THE JOURNAL OF

FAMILYPRACTICE

Helen Lippman, MAThe Joumal of FamilyPractice

Dhlippman®frontünemedcom.com

The author reported nopotential conflict of interestrelevant to this article.

INSTANTPOLL

Which of thefollowing bestdescribes your useof medical apps?

Ü / look up druginteractions,symptoms, etc,during visits

D / read medicaljournals andreference mate-rial on a mobiledevice

D / "prescribe " appsto patients withchronic conditions

D Allot the above

D None. I still usea laptop and a"dumb" phone

jfponline.com

How apps are changingfamily medicineMedical applications for smartphones and tablets areso ubiquitous that it's easy to become a victim of appoverload. Here's a look at FDA-approved apps, referenceapps, and apps tbat FPs are "prescribing."

I n April, hundreds of attendees atTEDMED, a conference on medical inno-vation, waited in line for a "smartphone

physical." Curated by Shiv Gaglani, a medicalstudent and an editor at the medical technol-ogy journal Medgadget, the exam involved10 apps that turn an ordinary smartphoneinto a medical device (TABLE i).' Among themwere the AliveCor Heart Monitor (picturedat right), which produces a one-lead EKG inseconds when a patient's fingers or chest arepressed against the electrodes embedded inthe back of what is essentially a phone case^-a pulse oximeter, and an ultrasound that cancapture images of the carotid arteries.'

All but one of the apps is paired witha physical component, such as an ultra-sound wand or otoscope. The exception isSpiroSmart, an app that uses the phone'sbuilt-in microphone and lip reverberationsto assess lung function. Shwetak Patel, PhD,of the University of Washington, one of itsdevelopers, told JFP that the accuracy ofSpiroSmart has been found to be within 5%of traditional spirometry results.^

WhUe smartphone physicals are notlikely to be integrated into family practice forsome time to come. Glen Stream, MD, boardchair of the American Academy of EamilyPhysicians, predicts that integration of someof their features is not too far away. "The spi-rometry appHcaüon is an especiaUy good one;it addresses one of the top 5 chronic condi-tions that contribute to health care costs,"

Dr. Stream said. The apps will be beneficial, headded, as long as they "are used in a way thatcontributes, to, rather than detracts from, col-laboration between patients and physicians."

For now. Dr. Stream and many of hisfellow FPs use mobile devices and medicalapps primarily to access reference materi-als, both in and out of the exam room. Somehave begun "prescribing" apps to tech-sawypatients. Still others have never used a medi-cal app, either because they prefer a desktopor laptop computer to a smartphone or tabletor because, as one FP put it, "I have a dumbphone."

Wherever you fall on the spectrum, it's asafe bet that you're going to be increasinglyinundated by the many manifestations of mo-bile health (mHealth).

Epocrates is No. 1 reference appThe number of medical/health apps for smart-phones or tablets is difficult to pin down; esti-mates range from 17,000 to more than 40,000,and growing."* More is known about physicianuse of smartphones and tablets.

A March 2013 survey of nearly 3000 physi-cians found that 74% use smartphones at workand 43% use them to look up drug information.''The favorite tool? A 2012 survey conductedby the University of Pennsylvania's PerelmanSchool of Medicine to identify the best medi-cal apps put Epocrates at the top of the list(TABLE 2)." Epocrates was the very first app

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The AliveCor appand Heart Monitor—a smartphone casefitted with sensors—cangenerate a one-leadEKG tracing in seconds.

cited by virtually all the FPs interviewed for thisarticle, as well.

Other drug references cited tend to bepatient-specific. Colan Kennelly, MD, a clini-cal educator at the Good Samaritan Fam-ily Medicine Residency in Phoenix, findsLactMed particularly useful. Developed hythe National Library of Medicine and part ofits Toxicology Data Network, the app lets youpull up medications quickly and see whetherand how they will affect hreastfeeding.

Another favorite of Kennelly's is theAgency for Healthcare Research and Qual-ity's ePSS (electronic Preventive ServicesSelector) app designed to help primary careclinicians identify the preventive servicesthat are appropriate for their patients. "Youjust plug in a patient's age and sex"—(preg-nancy, tobacco use, and whether the patientis sexually active are also considered)—"andit tells you what you should be checking for,"Dr. Kennelly said.

