Successful clinical outcomes involve both clinician and patient factors such as good decision making, accurate diagnosis, patient compliance, effective monitoring of the condition, and accurate interpretation of clinical results. With a general trend in healthcare towards personalized medicine, the smartphone holds great potential to play a role in personalized care and aid in the above mentioned factors. Through the use of apps, the increasingly powerful smartphone may be a useful aid in the healthcare and clinical industries. This review surveys the currently available apps in Google and Apple app stores that are purposed for aiding healthcare and clinical use, and discusses how they may also help transform the smartphone in a medically relevant device.
In ancient times, physicians made house visits to the sick, often administering medical attention within the comforts of the patient’s home. Although house-visits do continue to exist today, they are more common in smaller towns or village communities and the very affluent in cities. In the developed world, there is a trend of reversal in the mode of medical care of our forefathers: from doctors attending to patients in their homes, to patients consulting doctors in hospitals.
Such changes have risen out of the necessity for efficiency and improved healthcare. In a hospital/clinic, the concentration of medical expertise, equipment and sanitized environment improves the quality of healthcare over house-visits. Nonetheless, both models of consultation have their own disadvantages. In house visits, the physician’s travelling time slows down the immediacy of care and compromises diagnostic accuracy without the necessary medical equipment (e.g. X-Ray machine). On the other hand, we have the very real problem of long patient waiting hours just for a few minutes of consultation or the collection of test results.
Regardless of the consultation model, today’s world offers a solution which overcomes the flaws of each model: the smartphone. With the advancement and incorporation of technology into healthcare, it might be possible to do away with physical visits, especially with video or other imaging technology through smartphones. Patients can get a quick consultation or access their test results with accompanying clinical comments easily. If advanced equipment are required, there might be possibility to leverage on smartphone sensors as simple medical equipment (e.g. microphone as a stethoscope), turning the smartphone into a multi-purpose mobile medical equipment that can be used by both patients and clincians.
Nonetheless, when dealing with clinical procedures, accuracy and precision outweighs convenience and time. With the growth of technology in medical diagnostics (e.g. electronic ECG, electronic X-Ray), accuracy and efficiency are not necessarily mutually exclusive. Thus, there is potential for the use of apps and wirelessly connected peripheral added sensors to enable the smartphone to change the workings of the healthcare industry.
In spite of this potential and the pockets of activity towards this cause, there is a dearth of literature covering the already available clinical aid apps that both the patient and the clinician can leverage on. To address this, this review discusses the currently available clinically and medically relevant apps and how they might be incorporated into practice for better outcomes.
The future of mobile apps
Efficiency is one of pursuits of excellent healthcare especially in today’s growing demands of ageing populations in many developed societies. Incorporating mobile apps with internet connectivity into routine medical processes (e.g. consultations) enhances the convenience for both doctors and patients alike. In the common problem of long waiting times, registration and appointments can be booked using mobile apps without long queues for the receptionist. Similarly, medical results or clinically relevant pictures taken by patients can be sent through secured apps to physicians and specialists for consultations without the physical transfer of document between hospital departments. With increased efficiency in consultations and diagnosis, patients can be treated earlier, thereby improving prognosis. It might even be possible to do away with face to face outpatient consultations or routine follow-up through the use of apps. Patients can receive professional consultation through apps in the comfort of their homes, a scenario that is especially beneficial for elderly patients or those with high dependency to getting around.
Displacing medical equipment for lower healthcare costs
The rising costs of healthcare, contributed by the increasing costs of skilled personnel, medical equipment and infrastructure, poses a challenge to accessible healthcare to the less privileged in society. On this problem, the smartphone might help to reduce costs by displacing expensive medical equipment with clinical mobile apps that leverage on the many sensors in smartphones. One such example is the displacement of a heart rate monitor (costing between USD$70 - $150) with a free heart rate monitor app that functions via the in-built microphone or camera. Coupled with internet connectivity, one can even easily send results to clinicians, a feature that most current medical equipment lack. Should artificial intelligence be incorporated, these apps may further aid in diagnosis by detecting abnormalities.
Patient compliance to clinical advice and care is essential for successful clinical outcomes (Martin et al. 2005). The most effective treatment regimens would be rendered ineffective if patients failed to comply. This is particularly true for chronic diseases where patient compliance directly affects disease control. On this aspect, mobile apps that monitor patient conditions and sends reminders of treatment would certainly be a boon for chronic disease management. This is especially so if clinicians can use such apps to monitor disease/symptoms for diagnosis and adjustment of treatment methods.
