Tools for Improving Adherence to Treatment in Diabetes
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM@endocrine_witch #HealthXPH
Associate Professor, University of the Philippines College of Medicine
Chief, University of the Philippines Medical Informatics Unit
App Sketching by Johan Larsson,https://flic.kr/p/dHLKPt
Disclosure Statement of Financial Interest
I, Iris Thiele Isip Tan DO NOT have a financial interest/arrangement or affiliation with any healthcare related companies that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
Adherence & mHealth
Black and White Crime 2 by Egahen,http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8
Apps for diabetes
Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN
Apps (un)regulated
Adherence & mHealth
Black and White Crime 2 by Egahen,http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8
Apps for diabetes
Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN
Apps (un)regulated
Eating salad for health by typexmick,http://www.freeimages.com/photo/1432591
“ AdherenceWHO definition (2003)
the extent to which a person’s behavior - taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider
In developed countries, adherence to long-term therapies in the general population is around 50% and is much lower in developing countries.
WHO report (2003)“
Take your medicine! by Morgan,https://flic.kr/p/6jfAxH
The Five Dimensions of AdherenceWHO (2003)
Adherence to Long-term Therapies: Evidence for Action
mobile phone-conference image by xristine_faulknerhttps://flic.kr/p/4Xn9Q7
medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs) and other wireless devices
“ mHealthWHO definition (2011)
mHealth research
2002-2012
Mobile phone in hand 2 by DragonTash,http://www.freeimages.com/photo/1438235
Health promotion (38%)
Self-management (33%)
Communication (22%)
Remote monitoring (21%)
Data gathering (21%)
Improvement of adherence (20%)
Training/education (17%)
mHealth Research Impact AreasFiordelli M et al. Mapping mHealth research: a decade of evolution
J Med Internet Res 2013;15(5):e95
Conditions addressed by mHealth researchFiordelli M et al. Mapping mHealth research: a decade of evolution
J Med Internet Res 2013;15(5):e95
DiabetesObesity/Overweight
Mental health Tobacco use
Other kind of chronic condition HIV
Other acute conditionsWell-being
CancerMedication compliance/Appointment reminder
Sexual health Cardiovascular condition
Tuberculosis 0 5 10 15 20 25
MeasurementOn-person or embedded sensor sampling in real time
Ecological Momentary Assessment
Global positioning system
DiagnosticPoint-of-care diagnostics
Portable imaging
Biomarker sensing
Clinical decision supportSensor sampling for diagnostics
Treatment/PreventionPrevention & wellness interventions
Remote behavioral treatment
Medication adherence trackingChronic disease management
Dissemination of health information
Disaster support/care
GlobalAccess to healthcare services
Remote behavioral treatment
Dissemination of health information
Disease surveillance
Medication tracking and safety
Prevention & wellness interventions
Continuum of mHealth ToolsKumar S. et al. Mobile Health Technology Evaluation: The mHealth Evidence Workshop. Am J Prev Med 2013;45(2):228–236
Arrow background by ralev_com,http://www.freeimages.com/photo/1169793
conectandonos by El_Turista_Accidental,https://flic.kr/p/7EWqg3
There’s an app for that!
Patient Apps for Improved Healthcare: From Novelty to Mainstream (Oct 2013)
IMS Institute for Healthcare Informatics
40,000+ healthcare apps on US Apple iTunes app store
Adherence & mHealth
Black and White Crime 2 by Egahen,http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8
Apps for diabetes
Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN
Apps (un)regulated
Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013
n= 43,689 apps
Healthcare & Fitness or Medical
n= 20,007 apps
Miscategorized or only loosely health related
n= 23,682 apps
Genuine healthcare related
n= 16,275 apps
Consumer oriented
n= 7,407 apps
Healthcare professional oriented
1,980 therapy area specific apps
270 apps for endocrine, nutritional & metabolic diseases
Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013
Functionality score + User score = IMS Health App Score
No. of reviews + star rating [ ]
25 individual criteriainformation provided how user data tracked/capturedcommunication processesquantity of device capabilities[ ]
Top diabetes appsstrong functionality with ease of use
IMS Health App ScoreIMS Institute for Healthcare Informatics Oct 2013
Daily CarbMaxwell Software
Glucose BuddyAzumio, Inc.
