It will take more than incessant hype, circuitous access to clinical IT systems and consumers knee-deep in their own data to make physicians embrace the use of mHealth in their work and with their patients. Though the tally of health-related mobile applications has risen above 100,000 and continues to grow, a lack of relevance to provider practice and workload, along with poor use of the mobile form's innate advantages, are keeping acceptance rates at a slow pace, experts say.
"If it were as fabulous as promised, it would be ubiquitous, and it's not," says Jeffrey Benabio, M.D., physician director of health care transformation in the San Diego region of Kaiser Permanente, assessing the wares of mHealth application designers. "There's still a lot of work to be done, and until that work gets done, then I don't think it will be all that they promised."
A mere fraction of software written for health-related purposes is for doctors to work better and faster, and apps that cater to that purpose likely convert a mouse-dependent, typing-oriented desktop version of functions and data display to mobile use.
At Avera Health, a system with 35 hospitals in five rural western states, physicians can access the electronic record, but, "We're displaying a PC-optimized interface on an iPad, which is not ideal unless you use a keyboard and stylus," says Andrew Burchett, D.O., medical information officer. "It's difficult to navigate, and you surely cannot take advantage of the features of the tablet: the mobility, the tap in-tap out, scroll, pinch, zoom, all that kind of fun stuff." But a version that leverages such functionality is on the way [see Beyond the Flaws].
Physicians were among the first wave of adopters of smartphones and mobile devices for personal use, and "once you have something in your pocket, you start thinking about ways to use it; it's just natural," says Joseph Kvedar, M.D., director of Partners HealthCare's Center for Connected Health, Boston. Applications designed to improve physician workflow and mobility, such as instant access to drug information or remote viewing of patient electrocardiograms, "are doing pretty well, because they aren't disruptive — they're actually making the doctor's life easier for the most part."
When it comes to the glut of apps dealing with patient health data tracking and measurement, however, two barriers to physician acceptance loom large: the sheer number to select from, and the sheer amount of information potentially coming at physicians who agree to field incoming data from their patients. Doctors see personal liability risk in associating themselves with apps and recommending them, especially when not created by health professionals, Kvedar says. There is no reference that curates and catalogues them, he says, and physicians don't have time to investigate.
Kaiser Permanente has begun to evaluate and recommend apps, and it even has its own wellness tracker called Every Body Walk! The aim is to ascertain what's really valuable in what patients are asking for, yet what's manageable, Benabio says. "So many of my docs go home at night and then they have to log on to their electronic health record and do more charting after they put their kids to bed. Those people shouldering that burden don't have the capacity to say, 'OK, let's look at some of these other cool apps and see what we can learn,' because they just don't have the time for it."
Doctors might find more time once the health care payment system shifts sufficiently enough to payment for performance to merit investment in prevention and wellness. At Partners, where capitated risk contracts are gaining a foothold, physicians "start to really embrace virtual care," says Kvedar. "Virtual care enables them to extend the resources of their practice across a larger population of patients. And in these risk environments, you get compensated according to the size of the population you manage."
Benabio says the payment model is a primary influence on demand for mobility. For doctors still mainly taking fees for service and seeing little value in mHealth, "I don't blame them — you just get paid for what you do — but if they were just getting paid for outcomes, any tool that you'd put in a physician's hand to help him do that would be adopted readily."
Beyond the flaws
Despite a mismatch between native mobile device traits and desktop-oriented software, Avera Health's mobile version of its EHR is widely available in its hospitals and soon will be in outpatient settings — flaws and all. "We have had good adoption of that, but it's an incomplete solution," says Avera's Burchett. Users can navigate charts, read documents and find notes, but the application lacks capability to accept documentation and do complex ordering.
When Avera receives and implements the next version of the Meditech software platform in late 2014 or early 2015, it will be written in Web-based code, designed specifically for mobility and "a great tool," Burchett says. When physicians see the recent release demonstrated, "they want it tomorrow." Besides using the native mobile features, it fully supports ordering and documenting.
That will enhance acceptance by "helping the EHR become more integrated into the patient-physician experience." For one thing, a tablet in an exam room is less of a hindrance: Entering information from a patient on a tablet, which is "more like a stethoscope than it is the PC distraction in the room," allows more interaction and eye contact.
In addition, physicians won't have to go to a PC somewhere else to complete a patient encounter. Currently, Burchett says, "All I can do is use [the tablet] as a referential tool — that's part of what I have to do — and I have to go to another device to order, to document and to e-prescribe." Until physicians have an all-in-one mobile option, it will hinder their use of it.
The principles of interacting with a mobile device have to be harnessed to the maximum to make mHealth the revolutionary factor that marketing hype is so insistent on imputing, says Kvedar of the Center for Connected Health.
Being mobile is only part of the unique value.
The first distinctive attribute: "It's always on, always connected. And that's the first time in history we've been able to interact with a computer in your hand that's always on," he says.
It's a device that knows its location, Kvedar adds, "that knows your activity level, that knows how many text messages you're sending — there's so much there. That's really powerful."
Another aspect not available with computer use until now is the wide range of health information a practitioner can capture with that device, whether it be a blood test, a lab test, pictures of skin, or an accelerometer to detect walking distance.
All of that can be delivered literally in hand.
"This really is a special technology when it comes to health," says Kvedar. "It's not just another telehealth thing or another cool thing to do because it's a mobile phone. It's a game-changer."