Do smartphone apps have a role to play in healthcare?

At the beginning of 2013, Apple announced that its customers have downloaded more than 40billion apps, with more than 20bn in 2012 alone. Its developer community has created more than 775,000 apps and this has generated revenues of $7bn. One market area growing as fast as any is perhaps the most important – healthcare. ABI Research estimates that the market for mobile healthcare apps will be worth $400million by 2016, while the market research company Research2Guidance claims 247m mobile phone users downloaded a health related app in 2012. Apple has launched an Apps for Healthcare Professionals collection within its AppStore's Medical Category, which covers many different sectors like monitoring, nursing, imaging and patient education. The Medical Category has 240 health topics on its front page alone and an estimated 13,000 individual apps. For all makes of smartphone and tablets, there are said to be around 40,000 healthcare apps available. Don't confuse healthcare with 'wellness' There is a distinction to be made in the healthcare apps market between clinical healthcare and 'wellness'. The latter is more concerned with achieving and maintaining general fitness, while the former is targeted at medical issues – where some form of controlled, regulatory elements are in place – or, in some cases, still being developed. For the former, there is no question that mobile healthcare apps are having a major effect on the practice of professional medicine. A year ago, Manhattan Research claimed 62% of US doctors had some form of tablet computer, twice as many as in 2011. Many healthcare apps are already a major boon for professionals. One example is Medscape, one of the most downloaded apps from the AppStore. It enables clinicians to access news from 34 separate fields, allows articles to be saved and shared across social media and offers a clinical reference section featuring topics like safety guidelines on drugs and videos showing procedures. Other innovative apps targeted at professionals include: Muscle Trigger Point, from developer Real Bodywork, which shows more than 100 points for more than 70 muscles; Upper Respiratory Virtual Lab from Georgia University, which shows the upper airways using 3d mapping; and Skeletal System Pro II, developed by 3D4Medical with Stanford University's medical school, which gives a 3d look inside the whole body, features movement animation and allows connective tissues to be viewed using a scalpel tool. Several smartphones now offer apps that link with diagnostic tools, for example to perform urine analysis or check the blood sugar levels of people with diabetes. Ucheck for the iPhone can check for 10 different substances by analysing a photo of a standard urine test strip. GlucoDock allows diabetics to check their blood sugar levels before and after eating. Mobile-CliniQ works with Android phones and links via Bluetooth to a device that can check blood pressure, pulse, cholesterol levels and a patient's weight – all of which can be relayed to medical staff. Lifesavers for the developing world? Healthcare apps could be lifesavers for millions in the developing world, according to a report by the mobile industry association GSMA and global consultants PwC. Africa's 1bn inhabitants are amongst the world's least connected online, yet more than a third already own a mobile phone – and much the same is true in Asian countries such as India. "In maternal, newborn and child health, we are witnessing the game-changing effects that mobile technology has to offer through services such as pregnancy and birth registries, immunisation and nutrition tracking," said Patricia Mechael, executive director of mHealth Alliance. In richer countries, money is pouring into mobile health. One of the main aims is to let people with chronic illnesses better manage their conditions day to day and reduce time spent in hospital. According to PwC, by 2017 mobile health services could save $400bn a year out of a total annual health expenditure of $6trillion in the leading industrialised nations of the OECD. Smartphones can be powerful medical tools in surprising areas, for example psychological research. Josef Bless, a researcher at the University of Bergen in Norway, realised his mobile phone could be used to perform dichotic listening tests as used in his laboratory to measure brain function. In the test, each ear is presented simultaneously with a different syllable and the listener has to say which syllable seems clearest. The test indicates which side of the brain is most active during language processing. The app, iDichotic, was launched on the App Store in 2011, where it can be downloaded for free. Since then, more than 1000 people have downloaded it and many have sent their test results to the researchers' database. "Smartphones can be used as a tool for psychological testing, opening up many new possibilities and making it possible to gather large volumes of data easily and inexpensively," Bless says. Researchers have also developed a special version of iDichotic for patients with schizophrenia who suffer from auditory hallucinations. The app helps them to improve their focus, so that when they hear voices, they are better able to shut them out. Sebastien Mussalian is a senior engineering consultant at Team Consulting, the Cambridge based design consultancy specialising in medical devices. He says the potential to cuts costs is a key driver for several parts of the healthcare apps market. "The