By Shiv Gaglani

While smartphone usage among health care professionals has been consistently growing over the past few years—this year, 75% of US physicians reported using their smartphones at work and 30% claimed to make prescribing decisions from these devices—this past June was an inflection month for mobile health. WellDoc, a Baltimore-based health care technology company, received FDA approval to sell the first prescription-only smartphone app. More impressively, they convinced insurance companies to offer reimbursements for their app, which is designed specifically for type 2 diabetes management.

The billion dollar question is whether this development has opened the floodgates for physicians prescribing apps in addition to, or in lieu of, pills. Put into an individual clinician's perspective: Beyond using reference and medical calculator apps, how should you be using your smartphone in clinic?

Following the WellDoc announcement, I spoke about this question at back-to-back conferences drawing professionals from two different sides of the health care equation: clinicians and students at the American Medical Association meeting in Chicago and industry professionals at the MedTech Innovate conference in Philadelphia. While the former were reasonably guarded about whether or not to integrate these new tools into their workflow, the latter were optimistic about their ability to "disrupt" health care using mobile devices that promise higher patient engagement and reduced costs.

At both meetings I used the popular Smartphone Physical exhibit that I curated for the TEDMED conference in Washington, DC, to illustrate a few key issues regarding smartphone adoption in the clinic. Briefly, the Smartphone Physical emerged from the realization that many of the physical exam maneuvers I was performing as a medical student at Johns Hopkins (for example, vital sign measurements and auscultation for heart sounds and carotid bruits) were now capable of being performed or augmented by legitimate smartphone apps and devices that have already or will soon be FDA approved.

As a result of the experience, more than 300 TEDMED delegates received clinically relevant information using a smartphone-enabled weight scale, blood pressure cuff, pulse oximeter, ophthalmoscope, otoscope, spirometer, ECG, stethoscope, and ultrasound. In deciding whether to use any of these apps and devices, or to recommend them to your patients, consider the following questions that were raised during the Smartphone Physical exhibit:

Who is the end-user?

The answer to this question depends primarily on the data being measured, the user's access to and understanding of technology, and the sophistication of the app or device. Blood pressure and blood sugar levels are most useful in the context of longitudinal measurements, while sonograms and optic fundus exams can be useful on a much more discrete time frame. Thus, patients themselves should use apps and devices that focus on collecting data over time or in response to acute events, like a smartphone-based ECG used as an event monitor following palpitations or angina. Given that health literacy of patients and clinicians can differ vastly, these smartphone apps and devices should be both easy and reliable for accurate data collection.

Another concern is that the continued miniaturization and portability of these devices will lead to increased rates of self-diagnosis. Clinicians should be mindful of the potential for use, misuse, and abuse whenever deciding to use or recommend these apps and devices.

Where will the data go?

It is important to consider whose mobile device is being used to collect the data, as well as the privacy and security implications of this decision. At TEDMED some of the clinician-students performing the Smartphone Physical were using personal smartphones, so at the end of the conference went home with dozens of pictures of (anonymous) optic discs and eardrums. These may be easily shared with patients or other providers via email, which is both tremendously convenient and potentially risky since it opens a potentially non-secure line of communication between the patient and clinician. One important barrier to widespread adoption, though, is that many of these apps and devices do not yet integrate with EMR systems. A potential fix is to have a devoted mobile device for patient data, or to at least scrub the phone's data on a daily basis to ensure patient privacy. Fortunately, the app and device manufacturers realize this is an issue, so many are already incorporating HIPAA-compliant features. In addition, given that patients will collect data as well, clinicians should expect new tools to emerge such as streamlined dashboards that allow them to review longitudinal patient-collected data points.

What are the actual benefits and the associated costs?

The app or device should have a clear benefit to justify incorporating it into the workflow. According to a study published in Diabetes Care, the WellDoc mobile intervention showed significant reduction in blood sugar levels, which is why it is now available for prescription and reimbursement. Key potential benefits of these mobile apps and devices may include reducing costs, increasing access, and improving patient compliance, engagement, and outcomes. As with any technological intervention in medicine, however, the true costs and downstream effects should be closely monitored to ensure that we are making progress by adopting these tools, regardless of how impressive they may be.

A rapidly-growing minority are using smartphone-based apps and devices in their clinical practice. As more of these apps and devices gain regulatory approval and become reimbursable, clinicians must consider the questions above in the context of their own practice, both for the sake of the clinical practice and the care of patients.

---

Shiv Gaglani is an MD/MBA candidate at the Johns Hopkins School of Medicine and Harvard Business School. He writes about trends in medicine and technology and has had his work published in Medgadget, The Atlantic, and Emergency Physicians Monthly.

Keywords: Privacy, Health Insurance Portability and Accountability Act, Diabetes Mellitus, Type 2, Workflow, Patient Compliance, Mobile Applications

< Back to Listings