Clinical mobile apps
In view of the potential for mobile apps in the abovementioned areas, we did a survey of apps in the Google and Apple app stores using key words: “patient info management”, “patient health monitor”, “eye diagnosis”, “skin diagnosis”, “blood pressure”, “heart beat rate”, “medical calculator” and “patient compliance”. As of early 2016, we found over 1121 and 536 apps in Google Play Store and Apple App Store, respectively. Only about 139 apps of these were directly relevant to practical uses for healthcare. Of these, 30 apps were for patient data management and communication; 44 apps for patient health monitoring; 36 apps for clinical diagnosis; 21 apps for medical calculations; and 7 apps for patient compliance. Within these, we further classified them into nine categories based on their functions.
The various categories of apps relevant to healthcare and medical purposes
In healthcare, timely communication between a patient and doctor enables the former to get medical advice and the latter to keep track of the patient condition and intervene when necessary. A range of clinical communication apps have been developed to facilitate better communication between patients and clinicians. One notable example of such apps is ‘HealthJump’ (Healthjump Inc 2015) which not only allows patients to schedule their appointments with their doctors, but also provides medical records securely.
Patient data management is tantamount for accurate diagnosis/disease management and has to be secured to ensure patient confidentiality. Incomplete or missing reports can result in the loss of crucial information that could have serious clinical consequences (e.g. drug allergies). Apps in this area facilitate the viewing, storage and management of patient data without the spatial constraints of desk-bound medical computer systems. ‘My Patients’ (Evgeny 2015) and ‘Patient Reports Doctor ON GO-T’ (Siyami Apps 2015) are example apps that allow the clinicians to view patients’ medical history, diagnosis and prescription on the go. Such apps make clinical rounds in the ward or house visits much more convenient, doing away with bulky files and folders.
Besides secured data transmission and data encryption necessary for patient confidentiality, there are other limitations for such apps. One such limitation is the accessibility of file formats where certain medical equipment may store data (e.g. X-Ray, ECG printouts etc.) in specific file formats not easily accessed on the apps. It is also questionable if the small screen of these mobile devices would allow sufficient analysis of important test results (e.g. small abnormalities in X-Rays). Although difficult viewing conditions may increase human errors, this can be mitigated with image processing algorithms that perform automated diagnostic parameters to detect anomalies.
Patient health monitors and trackers [Tables 3, 4, 5, 6, 7, 8, 9, 10 and 11]
Apps in this category facilitate the recording and monitoring of disease conditions after diagnosis. In the example of hypertension, ambulatory monitoring may enable better diagnosis (Gan et al. 2003) as compared to readings taken at clinics that may be confounded by psychosomatic fear. Some apps in this category can do more to make a comparison analysis with previous data and alert the user of significant fluctuations in the condition. ‘Blood Pressure Diary’ (FRUCT 2016) and ‘PulsePRO’ (Cocoalena Software 2015) are examples of such apps that record, analyse and send the clinical measurements to attending physicians without the need of an ambulatory machine (typically costing up to hundreds of dollars). With a wide range of types and functions, other apps are also made to track patient’s general health, skin problems, eye problems, blood parameters, menstrual cycles and the presence of diseases. With such monitors and trackers, behavioural changes that improve eating habits and physical activity levels have been observed in young adults. Thus such monitoring apps do encourage patients to be more aware of their daily condition (Higgins 2015).
As a subgroup of the health monitoring apps, heart rate measurement apps form a significant bulk of the group in the mega app stores. Basic heart rate information can be an indicator of general health and aid in both monitoring and detection of cardiac problems. Apps in this category often function like a stethoscope by using the microphone or camera in the smartphones. One example, the ‘Cardiograph Heart Rate Monitor’ (BIG DREAMS Lab 2014) app measures the user’s heart rate via the placement of the index finger on the camera. Through the inbuilt camera flash, the app would then track the colour changes on the finger. There is also a significant move in this area towards peripheral devices, where there has been an increase in smart watches (built by major smartphone makers e.g. Apple, Samsung, etc., and other technology companies e.g. Fitbit) that monitors heart rate and send data to the smartphone.
Similar to measuring heart rate, measuring blood pressure is also another indicator of health status and condition. However unlike heart rate apps, the typical measurement of blood pressure would require the use of peripheral cuff devices connected to the smartphone. Nonetheless one app seems to be able to measure the parameter indirectly without the use of external devices. The ‘Instant Blood Pressure’ (Auralife 2014) relies on inbuilt camera and flash to provide blood pressure readings. As the technology is protected, it is likely that the dominant apps in this type would be more dependent on peripheral devices.
Apps in this category leverage on the camera/screen to allow for convenient and quick analysis and storage of eye images and tests. The ‘Colour Blindness Test’ (DaDo 2014) app tests for colour blindness and provides category of colour blindness in the result analysis. Another app such as ‘Pain Eye’ (Medina 2014) helps to investigate eye pain using captured images of the pupil using the smartphone’s camera. Using clip-on peripheral camera adaptors, ‘Peek Retina’ (Peek 2015) was created by a team of eye specialists, software developers, designers and engineers for remote diagnosis. Many apps in this category leverage on the inbuilt cameras in smartphones, and there is potential for these apps to even aid in detecting abnormalities when coupled with advanced image processing and artificial intelligent algorithms.