UK's NHS needs to cut costs and so do most other developed countries," Mussalian says. "Mobile healthcare apps can do that by providing remote monitoring, tracking and other forms of assistance for people in their own home. This can eliminate the need for carers to perform as many home visits, with major cost saving potential." One aim is to help carers and/or patients to use medical devices in the right way, especially when they are not in a medical environment, for applications like drug delivery or compliance – ensuring they are taking their medication at the right time. Diabetic patients are one example, already one of the most widely implemented. Machine to machine links are another emerging app, in which calibration of hospital equipment can be carried out remotely. It means the companies responsible for the systems can access them remotely in a hospital ward or other location, either to recalibrate them or simply to check settings, minimising disturbance and eliminating visits, again cutting costs. Business improvement is another growing professional area, such as better monitoring of the efficiency and performance of a workforce. This can sound a bit like a 'Big Brother' kind of app, but it can be a major boon for workers like carers or midwifes. They necessarily spend much of their time travelling and a GPS equipped smartphone or tablet loaded with the appropriate app can help them meet their employer's working practice requirements more easily, for instance showing where they have been and how long they spent there, all without the need for a huge amount of paperwork. Improving fitness, not curing sickness The other major part of the healthcare apps market – 'wellness' – is concerned with maintaining good health and improving fitness, rather than curing sickness. All kinds of body monitoring devices are available for this now vast worldwide market, using thousands of software apps which, only a few years ago, were little more than potential ideas. From blood pressure to eating habits, heart rate to counting calories consumed and burned, to hearing and vision tests, it is now difficult to think of any area of 'wellness' not being catered for. Two popular wellness devices are Nike's FuelBand and Jawbone's UP. The latter had problems initially, but has been reintroduced. It is a wristband fitted with a motion sensor and algorithms that passively track and quantify a wearer's steps, distance covered, calories burnt, active time, and idle time. It calculates calories burned based on your age, gender, height and weight, along with activity intensity and duration. UP can even track a user's sleep pattern, monitoring micro movements to determine whether they are awake, in light sleep or in deep sleep. Similarly, Nike's FuelBand uses an accelerometer to track running, walking, dancing and other everyday activities. A user sets a daily goal and the FuelBand tracks their progress, lighting up green when they reach their goal. A free mobile app is available for the iPhone, iPad or iPod touch enabling users to sync wirelessly. There are many other similar devices now being introduced, including Fitbit's Flex and the Basis Band. No one doubts that the growth in healthcare apps has the potential for good in both medical and wellness areas. But what about drawbacks? Are there any? There is an argument that the whole market is growing so quickly that it runs the risk of being seriously unregulated and could persuade people to do things that put their health at risk. One study by the New England Centre for Investigative Reporting claimed many apps do not follow established medical guidelines, and few are tested through the sort of clinical research that is standard for more conventional methods of treatment. In an examination of 1500 'paid for' health apps which have been available since June 2011, the Centre found more than one in five claims to treat or cure medical problems. The US Food and Drug Administration (FDA) has said such apps need regulation. Of the 331 therapeutic apps examined, nearly 43% relied on mopile phone sound for treatments. Another dozen used the mobile phone's light, while two more used phone vibrations. Scientists say none of these methods would work for the conditions in question. "We realised this could be a medium for mischief," says James Prunty, a Federal Trade Commission attorney who helped prosecute the US government's only cases against health app developers last year, shutting down two apps claimed to cure acne. Since then, the FDA has been debating how to oversee apps, but governments do not want to risk stifling growth. In March 2013, the FDA said any mobile health app regulation will be 'narrow', carried out 'judiciously' and without impeding sales of smartphones. And, in the UK in 2012, the then health secretary Andrew Lansley suggested GPs should recommend apps to their patients for tasks like blood pressure monitoring. "The risk is there, although things are changing," says Mussalian. "But a key benefit of healthcare apps in general – particularly for the wellness sector – is that it makes people feel empowered by their medical data. They want to know more than they get from their doctor, even though obviously we still need to go on trusting our healthcare professionals. "Millions of people now have a computer in their pocket that is as powerful as their desktop machine was a couple of years ago. We are only just starting to work out what we can do with that power and the healthcare app market is leading the way."