Mobile Medical Apps and Wearables

It’s no easy task for physicians to make use of data from their patients’ wearables and apps

Fitbit says that 14 million U.S. adults subscribe to a digital health/wellness service, and pay an average $174 annually for different apps.

So … we can probably all agree on one thing: Wearables, or mobile medical apps, are popular with consumers. But how about their doctors?

“In 2016 the American Medical Association conducted a survey to examine physician receptivity to various digital health modalities and determined there was considerable interest on the part of physicians,” says Michael Hodgkins, M.D., chief medical information officer for the AMA. “Specifically, physicians believed these tools could contribute to better patient care.

“However, recent studies have shown considerable variability in the accuracy of data from wearables, such as Fitbit, and there is an absence of evidence supporting the actual contributions these tools can make to improving health outcomes.”

Karl Poterack, M.D., medical director of applied clinical information for Mayo Clinic, echoes some of those misgivings.

“The eagerness to incorporate mobile medical apps and wearables varies with the individual physician,” says Poterack, whose research interests are primarily directed toward the use of wearable devices. “There is a lot of appropriate reluctance to do so, for multiple reasons.” Among them:

  • Very few practices have the infrastructure to import and sift through the massive amounts of data these devices can generate.
  • Physicians lack control over wearables, with no ability to perform quality control, and even no visibility into who is actually wearing the device.
  • Physicians have concerns about the liability and responsibility for reviewing the data – something that has not been clearly defined.
  • Physicians have questions about what some of the data even means clinically.

“What if my patient walks 5K vs. 10K vs. 15K per day?” he asks. “A device can accurately measure steps — but is that a modality worth measuring?

“On the other hand, as part of a plan determined jointly by the patient and physician, there are certainly physicians willing to utilize the ‘encouragement’ functions of fitness trackers,” he adds.

Swimming in data
In October 2018, the American Medical Association unveiled its Digital Health Implementation Playbook to present key steps, that is, “best practices and resources to accelerate the adoption and scale of digital health solutions.” Step No. 1? Identifying the need.

“The predicate for innovation is to always ask ‘What problem am I trying to solve?’” says Hodgkins. “Many well-meaning entrepreneurs develop a passion for an idea but don’t necessarily have the background in healthcare to really understand if that idea is something that addresses a real need.”

Poterack says that wearables historically have proved most valuable when used on a temporary or semi-permanent basis, e.g., to identify arrhythmia. “There’s a purpose to it, a question to be answered, and implications to the answer. There is good, solid equipment and a good reporting system. And at the end, you feel confident you’ve gone through the data and you’ve got the information you need to make a decision.

“It’s purpose-built and has a defined question to be answered.”

But as developers of mobile apps race to introduce new technologies, are they addressing these fine points?

Hodgkins says that physician practices can take steps to protect themselves from the influx of data that can accompany these new technologies.

“First, by designing specific protocols at the time of implementation, practices can empower other members of the care team to take the lead on monitoring and only involve physicians when there’s an abnormality or question,” he says.

“Second, some practices have partnered with the vendor to help limit the amount of data coming into the practice and/or EHR. [S]ome vendors provide resources to monitor data and escalate as needed. This allows physicians to only receive data that is required for decision-making related to a patient plan of care.

“Finally, practices have also contracted with other third-party data analytics and monitoring companies if their vendor does not provide these services.”

Even before the provider team can act on the data generated from mobile medical apps, they have to be able to access it. Which begs the question, How can the practice incorporate all this data into the electronic medical record?

“There is very little standardization among EMR databases, which presents an obstacle to easily incorporating data from mobile solutions—both wearables and apps,” says Hodgkins. “Much of what is occurring is at large healthcare institutions and is often accomplished through ‘brute force.’

“The most promising opportunity going forward is the use of standard application programming interfaces, or APIs, which are now being mandated. One standard API that is the focus of activity among EMR vendors is the Fast Healthcare Interoperability Resources (FHIR) API. But implementing this will still take considerable effort on the part of mHealth developers and EMR vendors.”

