From virtual visits to remote monitoring of patients after discharge, mobile applications are beginning to help physicians care for patients, even in the hospital.
This is fairly new territory for hospitals, and there's plenty of room for innovation, according to gastroenterologist Ashish Atreja, MD, MPH, FACP, chief technology innovation and engagement officer and director of the Sinai AppLab at the Icahn School of Medicine at Mount Sinai in New York.
Dr. Atreja recently spoke with ACP Hospitalist about which apps hospitalists should know about and how they can begin to prescribe them.
Q: What do we know about the clinical efficacy of apps and how inpatients can benefit?
A: At present, there are more than 165,000 apps in the health and fitness category. The evidence is really lacking for the majority of these apps. An app tied to telemedicine, wearables, and a secure messaging platform can help [hospitals] closely follow up with patients postdischarge, providing personalized education and ready access to the clinician. This remote monitoring aspect has been shown to decrease readmissions, especially in heart failure, in studies conducted at Mayo Clinic and Partners HealthCare. Apps provided during hospitalization, such as Epic Bedside and the Mayo Clinic app, have led to increased patient satisfaction. We do believe some of those apps will eventually create a more efficient and effective health care delivery arm and lead to some improvement in patient outcomes, like decreasing readmissions and improving quality of life for patients.
Q: Why is the evidence lacking?
A: The field has just exploded in the last 2 to 3 years, and most of the innovation is happening outside health systems—it's not under a governance like FDA, where clinical trials have to be done before the app is being implemented for patients. So there is no single incentive among these startup companies to actually build on evidence because that takes time, and sometimes the evidence may be contrary. As a provider community, we need to be able to distinguish the top-layer apps with the maximum evidence from the rest of the apps, which can be used but have limited evidence.
Q: How can clinicians navigate these apps and the evidence behind them?
A: The FDA-approved apps are a good place to start, but they are very limited—it's still less than 200. At Mount Sinai Hospital, we are trying to collate all the evidence that is published on the apps through MEDLINE and pull them onto a singular platform powered by Network of Digital Evidence in Health . . . which will then solve the problem of each physician having to go separately to PubMed or some other resources to find those top 10 or the top-tier apps.
Q: What are some apps that hospitalists should know about?
A: There are many disease-specific, patient-facing education apps currently in the [app] stores. There are other apps, which are physician-facing and in the clinical decision support category, such as Epocrates pharmacopoeia and Calculate and Read by QxMed to calculate perioperative risk and track journals. There are also guidelines apps like ACP Clinical Guidelines and teaching tools like Visual Anatomy Lite.
We have also seen an emergence of apps which allow remote monitoring during transitions of care and postdischarge. For example, HealthPROMISE is a mobile and web-based platform that has been developed at the Sinai AppLab through [National Institutes of Health] funding so patients can measure their quality of life through a mobile app, thereby sharing their health status with providers via an electronic platform for collaborative decisions and quality improvement. Over the past year, HealthPROMISE has been made available for acceptability and feasibility testing at 5 major medical centers, including Northwestern, University of Miami, University of Pittsburgh, Johns Hopkins, and Mount Sinai, targeting inflammatory bowel disease patients as the initial chronic disease population. It tracks patient symptoms, whether they are in the hospital or at home, and actually helps them know whether a treatment is working or not working. It renders itself very useful for patients who are hospitalized, so we can see whether we are able to control the symptoms before they are discharged and then track them after discharge to see if their symptoms are flaring up.
Q: What's the uptake on apps among hospitals?
A: I think each hospital is at a different stage right now. Some hospitals have very focused, special groups to look at the startups making new apps and see which are most effective and bringing them into the health system, and some are probably not that active. I have not seen any hospital which has made any apps mainstream, that it provides to every patient no matter what, apart from the standard electronic health record (EHR) apps or personal health record (PHR) apps. But I do imagine in the next couple of years, we'll have hospitals which will have some apps they would like to prescribe to nearly every patient who comes to the door.
Q: Should doctors be prescribing apps? How does that work?
A: I'm prescribing apps right now, and I have no doubt that this will become part of the ecosystem of the doctors very soon. We look at the app, and we find evidence, and we find that the patient will benefit from it. We either tell the patient about the app and have them download it, or we have a care coordinator who can walk him through the app. Right now, we have a prescription pad for an app, so we give that to the patient, but this is on paper. We are building on a framework where hopefully it can become seamless with our EHR.
Q: How do patients respond to app prescriptions?
A: I think it's the same with the medication adherence issue: The patient has to believe that the medication's going to be effective, and then they have to agree with the dose before they start taking it. We're finding an even bigger gap in what we call app adherence. From a previous study we did at Cleveland Clinic, we found that if we don't get the patients started on a new technology while they are with us, then it is one-third less likely that they will actually start using it. One of the things we do to enhance their app adherence is to have it downloaded in front of us.
Q: What do the apps cost?
A: Most of the apps that we are prescribing are free to end users like patients. There is a cost, however, to a health system to implement the app. There is a hidden cost of training the providers and training the patient and making sure the app is integrated into the day-to-day workflow. We can learn from EHR implementations that it takes about double the resources to implement and integrate an EHR in a health system that it takes just to license the software. Right now, many hospitals are just choosing to absorb the cost, and it's an investment for them.
Q: Which areas of health care are app developers focusing on?
A: The apps which are getting a lot of traction with health systems are in chronic disease management, whether that is heart failure, inflammatory bowel disease, or other chronic diseases, because that requires more patient monitoring, and that will eventually hopefully lead to a reduction in readmissions and decrease the cost of managing the diseases. You want to put lots of implementation efforts toward high-utilizing populations, so you can reap the benefits in terms of having them stay healthy and outside the hospital.
Q: How can physicians get engaged with this process and learn more?
A: There are often panels or presentations within regular medicine conferences that are focused on digital medicine. There are also conferences specifically focused just on digital medicine, including health2.0, HIMSS, and mHealth Summit. For more regular engagement, physicians can subscribe to newsletters or become part of a LinkedIn community like Network of Digital Evidence.