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When the Rx is an app

As apps monitor, manage and control almost every aspect of health care, some physicians are finding they help increase patient compliance and education.

By — Posted Nov. 5, 2012

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When Paul Mohabir, MD, noticed that more patients were arriving with smartphones in their hands, he thought some of the apps he used would be as valuable for them as they were for him. Since then, he has found smartphones to be a great tool to keep patients engaged and more compliant. He thinks the ways they are used are only going to grow.

There has been so much buzz about the potential benefits of mobile health — known as mHealth in health IT circles — that several organizations have formed to promote mobile health solutions and study their efficacy and potential risks. Discussions are taking place in exam rooms across the country about how a $1 app could be a viable alternative to prescribing a medication and help patients monitor their health. Some even have referred to the act of physicians recommending mobile health as “prescribing an app.”

In the traditional sense of prescribing, the phrase is not accurate, said David Collins, senior director of mHIMSS, a subsidiary of the Health Information and Management Systems Society focused on mobile health initiatives. “But in the digital wave of medicine, when it comes to mobile health, I’d say it does make sense. Patients are used to going to their doctor’s office, getting their problem solved and leaving with a prescription in their hands.”

There are no definitive numbers on how many doctors prescribe apps. But most industry watchers say such prescribing will grow more common as outcome-based payment models become more prevalent among payers and more patients buy smartphones and look for ways to use them for health management. Dr. Mohabir, a pulmonologist at Stanford Hospital and Clinics in Palo Alto, Calif., said his patients have been helped by apps he has prescribed: ones that track medications and monitor weight and cholesterol.

What apps are making headway

For the moment, there are a lot of reasons why many physicians aren’t prescribing apps to patients. Most industry insiders agree there is limited evidence regarding the efficacy of apps. There also are concerns about a lack of regulation that will inform physicians and patients about an app’s quality. And the number of health app users is small: A November 2011 report from Pew Internet & American Life Project found 10% of smartphone users have downloaded health-related apps.

However, mobile health advocates say these barriers are being overcome. A handful of controlled trials looking at the efficacy of apps to control chronic conditions show that mobile technology has great promise in improving the way patients are monitored and in reducing costs by keeping patients away from the physician’s office. The Food and Drug Administration has approved a select number of apps that deal with clinical care. Its oversight may expand if a bill expected to be introduced in the U.S. House of Representatives calling for the creation of an FDA Office of Mobile Health makes its way through Congress. And the number of smartphone users is only going up.

Mobile health advocates said physicians can feel comfortable prescribing apps that help modify behaviors. That is really no different from physicians prescribing a diet, a support group or any other resource, said Harry Greenspun, MD, senior adviser of health care transformation and technology for the Deloitte Center for Health Solutions. He said it’s a matter of physicians getting more creative with the ways they engage their patients and provide the best care to them.

Many patients are attracted to the convenience of a health management tool on a device they probably have with them anyway. If they need to log blood pressure or blood glucose levels, they don’t have to worry about finding their log book or remembering to record the information when they get home.

Tom Martin, manager of mHIMSS, said the “gamification,” or the competitive design, of some apps is a powerful motivator that can help keep patients compliant. People’s competitiveness makes them strive to do better, he said.

More organizations are getting involved in app promotion and development. The American Medical Association launched a consumer weight loss app in February. The American Academy of Family Physicians’ journal,American Family Physician, unveiled an app to help physicians find AFP content by topic that can be shared with patients. And the Dept. of Health and Human Services’ Office of the National Coordinator of Health Information Technology has organized several app contests for developers to submit ideas that the ONC will develop and promote. A contest that took place in July sought an app that will help consumers identify and reduce their risk of heart disease.

The mHIMSS website also has a guide to help physicians evaluate apps by knowing what to look for.

Who is prescribed an app

Physicians say whom they prescribe an app to depends on the condition they are treating, what they want to accomplish and how motivated the patient is to trying something new.

In addition to being comfortable with the technology, the patients must be self-motivated, said Dr. Mohabir, a clinical assistant professor of pulmonary and critical care medicine at Stanford University School of Medicine.

Dr. Greenspun said patients who already have dedicated themselves to accomplishing a task will find apps useful.

However, doctors say even patients who don’t seem motivated can benefit from an app prescription. Even though some patients might not be candidates for apps, Collins said, they may have caregivers who would welcome an app as a way to make their jobs easier.

Many physicians who prescribe apps say they do so in the same way they approach patient education — by having a conversation with a patient and offering suggestions. Once the patient leaves the exam room with an app recommendation in hand, what happens next depends on the physician’s reasons and motivation for prescribing the app, as well as the patient’s motivation level.