The benefits of mobile textbooksTexthook apps and online texts are slowlygaining in popularity. A recent survey byManhattan Research found that in 2013 for

the first time, usage of electronic medicaltexts surpassed that of print editions.' Part ofthe appeal is that mobile texts are easy to tote."Apps make it possible to carry around infor-mation from a number of textbooks with noadded weight," said Richard Usatine, MD, ofthe University of Texas Health Science Cen-ter at San Antonio and editor of JFP's PhotoRounds column. Dr. Usatine is also a princi-pal of Usatine Media, which turns medicalreference materials into apps.

Dr. Usatine's own experience is a casein point. He recently used a textbook app toprepare to take his boards (for the fifth time)."I've brushed up each time," he said, "hut thistime I really studied because it was fun.

"With a print textbook you have to cov-er up the answers so you don't see them.Here, you don't get to see the answer untilyou commit to one of the multiple choiceanswers. Then you get told what the correctanswer is and why you got it right or wrong,"Dr. Usatine said. Interactivity, including theopportunity to watch a video, say, of a proce-dure to review how it's done before embark-ing on it yourself, is a big part of the value ofapps, he said.

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Apps improvepatient care—an expert tells howEricTopoi, MD

www.jfponline.com

TABLE 1

10 components ofthe "smartphone physical'

Device

1. iHeaith Body Analysis Scaie

2. Withings BP Monitor

3. Masimo iSpO2

4. Weich Aiiyn iExaminer

5. EyeNetra NETRA-G

6. CeiiScope Otoscope

7. SpiroSmart Spirometer'^

8. AiiveCor Heart Monitor

9. ThinkLabs ds32-t- Stethoscope

10. Mobisante MobiUS SP1 System

Function

Body analysis (eg, weight, BMI,body fat, muscle and bone mass)

BP, heart rate

Oxygen saturation, puise,perfusion index

Fundoscopic examination

Visuai acuity

Ear drum visuaiization

Spirometry

One-iead EKG

Stethoscope

Ultrasound

FDA approved*

Yes

Yes

Applied

Yes

No

Stiii in prototype

Stiii in prototype

Yes*

Yes

Yes

BMl, body mass index; BP, blood pressure; EKG, electrocardiogram; FDA, US Food and Drug Administration.*The FDA reviews about 20 mobile medical apps per year.This application does not require an external device.

*Approved for sale to clinicians and to patients by prescription; over-the-counter status is being sought.

Rx: AppIn January, Eric Topol, MD, a prominent car-diologist and chief academic officer of ScrippsHealth in La Jolla, Calif., demonstrated theAiiveCor heart monitor and other mohile de-vices on NBC's Rock Center." In March, hewent on The Colhert Report and examinedStephen Colbert's ear with an otoscope smart-phone accessory (CeUScope) like the one usedin Gaglani's smartphone physical.'* Dr. Topol'suse of the mobile heart monitor to assess anairplane passenger in distress midflight alsoreceived widespread news coverage.

In response to an interviewer's question,Dr. Topol said he is now more likely to pre-scribe an app than a drug." While it's unlikelythat any FP could make such a claim, manyhave begun recommending apps to tech-sawy patients.

Smartphones as symptom trackersA January 2013 Pew Internet study found that7 in 10 US adults track at least one healthindicator, for themselves or a loved one. Sixin 10 reported tracking weight, diet, or exer-cise, and one in 3 said they track indicatorsof medical problems, such as blood pressure,

glucose levels, headaches, or sleep patterns—usually without the aid of a smartphone.'"

In fact, half of those who report trackinghealth measures said they keep the information"in their head," and a third still use pencü andpaper.'" That could change, of course, if theirphysicians suggest they do otherwise (TABLE 3).

Kelly M. Latimer, MD, an FP in the Navystationed in Djibouti, Africa, routinely askspatients whether they have a smartphone andoften recommends apps to those who do.

"It sounds like you have a lot of differentsymptoms," she might say to a patient whocomplains of frequent headaches. "It willhelp me if you keep a headache diary."

