Smartphone Apps: Architecture Trumps Content

According to this The Wall Street Journal article, the prospect that "your doctor may soon prescribe you a smartphone app," has put us on the cusp of a new age of m-healthiness. 

 

Regular Population Health Blog readers are not surprised. They have an "over-the-horizon" awareness of health information technology and know that the health app ecosystem has been flourishing for quite some time. 

 

What is surprising, however, is how the news article from a prestigious news organization conflated architecture and content. 

 

The PHB explains.

 

The WSJ article describes how intrepid e-researchers from marquee academic institutions are documenting the impact of apps on medication compliance, symptom management, risk reduction and provider-patient communication. Once users open these apps, there's not only an eHealth technology platform but an accompanying library of tailored e-prompts, e-reminders, e-pop-ups, e-recommendations, e-messaging, e-images and e-videos.  Mix one app with one patient and quality goes up and costs go down.

 

Unfortunately, what the article failed to mention is that much of that content made up of information that is freely available in the public domain, and that these app developers have reconfigured and adapted it according to the interests, expertise and culture of their sponsoring institutions.

 

While policymakers and researchers would like to believe that on-line and public domain health information is a commodity, the fact is that buyer, purchaser and provider organizations have been accessing and downloading it for years.  They've take special pride of ownership in the wording, editing, formatting, presentation of that content.  That's what makes it "theirs" for both their providers and their patients.  After all, all healthcare is local.

 

This has important implications for the smartphone app indsutry.  While the academic e-researchers and business e-developers dream of having their apps adopted by delivery systems everywhere, the problem is that their apps are often tethered to their own organizations' content. 

 

In other words, you can have any breast cancer, heart failure or post-hospital discharge smartphone-based solution that you want, just so long as you also import their prompts, reminders, pop-ups, recommendations, messages, images and videos. 

 

The Population Health Blog believes the secret sauce for competitive success for app developers is accordingly three-fold:

 

1) Architecture Trumps Content: Smart app developers understand that the value proposition of the underlying technology architecture is separate from the value proposition of the content.  The app itself needs to be independently stable, secure and snappy with minimal branching logic, an easy-to-use interface and freedom from annoying bugs, whether it's heart failure in for a hundred patients in Halifax or a dozen persons with diabetes in Des Moines. 

 

2) Architecture Supports Content: Very smart app developers also understand that the architecture should be able to accommodate any content that is preferred by their customers. If ABC Regional Health System wants their in-house policies, procedures, pamphlets, web-pages, in-house guidelines and electronic record prompts to be reflected in a smartphone app, then the app's framework should be able to import it.  Think plug and play.

 

3) Architecture Has Content: That being said, not every buyer, purchaser or provider will have all the content needed to manage a target population. That means app developers will need to have generic content ready to go to fill in the gaps. 

 

The business case for apps may be similar to selling a house.  First off, make sure the foundation is solid and the roof is intact.  Be prepared to move walls and windows, if that's what the buyer wants.  And, if the house needs to be furnished with some furniture, do it; if the buyer wants some or all of their furniture to furnish the house, do it.

 

Image from Wikipedia

Curing the Healthcare Digital Divide: There's an App for That

Whither meaningful use?

For better or worse, policymakers, politicians and health leaders in the United States are committed to achieving paperless healthcare environment. Even if there is lack of high quality research and reasonable skepticism over the ultimate cost and quality merits of "e"care, there is no going back.

As a result, visitors to ehospitals and eclinics are increasingly surrounded by monitors that, in turn, are surrounded by providers. To gain their attention, patients need to have internet access to make appointments, update medications, obtain education and communicate with their doctor.

And what if they don't have that access? For the last decade, that worry has been characterized as "the healthcare digital divide. " As recently as 2014, it's been documented that the lack of computer hardware and access can have important healthcare implications for persons with low socioeconomic status.

For the doctors and nurses staring at screens all day, the millions of Americans who are living paycheck to paycheck risk being out sight and out of mind.

But it turns out that that it doesn't need to be that way.

The PHB explains.

Check out this telling report from the Federal Deposit Insurance Corporation on the "unbanked" and "underbanked."  Not having a bank account (unbanked) or using any financial services (underbanked) are linked to persons with low income, being of color, disability and being unemployed.

In other words, these are the very persons at risk of being on the losing end of the health care digital divide.

While there's interesting data on how close to 8% of U.S. households are unbanked and just over 20% were underbanked, there were also these stunning observations:

"Relative to fully banked households (86.8%), underbanked households were somewhat more likely to have had access to mobile phones (90.5%) and smartphones (64.5% of underbanked households compared with 59.0 percent of fully banked households)."

