, at least it isn’t today. Prescribing patients to spend additional money is likely going to prevent widespread uptake. Or maybe different payers will have different “app formularies” so providers will have to wade through lists to see what approved apps are free based on payer. That would be great. Also, if providers aren’t paid for responding to app messages or alerts it’s likely not going to happen.

I’m curious to see where this goes in the UK and also within some larger health systems in the US. I think prescribing apps is crucial so we’re going to see organizations start to address some of the obstacles I listed above. I’m sure I’m missing some benefits and obstacles. What others can you think of?

Travis Good is a physician involved in health IT startups.  He blogs at HIStalk Mobile.

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  • Anonymous

    How about the complete lack of evidence that “prescibing” apps improves patient health?

    Repeating “I think that” over and over doesn’t cut it.

    • Anonymous

       I would disagree that there is no data that apps can improve health. There are plenty of types of patient-controlled data that have been shown to  improve health outcomes: blood glucose monitoring shared with provider in digital format, food journaling for weight loss, interactive medication lists, etc. Apps just provide a comparatively user-friendly means of accomplishing these types of patient engagement.  What is of research interest is mainly the content, not the specific format.

      • Jeff Brandt

        SaraJMD, I agree, just as a scales helps me to lose weight.  Awareness.

  • Ronald Yap

    In an attempt to improve doctor/patient communication I’ve created free, no ad apps to help patients track urinary patterns, symptoms, and psa tests (Bladder Pal and Prostate Pal).  I think it’s a useful tool that can increase efficiency of care.  One can foresee a time where electronic mointoring via mobile apps can facilitate evists with skype or some other conferencing modaility

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Your physician is a covered entity under HIPAA. He/she has a responsibility to keep your data as private as possible even in this Internet age.
    App vendors are not bound by HIPAA. If you want doctors to recommend useful software tools for patients to use safely, those tools will have to be part of the EHR, or otherwise have a contractual relationship to the physician, including a HIPAA mandated BAA.
    Health Vault is not encumbered by such niceties and neither are all the other “app” developers, because personal health data is a prized possession in the cyber-marketplace today.

    By strange coincidence, I just posted some thoughts pertinent to this subject a few minutes ago http://onhealthtech.blogspot.com/2012/03/where-is-health-cares-big-data.html

    • Anonymous

      ” If you want doctors to recommend useful software tools for patients to use safely, those tools will have to be part of the EHR, or otherwise have a contractual relationship to the physician, including a HIPAA mandated BAA.”

      Margalit, this is a particularly broad reading of a physician’s obligations under HIPAA. Why for example would the tools HAVE to be part of the EHR? Couldn’t that just as well increase the risk of a security breach as reduce it? I’m not sure there’s a lot of support for your assertion.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        The apps don’t HAVE to be part of the EHR, but at the very minimum I would expect that physicians know enough not to “prescribe” to their patients apps where PHI is collected from them and sold to the highest bidder. Prescribing, I think, carries some responsibility, such as considering side effects.

        We are all busy with protecting against third party breaches, but the real danger to privacy is right inside the database. Even with a BAA, software vendors can legally aggregate and sell data. Without such constraints, there is absolutely nothing (except some tiny print somewhere) to protect, or warn, a patient that their medical information can be disclosed at will.

  • Jeff Brandt

    Great piece,  I have been recommending HealthVault for quite awhile as the platform for sharing.  The main issue I see is that there are no standard for Health App and most of the so called health app on the market are have nothing to do with medical health.  Most are not even secure. If you can get to your PHR without a password, it is not secure.

    The FDA has stepped in with guidelines for Medical App, if the FDA start to crack down on Apps 99.9% of the so called health apps will disappear.  This is good and bad.  The FDA is just trying to keep us safe and make sure developer produce good quality medical software.  I feel that this has not been vetted out, yet so many developers are playing wait and see.  We do need some agency like the FDA to control this development but I am not sure if they are the dept to provide this control.  When an app has to be a certified Class 1 MDDS device  just because it displays device patient data, I have to believe they don’t quite understand the new field of Apps.

    Jeff Brandt
    http://comsi.com

  • http://profile.yahoo.com/QWO7MPHWTIOR467JKDJUTCZJTU Clark

    Some good points to consider, and I agree that the patient’s overall experience can be enhanced by having an app that directly relates their treatment experience to their physician or dentist.  As a practicing orthodontist, we recognized this ‘gap’ in communication between our patients and our referring dentists, and we created an app specifically to address this (SorrisoOrtho on iTunes).  We give the app to our patients as part of the new patient process, and explain how it can be used….they get it immediately.  Once downloaded to their phone – we use the app to record and store videos of their treatment instructions that are specific to their treatment. The app does a lot more – and it works, our patients love it.

  • http://www.healthasahumanright.wordpress.com/ Erin Gilmer

    This is a great discussion.  As I increasingly spend time with entrepreneurs in the mHealth/eHealth/HIT sector as well a my work in patient advocacy, the ultimate questions are (a) how to engage doctors to use the apps their patients want to use and (b) the legal risks of using these technologies and platforms.  The great thing about this field right now is the wide latitude of innovators to come out with increasingly incredible tools that really empower patients to take part in their health care which will hopefully translate into increasing communication  and easier communication between doctors and patients.  The blessing is two sided however, with the possibilities comes unbridled proliferation of apps and tools – who’s to say what is the best? most useful? most user friendly? No doctor I know has the time to really explore these apps and requests from patients asking doctors to join and review their app as described above is a huge issue.

    As for the legal risks, I continue to tell people that the risk is not so much the laws that are in place now, but the laws that are to come.  A lot can be done right now.  HIPAA is oft misconstrued and likely does not provide the type of privacy we expect, online privacy is not much better.  There’s a thin line and much confusion.  The result will be further legislation down the line to address these issues (Jeff speaks of FDA regulation).  Meaning that companies who develop these technologies are left to set the standards.  But are they sufficient?

    Even if the privacy issue were clear, how to get doctors who have so much on their plate already to engage?

    And finally, on a tangent, because Microsoft Health Vault was mentioned – I would suggest looking at PatientsLikeMe.  I think their tool is the most comprehensive – but with a twist.  Patient information is all open under whatever username the patient chooses.  I think it far exceeds MS HV in usefullness and tracking of each person’s health as a whole as well as allowing patients to connect with others “like” them.

  • http://twitter.com/DoctorAlert HealthCare Alert Inc

    Good article

  • Tashfeen Ekram

    The other tactic that could be used is to get patients to be the product advocate and taking it to the doctors.