She used to give such patients paper andpen. Dr. Latimer noted. "Now I ask them todovwiload the app (iHeadache, in this case)right then and there and do a quick review"so they're ready to use it at home.

Apps are also a good way to help peo-ple with anxiety. Dr. Latimer has found. Shefrequently recommends apps like Relax-ation Techniques and Breathe2Relax, andoften suggests apps like Calorie Count andMyFitnessPal to boost patients' efforts to loseweight and get in shape.

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TABLE 2

2012 medical app survey identifies top 8

Epocrates Essentials (comprehensive clinical reference suite)

MedCalc (medical formulas, scores, scales, and classifications)

Medscape Mobile (drug and condition reference, medical news, CME courses)

DynaMed (clinical reference, updated daily)

VisualDX (visual diagnostic clinical decision support system)

Micromedex Drug Information (comprehensive information on drugs, doses, and interactions)

Skyscape (customizable repository of drug and clinical information, medical calculators, etc )

Diagnosaurus DDx (diagnostic search tool)

TABLE 3

A sampling of apps your colleagues are prescribing

Condition

Anxiety

Headache/migraine

Medication/OC management

Menopause

Pain

Sleep problems

Voiding

Weight loss

App

Breathe2Relax : =Relaxation Techniques

iHeadache

GoodRxMedMoryMyOCMyPill

BioDeskmyPause

WebMD Pain Coach

Sleep Diary

Bladder PaliP Voiding Diary

Calorie CountLose It!MyFitnessPal

OC, oral contraceptive.

Abigail Lowther, MD, an FP at the Uni-versity of Michigan in Ann Arbor, also rec-ommends apps frequently. But she typicallybroaches the subject only with patients whohave their smartphones out when she walksinto the room.

Among the apps Dr. Lowther prescribesare myPause to track menopausal symptomsand Bladder Pal, a voiding diary for womenstruggling with incontinence. She adviseswomen taking oral contraceptives to use thetimer function on their phone to remem-ber to take a pill at the same time every day.

But there are apps (myPill, for one) that dothat, too.

I The upside of patient apps. A smart-phone is ideal for keeping a symptom diarybecause it's something that most people arenever without. Anyone can use the notes func-tion on a phone or tablet to jot down detausabout exacerbations, but those using disease-specific apps tend to capture more preciseinformation. Some patients print out the infor-mation they've gathered and bring a hard copyto an office visit, while others simply showtheir physician what's on their smartphone.

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"Smartphonesmake our liveseasier incountlessways, butunfortunately,when it comesto curing acne,there's no appfor that," thechairman of theFederal TradeCommissionstated in apress release.

Can apps affect outcomes? There are fewhigh-quality studies and the jury is still out,but "the smartphone has a very bright futurein the world of medicine," the authors of areview of smartphones in the medical arenaconcluded. After examining the use of apps totrack (literally) wandering dementia patients;calculate and recommend insulin dosages forpatients with type 1 diabetes; and teach yoga,to name a few, the researchers concludedthat "the smartphone may one day be recog-nized as a diagnostic and therapeutic tool...as irreplaceable as the stethoscope.""

Dr. Lovrther recalls an obese patientwho found MyFitnessPal to be helpful whereother, more traditional diet programs hadfailed. The reason? He was less than truthfulwith the people overseeing the weight lossprograms about what he'd eaten when hetried—and failed—to follow diets like WeightWatchers. He then ended up feeling so guiltythat he abandoned the effort entirely. But, hetold her, he "wouldn't lie" to an app.

I...and the downside. Even physicianswho haven't begun recommending apps topatients are aware that carefully trackingmeasures related to chronic conditions likehypertension or diabetes often results in bet-ter control. But in some cases, there may betoo much of a good thing. Evidence suggeststhat for some patients vdth type 2 diabetes,glucose self-monitoring is associated with de-pression and may do more harm than good.'^

Dr. Lowther has witnessed a similar phe-nomenon in patients using disease-trackingapps. "Sometimes people get too focusedon the problem and drive themselves crazy,"she observed, adding that those with highblood pressure are particularly at risk. "Ithink sometimes it's hard for patients to un-derstand the concept of an average value andnormal fluctuation," Dr. Lowther said. Whenthat happens, "I have to tell them to back off."