GoMealsSanofi Diabetes
1
2
3
Currently, there are more than 15,000 health-related apps (free and paid) on app stores, but we were not able to find any study assessing any of them.
So what is publicly available has not been evaluated, and what has been evaluated is not publicly available.
Mapping mHealth Research: A Decade of Evolution Fiordelli M, Diviani N, Schulz PJ. J Med Internet Res 2013;15(5):e95“
Puzzle 1 by jakubson http://www.freeimages.com/photo/1072527
Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based GuidelinesChomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
iPhoneAndroidBlackberryNokia
online markets + journal databases
+ gray literature on mobile apps
INCLUSION criterionself-monitoring
of blood glucose
EXCLUSION criteriaNo English user interface
Intended exclusively for HCPs
n = 973
n = 137 (101 online + 26 literature search) Smartphone icon by Loraw200,
http://www.freeimages.com/photo/1377498
Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based GuidelinesChomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
SELF-MONITORING
Blood glucoseWeight
Insulin & medicationBP
EDUCATION
Disease-related
ALERTS & REMINDERS
Integration of SOCIAL
MEDIA functions
Disease-related DATA EXPORT &
COMMUNICATION
Synchronization with Personal Health Record (PHR) systems or patient portals
Features from brainstorming
of authors; focus group discussions between
MDs and patients
A tree on the horizon by Ydiot,http://www.freeimages.com/photo/1113494
GAP ANALYSIS [
Literature typically reflects emerging applications and new trends ...“... the market gives a good indication of mature applications and functionality.
Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
A tree on the horizon by Ydiot,http://www.freeimages.com/photo/1113494
GAP ANALYSIS[
Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
Literature Search
PHR or Web server
synchronization18 (69%)
Insulin & medication
recording 17 (65%)
Diet recording 17 (65%)
Data export &
communication 16 (62%)
Insulin & medication
recording 63 (62%)
Data export &
communication 61 (60%)
Diet recording 47 (47%)
Weight management
43 (43%)Online Market
#1 Insulin/meds#2 Communication#3 Diet#4 Physical Activity
#5 Weight#6 BP#7 PHR
#8 Education#9 Social Media#10 Alerts
Features of Mobile Diabetes Apps: Review of the Literature & Analysis of Current Apps Compared Against Evidence-based GuidelinesChomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
A CB
Variables in diabetes self-management NOT addressedPersonalized feedback
Patient monitoring by primary care physician
Foot & eye care
Psychosocial care
Immunization
Complication management
Very little influence of social media on current diabetes mobile applications
Provide link to groups on FB or TwitterNo functional links or integration
between information in app & social media
Instagram and other social media apps by Jason Howie,https://flic.kr/p/d41HES
Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G. J Med Internet Res 2011;13(3):e65
Mobile Apps for Diabetics: A Systematic Review & Expert-based Usability Evaluation Considering the Special Requirements of Diabetes Patients Age 50 Years or OlderAmhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
iOS n=276Androidn=266Both n=114
Smartphone icon by Loraw200,http://www.freeimages.com/photo/1377498
GENERAL INFORMATIONName/languageDate of release/
updateDesktop app
OPERATING SYSTEM
iOSAndroid
Both
DEVELOPER INFORMATION
Name
POPULARITY/USER RATINGSNo. of downloads/
installationsUser rating
No. of user ratings
TARGET USER
GROUPSPatients
Physicians/qualified health personnel
Both INTERFACESInterface/
connectivity to external sensor(s)/
device
ACQUISITION COSTS Freeware
Exact priceAvailability
as”lite” version
Feb-Apr 2013
0
25
50
75
100
Free Paid Paid/Lite
iOS (n=276) Android (n=266)Both (n=114) Total (n=656)
Price distribution of diabetes apps and “lite” versionsAmhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
%
Worried senior woman talking by SalFalko,https://flic.kr/p/gFCeMN
Usability & Assessment Criteria for Diabetes Apps for ElderlyAmhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
COMPREHENSIBILITYUse of understandable semantics, simple comprehensibility & interpretability of displayed
images and depictions, simple self-explanatory menu structures
USABILITYInstant and easily understandable feedback, intuitive usability,
simple recognition of click-sensitive areas
PRESENTATION (Image & Text)Sufficient color contrast, large size of operating elements, ability to adapt the size of
operating elements and displayed images
GENERAL CHARACTERISTICSHigh fault tolerance/efficient fault management,
password-protected services
Randomly selected 66/656 apps (iOs n=29, Android n=28, Both n=9)
Comprehensibility
Presentation
Usability
General characteristics
0 1 2 3 4 5Likert Scale
Usability Assessment of Diabetes Apps for ElderlyAmhold M, Quade M, Kirch W. J Med Internet Res 2014;16(4):e104
Adherence & mHealth
Black and White Crime 2 by Egahen,http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8
Apps for diabetes
Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN
Apps (un)regulated
Patients face a dizzying array of healthcare apps to choose from,
with little guidance on quality or support from their doctors.