Like the ophthalmology apps, skin diagnosis apps leverage on the smartphone inbuilt camera and image processing algorithms. Captured images of the skin are compared against a database of disease images. Apps such as ‘Mole Doctor Skin Cancer App Dermatologist’ (Teodorescu 2014) and ‘Skin Analytics’ (Skin Analytics Development 2014) enable the comparison of mole pictures against skin cancer images. These images can then be sent to dermatologists, making diagnosis more convenient. One limitation of such image based apps is that they are sensitive to the lighting and environmental factors during image capture. Such factors may severely affect the quality of the images and lead to poor diagnostic accuracies.
One frequent clinical mistake that can be fatal in medical treatment is the calculation of dosage. To prevent these mistakes, there are apps available to provide necessary medical calculations, conversions and chemical formulae checks. One such app, ‘Calculate by QxMD’ (QxMD Medical Software Inc 2015) app provides a number of unique calculators specific to various medical specialities and decision support tools including risk analysis. Another example, the Thyroid-SPOT (Sim et al. 2016) apps (Doctor and Patient versions) compute the homeostatic euthyroid set point, guiding the optimization of personalized treatment plans as well as to monitor the patient’s condition. With these apps, more informed patients can also do their part and check their prescription or treatment regimen thus reducing clinical errors.
As discussed earlier, patient compliance is a key factor in the success of treatment regimens. Considering also that most patients are willing to receive medication reminders (Kebede, et al. 2015) and likely to possess smartphones, medication reminder apps can improve compliance. One such example, ‘Medisafe Meds & Pill Reminder’ (MediSafe™ 2016) monitors and has reminders for scheduled medication times. Such apps are particularly useful for the elderly and those with multiple treatment regimens concurrently.
With the smartphone becoming increasingly versatile in different fields of work, there is great promise for its role in the future of personalized medicine. In the current survey of the available apps in the largest apps stores: Google and Apple, we surveyed relevant apps that benefit both clinicians and patients. While there are many apps within the various medical specialities that may exist, they were not covered as focus is given to areas where patients can play a role, such as taking pictures (skin/eye) for better monitoring and diagnosis. Obviously, certain levels of technical savviness and acceptance from the users (both patient and clinicians) are necessary for the desired benefits of using these apps. The apps surveyed in this review focus on the many clinical aspects with the end-goal of improving the efficiency, cost, simplicity and effectiveness of healthcare. While a horde of apps exist, the majority found in Google and Apple app stores are either glossaries of clinical information apps for health professionals, or basic health knowledge apps for the layman. Even amongst the numerous apps designed for clinical data management and monitoring health, only a minority were found to be of direct practical use. In fact, focussing on the directly practical apps, there is a paucity of evidence-based or professional-informed apps (Majeed-Ariss, et al. 2015; Krebs and Duncan 2015; Subhi et al. 2015). One contributing factor for the dearth of apps in certain medical specialties is that certain diagnostic or monitoring procedures may be dependent on peripheral devices (see example of blood pressure and Peek Retina above). Such demands of peripheral devices thus limit the exploitation of smartphones. Other factors include the administration and certification required of medical devices which would vary between countries, and also for the device type. As there are a large number of smartphone models and makers, the in-built sensors in these phones would vary. This results in significant inter-equipment errors that may prevent any standardized guidelines or procedures required for professional clinical use. These make certification and use of smartphone as medical devices more challenging and unlikely to be approved by various authorities (scope of this is beyond this article due to the varying requirements). In the event they are approved for use, it is likely that many of these smartphone-dependent devices will require skilled personnel. As a result, clinical apps will mostly play a supportive role rather than as direct medical equipment replacements. Such limitations may be slightly mitigated by standardised peripheral devices, but these peripheral devices have their own limitations in accessibility to the general public.
Nonetheless in societies with less stringent medical regulation and where specialized medical equipment may not be readily available, the smartphone certainly has a role not only as a patient companion, but also as a screening tool for health problems. The smartphone has already been shown to aid in numerous areas: patient monitoring, transmission of clinical data between patients and clinicians, encouraging patient compliance, and helping with clinical calculations and decision making. Certainly the patient now has the resources to take better ownership of their own health with such apps (regulatory board approved or not) at their disposal.
With an obvious role in personalized healthcare, the smartphone promises to be a portable medical toolkit/clinical gathering device for both clinicians and patients. Much remains to be done with much more apps and peripheral devices that can be made, but with the collaborative effort between medical specialists, software developers and hardware engineers, the future of the smartphone medical toolkit can be materialized. The days of convenient house-visits might return in the form of app consultations.
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