"Notably smaller, but still significant, proportions of unbanked households had access to mobile phones (68.1%) and smartphones (33.1%)" (bolding PHB).

In other words, persons of low socioeconomic status are more likely to have smart phones vs. the "banked" population. They may not have a checking account, but, compared to other segments of the population, they are also more able to use these devices to access and manage their "e"care.

The PHB's conclusions?

1. Not  explicitly fostering heandhelds as a part of the healthcare informatics "ecosystem" may be shutting out persons of low socioeconomic status from the health system. While the Washington DC's "meaningful use" (MU) criteria are not explicitly tilted toward desktop/tower computing, they seem to conspicuously silent on advocating for ease of smartphone use, for example, to manage appointments, medications, education and messaging. 

Compare MU that with Google's mobilegeddon and the unwillingness of innovative systems (like this and this) to wait for CMS to catch up.  They're loaning handhelds to patients.

What do you know: if you want to increase access to healthcare for the economically disenfranchised, there truly is an app for that.  It was there all along.

2. Yet, smartphones for the economically vulnerable and access to health information technology are not necessarily a slamdunk.  This report reminds us that smartphone contracts are vulnerable to non-payment and that it's not unusual for service to be turned off. 

Health systems that can navigate that reality that will win.

Image from Wikipedia

The Future of Digital Medicine: Smartphones Will Replace the EHR As the Workhorse Informatics Device In Clinical Care Settings

As a former New Yorker, the Disease Management Care Blog has always had an abiding respect for the Big Apple's taxi drivers. That increased considerably after it left its wallet in a Manhattan cab and it turned up in Virginia a year later - in the possession of an individual allegedly involved in organized crime. This and other evidence of the cabbies' shrewd business acumen makes the DMCB wonder why Hizzoner required that they start using hybrid cars. If they're such a gas-conserving and money saving no-brainers, the DMCB figures the cabbies would have figured out a way to get them on the streets all by themselves.

Which brings the DMCB to smartphones and healthcare. How can this be, you ask? Read on.

Thanks to the Covering Health blog and their link to this report from the California HealthCare Foundation (CHCF), the DMCB not only got to delight in the new term 'techfluentials,' it learned that these little electronic mini-slabs have remained remarkably recession proof. They're now in use by 42% of consumers. Even more impressive, however, is their uptake among supposedly tech-wary physicians. Fully two thirds of providers currently possess smartphones and that's projected to exceed 80% by 2012.

There are over 5000 iPhone health-related apps and about a third have been designed for physicians and other providers. They include medical and drug reference libraries, dosage calculators, clinical alerts, decision support tools, viewers for lab and radiology reports (including the x-rays themselves), communication portals designed for patients as well as physicians, patient status monitors (for example, in the emergency room and labor suite), continuing medical education (CME) tools and the means to access a patient's personal health record (PHR)

In the meantime, the Feds continue to promote a stubbornly expensive and unwieldy electronic health record (EHR). With their usual complex web of financial and regulatory sticks and carrots, Washington's bureaucrats remain fixated on the big boxy multifunctional and proprietary personal computer-based systems with screens and keyboards populating every clinic room and hallway.

In contrast to that orthodoxy, the DMCB agrees with it's colleague Vince Kuraitis. He predicts the EHR will evolve into a PC-centric platform of distributed cross-functional and plug-and play devices. Yet, thanks to the California Foundation report, the DMCB wonders if things may become even more complicated than that. It could be that the handheld smartphone, not the screen and keyboard, turns out to be the central hub of digital care. In other words, the iPhone won't be slaved to PC-based EHR systems, it'll be vice versa. What's more, there won't necessarily be a desktop or a hallway. In fact, the clinic's boundaries may turn out to be even more fluid than we ever anticipated.

And it's all happening without Federal intervention.

Which brings the DMCB back to the New York City cabbies. Despite the best intentions of the Mayor, there have been problems, suits and delays. The DMCB also recalls reading that the involvement of NYC government in the first place may have ironically led some cab companies, pending better understanding the law, to delay buying any hybrids.

And, despite similarly good intentions extending back through several administrations, Federal meddling in the promotion of EHRs have also caused many physicians to delay the purchase of an EHR. Unlike the NYC cabbies, however, the docs have had another smaller, nimble, cheaper and remarkably functional option. It's the smartphone, which may have been partially spurred by the continuing travails of the Fed's love affair with the EHR. It seems that while providers have been waiting for Dr. Blumenthal et al to clarify just how good the EHR can be, physicians have apparently turned to the next best thing.

In fact, based on CHCF's report, it may be turning out to be the better thing.

('’)