Says Poterack, “With regard to ‘medical grade,’ physician-provided devices, there is usually the ability to generate a ‘summary page’ of key data that can easily be incorporated into the record. With regard to consumer-grade devices, other than a couple of isolated examples that probably work better in theory than practice, I’m not aware of this occurring.”

Workflow
To accommodate the influx of data that comes from mobile devices, providers may have to reconfigure the roles and responsibilities of the office team.

“There’s a lot of variation here,” says Poterack. “This is a big part of the difference between a device ‘prescribed’ and provided by the physician, where the workflow can be designed from the ground up, versus a consumer-grade device controlled by the patient, which is much more problematic.”

Cardiology practices may be out front on this, he says. They tend to have more experience with wearables – many of which monitor the cardiovascular system – than other types of providers. But vendors of digital systems can help.

“Some of these [devices] come with the ability to collect data, sift through it, find important things in it, and report that data,” says Poterack. “In a sense, it is ‘prepacked’ with the device, or the developers provide a very solid interface with your system.”

Says Hodgkins, “Physician practices aren’t all created equal, so they will likely have different workflows and processes for incorporating digital health technology.

“Planning is key, so it is important to ensure that the first six steps of the [Digital Health Implementation] Playbook are thoughtfully considered. If they are, then redesigning the workflow has likely already been considered, so practices are better prepared for when it’s time to do that work. For example, they’ve already decided that technology is the right solution to achieve a specific goal. And they know what level of support the vendor can provide related to training, EHR integration, etc.”

Practices that successfully redesign workflow are those that fully understand their current method of operating, and then map out what areas require change with the integration of a new technology solution, says Hodgkins. “They have identified where internal resources can be used and if/when external resources and support are needed.

“Again, planning and involving all necessary team members is key for long-term success. It’s also important to not think of this as a one-time activity. Practices should be prepared to continue iterating and improving as they learn.

“Specifically, with remote patient monitoring (RPM), we’ve talked with practices that have had success staffing RPM activities both internally (with medical assistants, nurses and advanced practice providers) and with external companies,” he continues. “Sometimes the vendor can support monitoring the patient data that comes into the system and alerting the practice when abnormalities arise. Some can also support training patients and serve as customer support.”

Success?
How would a practice define “success” in its ability to incorporate data from wearables and mobile medical apps?

“That’s very context-dependent,” says Poterack. But he offers this definition: The ability to “receive data that contributes to fulfilling whatever need you have identified.”

“There is a tremendous amount of data that’s out there for the taking,” he says. “Vendors are collecting this data, and there are indications they understand the importance of it. But I’m not sure they know what to do with it. There’s a lot that can be done with the data out there. We have to figure out what that is.”

Says Hodgkins, “In the Playbook, we have proposed that practices view success as coming from some positive impact towards achieving the quadruple aim of healthcare — improved outcomes, improved patient experience, reduced costs, and increased professional satisfaction.” “More broadly, at the AMA, we also aim to make technology an asset, not a burden, by providing resources to help practices implement effective, validated and trusted digital health solutions the right way.”


Digital playbook for docs

The American Medical Association’s “Digital Health Implementation Playbook” offers physician practices 12 steps to follow to build a strong foundation for success in digital health.

  • Step 1: Identifying the need. (“What’s the problem?”)
  • Step 2: Forming teams. (“Who needs to be involved and when?”)
  • Step 3: Defining success. (“What are we trying to achieve?”)
  • Step 4: Evaluating the vendor. (“What’s the right technology?”)
  • Step 5: Making the case. (“How do we get political and financial buy-in?”)
  • Step 6: Contracting. (“What’s our expected timing, budget and plan with our vendor?”)
  • Step 7: Designing the workflow. (“What will we need to integrate this technology?”)
  • Step 8: Preparing the staff. (“Does everyone know what they need to do to make this successful?”)
  • Step 9: Patient relationship. (“What does the patient need to know?”)
  • Step 10: Implementing. (“How does it work in practice?”)
  • Step 11: Evaluating success. (“Did it work?”)
  • Step 12: Scaling. (“What’s next?”)

Source: Digital Health Implementation Playbook, American Medical Association, https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook