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Association of American Medical Colleges Tomorrow's Doctors, Tomorrow's Cures®

Explosive Growth in Health Care Apps Raises Oversight Questions

AAMC Reporter: October 2012

—By Stephen G. Pelletier, special to the Reporter

More robust, downloadable tools on mobile devices increasingly enable us to measure our heart rates, blood pressure, and blood glucose levels. Type your symptoms into an app and you can find out what might be ailing you. Apps can help us count calories, assess exercise regimens, get details about medication, and track other aspects of our well-being.

Some experts estimate the number of health-related mobile apps at no fewer than 40,000. A recent study from Juniper Research, a British company that studies trends in mobile technology, suggested there will be 44 million downloads of mobile health care apps in 2012—a figure projected to rise to 142 million by 2016. And according to the Mobile Health Market Report 2011–2016, revenues for health care apps increased from $718 million to $1.3 billion between 2011 and 2012.

Students develop award-winning apps

Given society’s embrace of mobile devices, consumers inevitably will turn to mobile apps to manage their wellbeing and health care. The rise in consumer use parallels increased traction among physicians and other health practitioners. Broadly speaking, these trends are part of the rise of mHealth, the use of mobile technology to improve health and health care delivery.

One interesting trend in mHealth has been the development of award-winning apps by entrepreneurial medical students.

Craig Monsen and David Do, both fourth-year medical students at Johns Hopkins University School of Medicine, are the brains behind Symcat, an acronym for symptomsbased, computer-assisted triage. Users who access Symcat through a computer or mobile device can enter a symptom and almost immediately have a possible diagnosis of their condition, complete with treatment options. The suggestions are drawn from aggregated, anonymized patient records collected by the Centers for Disease Control and Prevention (CDC). This past June, Symcat won the $100,000 grand prize in the Robert Wood Johnson Foundation Aligning Forces for Quality Developer Challenge.

Symcat was inspired in part by the duo’s experiences during emergency medical rotations, where they treated patients who did not have genuine medical emergencies. “We recognized that many patients were there because they didn’t know what other options were available to them,” Monsen said. “They were missing a critical piece of information.” Monsen and Do realized that a datadriven medical app might help patients bridge that gap.

Another data-based app, VaxNation, was developed by students from Baylor College of Medicine, the University of Texas School of Public Health, and Rice University. Its focus is to provide “an effective, efficient, and equitable way” for individuals to track their vaccinations and educate themselves about the risks and benefits of vaccines and the diseases they prevent. Like Symcat, VaxNation relies on input from the CDC—in this case, on the CDC’s highly detailed guidance about vaccinations. Earlier this year, VaxNation won first prize in the Institute of Medicine’s “Go Viral to Improve Health” collegiate challenge.

Oversight questions

The explosive growth of health care apps introduces critical questions—not the least of which are whether apps can improve care. To be an accepted part of health care, how should apps be evaluated or even approved? How can their efficacy be measured?

In the July issue of Scientific American, Francis S. Collins, M.D., Ph.D., director of the National Institutes of Health, said that mobile devices “offer remarkably attractive low-cost, real-time ways to assess disease, movement, images, behavior, social interactions, environmental toxins, metabolites, and a host of other physiological variables.” These tools can bring innovation to biomedical research, Collins wrote, and even “help build the foundation of evidence that so many mHealth applications currently lack.”

Like others in this fast-emerging and fast-evolving space, Collins sees a need to assess mHealth tools. Researchers and developers “must pull together to find ways of evaluating new technologies,” he wrote.

To answer that challenge, experts are pursuing how to bring appropriate regulation and standards to the world of health care apps.

Last summer, the U.S. Food and Drug Administration (FDA) said it was seeking input on a “proposed oversight approach for certain mobile applications specific to medicine or health care.” At the time, Jeffrey Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health, said the agency’s focus would be on “only those mobile medical apps that present the greatest risk to patients when they don’t work as intended.” In August, FDA spokesperson Erica Jefferson said the FDA was still working to finalize the guidelines.

At Johns Hopkins University, the universitywide Global mHealth Initiative applies well-established research methodologies—such as clinical review, randomized controlled trials, and real-time data analysis—to understand the impact of mobile strategies on health outcomes.

“We ask what the principle is—what is the quality of the app itself, and is it based on good science?” said Alain B. Labrique, Ph.D., M.H.S., M.S., the initiative’s director. “Have the strategies been evaluated in some rigorous way and then demonstrated to have an impact?”

As a spinoff of the Johns Hopkins initiative, a group of faculty created, an independent online publication written by physicians and medical students who comment on and review mobile medical technology and applications. Similarly, reviews of orthopedic apps are available at, founded by Orrin I. Franko, M.D., a fourth-year resident in orthopedic surgery at the University of California, San Diego, School of Medicine.

Medical journals also are beginning to evaluate apps. In addition to papers in existing publications, the growth of medical apps has spawned creation of the Journal of Mobile Technology in Medicine, another of Franko’s projects.

In the private sector, meanwhile, the startup company Happtique, a subsidiary of the Greater New York Hospital Association, is developing a certification program that will assess the functionality, privacy, security, and content of health care apps. In addition, Happtique recently launched a pilot program for its mRx™ solution, an app that enables physicians and other practitioners to prescribe medical, health, and fitness apps to their patients.

Potential and promise

Assuming this variety of approaches results in appropriate standards and regulations, how should society think about the ultimate potential of health care apps? According to experts in mHealth, their promise should not be underestimated.

“Generally speaking, I think mobile apps have the potential to bring point-of-care reference directly to the physician. If implemented properly, that can result in better medical decisions for patients,” Franko said. From an individual’s perspective, he added, “mobile apps have the potential to help guide patients, reinforce good behaviors, and provide valid information in a convenient and usable format, either for sharing with their physician or to help refer them to the appropriate provider.”

Leslie Saxon, M.D., a professor of clinical medicine at the University of Southern California Keck School of Medicine (USC), and director of the USC Center for Body Computing, believes mobile apps will be “a large part of the future” of health care and that issues of regulation and standardization are “surmountable.”

One exciting dimension of mHealth, Saxon said, is that it allows solutions in health care to be shared quickly across the world’s population. Another plus, she said, is that mobile apps provide a means for more data about a patient’s health to be put directly into the hands of that patient. “I think that the home runs in terms of apps are going to be those that don’t just tell a piece of your health care story, but a lot of it, and allow [the patient] to input data,” Saxon said.

At Johns Hopkins, Labrique had a similar take. “I think the ubiquity of [mobile devices] in our society specifically has the potential to transform the way that we see the health system evolve, as we move from a reactive model to a proactive, prevention-driven model,” he said. “The ability to have access not just to health information, but also information about how individuals are performing in their management of their own health status, enables [patients] to have a better conversation with clinicians and care providers and engages [patients] more proactively in that process.”

Looking to the future, Saxon said, “Health care is going to be more patient-centered and delivered over mobile devices. I think that’s really going to move the needle on health care outcomes and satisfaction.”

October 2012 Home

opening an app on a touch screen

“I think that the home runs in terms of apps are going to be those that don’t just tell a piece of your health care story, but a lot of it, and all [the patient] to input data.”

Leslie Saxon, M.D., professor of clinical medicine and director of the Center for Body Computing at the University of Southern California Keck School of Medicine

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