Thoughtful recommendations of health apps

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 futzingwith 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.

Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech.

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