“It’s one thing to just prescribe an app and say, ‘Hey, use this thing,’ as opposed to something that enhances the engagement between the patient and the doctor,” Dr. Greenspun said.

He said physicians might prescribe an app that collects or creates data the physician wouldn’t usually keep constant track of, such as exercise apps that monitor heart rates and calories burned. In those cases, “it’s no different than just giving someone a pamphlet,” he said. It’s simply meant as a resource for the patient. But in other cases, the physician may need the information collected by the app as a way to engage the patient.Steve Levine, MD, associate dean for clinical research and faculty development at The State University of New York Health Science Center in Brooklyn, is involved with a project funded by the Patient-Centered Outcomes Research Institute to develop an app for stroke patients for the National Stroke Assn.Eventually, he said, apps will be able to send summarized reports of data that are uploaded directly to an EHR. Until that happens, physicians are too pressed for time to manage the data that some monitoring apps might produce. But when an app replaces pen-and-paper log books, the technology may make the information easier for physicians and patients to digest, because many are able to create summaries that can be emailed before a visit.

For cases in which a physician may wonder how compliant a patient is, the data collected by an app may drive the conversation in the exam room. Experts say these are the same conversations physicians always have had with patients, but the data provide more points of entry for discussion.

The more monitoring and management that can be done from a mobile phone, the more compliant Collins thinks patients will be. “What’s neat about mobile in general is that people like it,” he said. “It’s part of their daily life already, and it’s not overwhelming to them.”

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Patients more enthused than doctors about mobile health

A June study by PwC measured the responses of consumers and physicians in 10 developed countries, including the U.S., to questions about their use of mobile health.

Patient mobile health beliefs

59% say mobile health has given them solutions that have replaced some doctor visits.

52% say mobile health will lower health care costs within three years.

49% think it will change the way they manage their overall health.

48% say it will improve health care quality within three years.

48% think it will change the way they manage chronic conditions.

48% say it will change the way they manage medication.

46% believe it will make their health care more convenient within three years.

Physician mobile health beliefs

42% say mobile health will make patients too independent.

27% will encourage patients to use mobile health apps.

13% will discourage patients from using mobile health apps.

Source: “Emerging mHealth: Paths for growth,” PwC, June (link)

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Britain to promote app prescriptions

In an effort to reduce unnecessary visits to physician offices, the United Kingdom Dept. of Health said it plans to ask physicians to encourage patients to use mobile apps to track biometrics and symptoms.

Health Secretary Andrew Lansley said in February that he had compiled a list of 500 mobile tools — and was seeking suggestions for others to add to the list — that he would recommend to general practitioners to prescribe to patients. Lansley said he hoped to save the National Health Service “millions of pounds” in unnecessary office visits by giving patients the information and advice they need to stay healthy without making appointments to see their doctors.

The NHS launched NHS Direct, a 24-hour telephone advice line, in 1998 and a website in 1999 that featured symptom checkers. In May 2011, NHS Direct unveiled a mobile app that has been downloaded more than 1 million times as of November 2011. Lansley said 25% of the people who used the NHS Direct website and app visited their doctors less frequently.

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Apps: prescriptions insurers like but don’t cover

Many mobile health proponents say one of the biggest barriers to widespread use of apps in health care — and the reason many physicians shy away from prescribing apps to patients — is the lack of compensation for care delivered by a mobile device.

PwC’s June report, “Emerging mHealth: paths for growth,” found that payers are far more supportive of mobile health tools than physicians, with 40% encouraging patients to use them compared with 25% of physicians. Although payers are supportive of physicians recommending mobile applications, few, if any, pay physicians in conjunction with mobile health.

“Reimbursement policy is skewed in favor of face-to-face medical treatment over digital or mobile application,” limiting physician interest in it, wrote Darrell West, vice president and director of governance studies and director of the Center for Technology Innovation at the Brookings Institution, in a report he published in May that examined issues in technology innovation.

Experts say the lack of evidence that mobile apps deliver effective results is one reason payers have shied away from coverage.

But some momentum is building around app coverage. In its 2010 National Broadband Plan, the Federal Communications Commission made suggestions to the Dept. of Health and Human Services for how it can advance the use of mobile health solutions, called e-care in the report. Among its suggestions was for HHS to identify e-care applications whose use could be encouraged through outcomes-based payments. It also called on HHS to support further testing and pilot programs of e-care applications. It said that as more outcomes-based payment models are developed, the Centers for Medicare & Medicaid Services should look for ways to reimburse for use of e-care technologies.

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External links

“Meaningful Consumer Engagement,” Optum Insititute, September (link)

“Emerging mHealth: Paths for growth,” PwC, June (link)

“Half of adult cell phone owners have apps on their phones,” Pew Internet & American Life Project, Nov. 2, 2011 (link)

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