Some efforts are underway to help provide professional healthcare
guidance in both the US and the UK but these are limited in scope
and impact to date.
“
Hyperwall by Florian Plaghttps://flic.kr/p/8aro3Y
It’s the Wild West out there. It’s hard to sort through them all and there’s little evidence about which ones really work.
Murray AitkenExecutive Director
IMS Institute for Healthcare Informatics
“
Apple by VanessaGF,http://www.freeimages.com/photo/1427461
An app a day keeps the doctor away. “ When a prescription drug goes
generic, it has at least seven years of data about its effectiveness and safety, which gives physicians assurance that patients can use it for self-care.
Medical apps have no history of either effectiveness or safety.
Mike PaskavitzEditor-In-Chief, Quantia Inc
“
Mobile apps that are NOT medical devices ... will NOT be regulated by FDA.
Mobile apps may meet the definition of a medical device but because they pose a lower risk to the public, FDA intends to exercise enforcement discretion
Mobile apps may meet the definition of a medical device but because they pose a lower risk to the public, FDA intends to exercise enforcement discretion.
Caledos runner by Nicola,https://flic.kr/p/fP18Jx
Although the FDA has focused on safety, it has largely left the review and certification of apps to the marketplace.
The currently available reviews of mHealth apps have largely focused on personal impressions, rather than evidence-based, unbiased assessments of clinical performance and data security.
Powell AC, Landman AB, Bates DW. In Search of a Few Good AppsJAMA. Published online March 24, 2014,
doi:10.001/jama.2014.2564
“
Mobile medical applications that FDA has cleared or approved
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/
MobileMedicalApplications/ucm368784.htm
http://spectrum.ieee.org/biomedical/devices/bluestar-the-first-prescriptiononly-app
This is a piece of software getting the same treatment as a medical device. It’s pretty world-changing.
Sonny VuCofounder, Misfit Wearables
“
Patient Apps for Improved HealthcareIMS Institute for Healthcare Informatics Oct 2013
Evaluation & Evolution of Diabetes Mobile Apps: Key Factors for HCPs Seeking to Guide Patients Ristau R, Yang J, White J. Diabetes Spectrum 2103; 26(4):211–215
PATIENT
DEMOGRAPHICSOlder generation less likely to be
technologically savvy
FINANCIAL BURDENCan the patient afford the device & the app?
Busy woman by JetMedia,http://www.freeimages.com/photo/1070268
Evaluation & Evolution of Diabetes Mobile Apps: Key Factors for HCPs Seeking to Guide Patients Ristau R, Yang J, White J. Diabetes Spectrum 2103; 26(4):211–215
DEVICE & APP
PLATFORMNot all apps available
for all platforms
APP FEATURESLogging & tracking, data sharing & social support,
SMS & reminders
EASE OF USE Easy to navigate,
modify, enter, retrieve & share data
GUIDELINES & REGULATIONSFollow guidelines?
FDA approved? Busy woman by JetMedia,http://www.freeimages.com/photo/1070268
Adherence & mHealth
Black and White Crime 2 by Egahen,http://www.freeimages.com/photo/1115701
The App Store by PhotoAtelier,https://flic.kr/p/9rCQw8
Apps for diabetes
Runkeeper and health on iPhone by Jason Howie,https://flic.kr/p/e5CBwN
Apps (un)regulated
Measurable behavior change is the desired outcome of diabetes education. The diabetes professional community must step into the market void and embrace mobile technology as part of the solution.
“