Who's minding the (app) store?The mHealth arena has been called "the wildWest."'̂ With at least one app for virtually ev-ery aspect of health and medicine you canthink of, it's not hard to understand why.

In an article on the use of symptom dia-ries in outpatient care, Bryan Hodge, DO, an

FP in Hendersonville, NC, mentions mobileself-tracking apps as one of a number of waysfor patients to keep symptom diaries." Giventhe fact that few of these apps have been vali-dated. Dr. Hodge writes, "The best approachis to familiarize yourself with a few optionsthat you can offer to your patients.""

I That depends on the nature of theapp. An app that tracks calories consumedor simply keeps an organized nie of patientsymptoms may do little harm; an app that con-veys physical measurements that a patient orphysician may act on or calculates medicationdosages requires a higher level of vigilance.

A recent study of smartphone apps thatcalculate opioid dosage conversion, for ex-ample, found a lack of consistency that raised ared flag about the reliability of information pro-vided by unvalidated apps. Better regulation ofmedical apps is crucial to ensure that patientsafety is maintained, the authors concluded.'^

The FDA's roleThe US Food and Drug Administration, whichhas approved more than 75 medical apps,issued a proposed approach to its oversight ofthe apps in 2011.'**

Under the proposed rules, the agencywould regulate mobile apps that were eitherused as an accessory to a medical device al-ready regulated by the FDA or that transforma smartphone or tablet into a regulated medi-cal device. A final rule has not yet been issued,but a spokesperson told Congress that it willbe forthcoming before the end of the year."

False claims are a target of federal regula-tion, as well. In 2011, the Federal Trade Com-mission pulled 2 acne apps off the marketbecause both advertised—without scientificevidence—that the light emitted by smart-phones equipped with the apps could treatacne. "Smartphones make our lives easier incountless ways, but unfortunately, when itcomes to curing acne, there's no app for that,"the FTC chairman stated in a press release.'"

In May 2013, the FDA sent an "It has cometo our attention letter" to Biosense Technolo-gies regarding its uChek urine analyzer app.The problem, the letter stated, is that the dip-sticks that the app allows a mobile phone toanalyze are cleared by the FDA only wheninterpreted by direct visual reading. But the

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phone and device together function "as an au-tomated strip reader"—a urinalysis test systemfor which new FDA clearance is required.'^

Other ways of evaluating appsHapptique, a mobile health solutions compa-ny, recently announced the launch of its HealthApp Certification Program—a voluntary pro-gram designed to help clinicians and patientseasily identify apps that are credible and safe.̂ ""We wül be certifying medical, health, and flt-ness apps, Corey Ackerman, president andCEO of Happtique, told JFP. The program iscurrently accepting medical education andnursing apps for review, and "discussions areunderway with numerous other organizationsthat will provide experts for apps in additionalsubject matter areas," Mr. Ackerman said.

There are other means of evaluatingmobile medical apps that fall outside of themedical device realm, of course—starting byperusing the reviews posted at the app stores.Exchanging information with other cliniciansusing an app you're interested in is anotherway to learn more about its efficacy. (Yes,there's an app for that, too: Doximity, the pro-

fessional network for clinicians.)Other suggestions for safe use of apps:• Peruse iMedicalApps (imedicalapps.

com), the self-described leading physi-cian publication on mobile medicine.Its physician editors and team of clini-cians research and review medical apps.

• Consider the source. An app that hasbeen developed by a medical society,federal agency, or prestigious medicalschool, for example, is more trustwor-thy than one from an unknown source(a point you would be wise to pass onto your patients).

• Try the app yourself before you recom-mend it to a patient.

Finally, keep the privacy provision in theHealth Insurance Portability and Accountabil-ity Act in mind. Before using any app throughwhich private patient health information canbe transmitted or stored, ensure that the datawill be encrypted and that your mobile deviceis password-protected, advises mHIMSS, themobile branch of the Healthcare Informationand Management Systems Society. '̂ DFP

References1. TEDMED. The smartphone physical. Available at: http://www.

smartphonephysical.org/tedmed.html. Accessed lune 14,2013.

2. AliveCor. AliveCor heart monitor. Available at: http://www.alivecor.com/. Accessed June 14, 2013.

3. Ubiquitous Computing Lab, University of Washington.Mobile phone spirometry. Available at: http://ubicomplab.cs.washington.edu/wiki/SpiroSmart. Accessed June 19,2013.

4. Association of American Medical Colleges. Explosive growthin health care apps raises oversight questions. Available at:https://www.aamc.org/newsroom/reporter/october2012/308516/health-care-apps.html. Accessed June 14,2013.

5. Alvarez A. How are physicians using smartphones for pro-fessional purposes? April 22, 2013. Available at: www.kantarmedia-healthcare.com/how-are-physicians-using-smart-phones-for-professional-purposes. Accessed Jtme 14,2013.

6. Penn Medical Student Government. 2012 Medical app surveyresults. February 9, 2013. Available at: http://msg.med.upenn.edu/?p=17784. Accessed June 19,2013.

7. Comstock J.Manhattan: 72% of physicians have tablets. April 18,2013. Available at: bttp://mobüiealthnews.com/21733/manhat-tan-72-percent-of-physicians-have-tabIets/. Accessed June 19,2013.

8. Dr. Eric Topol on NBC's Rock Center. January 24,2013. Availableat: http://www.youtube.com/watch?v=0B-jUOOrtks. AccessedJune 14,2013.

9. Comstock J. Topol turns Colbert around on digital bealtb. March27, 2013. Available at: http://mobihealthnews.com/21263/topoi-tums-colbert-around-on-digital-healtb/Accessed Jtme14,2013.

10. Pew Research Center. Tracking for health. January 28, 2013.Available at: http://pewintemet.org/Press-Releases/2013/Tracking-for-health. Accessed June 14,2013.

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dents./Med/«feraeifles.2012;14:el28.

12. Mendoza M, Rosenberg T. Self-management of type 2 diabetes:a good idea or not? ] Fam Pract. 2013;62:244-248.

13. McMillan R. iPad: 'Wild West' of medical apps seeks sheriff. De-cember 12, 2011. Available at: http://www.wired.com/wiredent-erprise/2011/12/fda_apps/. Accessed June 14,2013.

14. Hodge B. The use of symptom diaries in outpatient care.Fam Pract Manag. 2013:20:24-28.

15. Haffey F, Brady RR, Maxwell S. A comparison of the reliability ofsmartpbone apps for opioid conversion. Drug Saf. 2013;36:lll-117.

16. US Food and Drug Administration. FDA proposes health "app"gtiidelines. July 19, 2011. Available at: http://www.fda.gov/forconsumers/constunerupdates/ucm263332.htni. AccessedJune 14,2013.

17. Pavlovic P. 10 issues that mobile medical app develop-ers should keep in mind. April 18, 2013. Available at: http://www.mhimss.org/news/10-issues-mobile-medical-app-deveiopers-should-keep-mind. Accessed Jtme 14,2013.

18. Federal Trade Commission. "Acne cure" mobile app market-ers will drop baseless claims under FTC settlements. Septem-ber 8, 2011. Available at: http://www.ftc.gov/opa/2011/09/acnecure.shtm. Accessed June 14,2013.

19. FDA. Letter to Biosense Technologies Private Limited concern-ing the uChek urine analyzer Available at: http://www.fda.gov/MedicalDevices/ResourcesforYou/Industry/ucm353513.htm.Accessed June 14,2013.

20. Happtique publishes final standards for mobile health app cer-tification program. February 27, 2013. Available at: http://www.happtique.com/happtique-publishes-ñnal-standards-for-mo-bile-health-app-certification-program/. Accessed June 19,2013.

21. mHIMSS. Privacy and security. Available at: http://www.mhimss.org/resource-topics/privacy-security. Accessed June14,2013.

A weight lossapp would bemore likely tohelp this patientreach his goalthan other dietprogramsbecause he"wouldn't lie"to an app.

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