an introduction to developing health apps

1. an introduction to developing health apps andypulman web team leader, school of health & social care, bournemouth university mental health care using apps, telehealth and telecare conference 19th june 2013

2. in a nutshell • rise of the mobile phone • app overview • health and mental health apps • building an app (in four steps) • case study: diabetes and alcohol guide • restraints • final thoughts

3. rise of the mobile • two-thirds of the world's population – over 4 billion people – now have access to a mobile phone (naughton 2012) • mobile now accounts for 10% of all internet usage worldwide (russell 2012) with recent surveys estimating that mobile internet usage will exceed desktop usage between 2014 and 2020 (anderson & rainie 2008; richmond 2011). • pew’s 2012 mobile health study found that 19% of americanmobile owners had apps installed that helped them track or manage their health, with 24% of those aged 18 to 29 owning such apps.

4. apps • apps harness the power of the internet with the simplicity of multi-touch technology on a smaller screen and can be run on computers, smartphones or tablets. • in 2007, steve jobs launched apple’s app store with 500 applications (ricker2008). • as of may 16th 2013, usershad downloaded over 50 billion apps from apple’s app store with the google play store now standing at around 48 billion app downloads). • estimated that users were downloading more than 800 apps per second at a rate of over two billion apps per month on the apple app store.

5. apps (2) • feb2013: a five-year-old boy ran up a huge bill on his parents' ipadin ten minutes. After downloading the free zombies vs ninja’s app he found his way into the game's online store and innocently ordered dozens of add-ons - totalling £1,710.43. • march 2013: a 17 year old from south london becomes one of the world’s youngest tech millionaires after selling his mobile app to yahoo! • angry birds, a casual puzzle game, became an international phenomenon within a few months of its release and is now the number one paid app of all time - rovio net profit after tax in 2012 was € 55.5 million (2011: € 35.4 million).

6. health apps • 13,000 health apps intended for use by consumers available for download in apple’s app store (mobihealthnews 09/11) • due to their commercial nature, there is little research available relating to the design, development, implementation, use and regulatory procedures for approving and monitoring health-related diabetes apps in the uk (d4 research 2012).

7. mental health apps Some examples: • mayo clinic meditation (apple - £ 1.99p), a clinically validated method of meditation developed by the mayo clinic, which aims to help users feel more focused and relaxed throughout their day. • The my journey app (android - free) is designed to help you keep track of how you’re feeling. By working through the set questions with an easy-to-use rating wheel, my journey can help you make informed choices about what to do to improve your mental health.

8. mental health apps (2) • recovery road (apple - free) to provide those suffering from anorexia nervosa and bulimia with the right support tools from the privacy of their own phone. A phd researcher had witnessed her close friend repeatedly fail to record what she was eating and feeling on paper when advised by her therapist, and felt an app would be an appropriate means to provide round-the-clock assistance to other girls in the same situation. • my favourite things (in development - good et al. 2012) is intended to be an application that is designed upon the theory of reminiscent therapy (rt). It is not intended to replace therapy but to serve as a standalone support mechanism. Based upon rt theory, the application could potentially promote positive mood and therefore increase a sense of well being.

9. step 1 – have an idea “if you're an entrepreneur looking for a revolutionary idea, you will probably need to take inspiration from wherever you can find it, including rivals' products and services, fiction, and even your own childhood dreams.” “when you encounter naysayers, just keep forging ahead.” richardbranson: 06/05/13 newton, upon observing an apple fall from a tree (or it falling on his head!) suddenly thought of the universal law of gravitation…

10. step 2 – build it • apache cordova is an open source solution which allows users to author native apps using web technologies like html, css and javascript and then deploy them across multiple platforms on different app stores. You will also need: • apple developer account - £ 60 for a one year membership to the iOS developer program – you can release as many apps as you like. • a mac of some sort to develop on. • to download a free copy of xcode which is the software tool for app development which apple supplies.

11. step 3 – release it • apple review all apps to ensure they are reliable, perform as expected, and are free of offensive material (this normally takes a week or so). • once you get your app approved, it is listed on the app store and can be downloaded by anyone in the world, 24-7. • you can charge for your app or give it away for free if you prefer. • apple keep 30% of any money made and you get the other 70% so for each app you sold at £ 0.69p you’d get £ 0.48p. If you sold 100 apps you’d get £ 48 and so on…

12. step 4 – promote it

13. understanding influenced by lifeworld • the aim of my research was to develop an insight into young people’s current use of web and mobile technology and its potential impact on their health-related quality of life (hrqol) • lamb (2012) suggested clinicians involved in care of young people with type 1 diabetes should explore online examples experiences contributed to forums as they made for sobering reading. • talking to young people with type 1 diabetes in-depth and imagining what it was like (todres 2008). • one of the only reviews of features of mobile diabetes apps (chomutare et al. 2011) surprisingly uncovered that a critical feature strongly recommended by clinical guidelines - personalised education, an area my research was interested in - was not included in current applications for type 1 diabetes.

14. sociotechnical design • the aim of a design is to create something that fits, but creating something that fits comfortably and naturally is not always easy. • sociotechnical design is a response to the desire to create systems which are useful and apt (faulkner 2000). • human needs should neverbe forgotten (mumford 2006) e.g. touchscreen  • key characteristic of sociotechnical thinking lies in its ability to highlight the importance of developing new ways of working which significantly met the needs of both clients (patients) and users (service providers).

15. method overview • recruitment conducted at a local district hospital in the south west (and a local university) with data collected by semi-structured, in-depth qualitative interviews. • nine one hour interviews were conducted and transcribed with patients aged between 18 and 21 with type 1 diabetes. • six main experiential themes were identified. • data analysis was also undertaken during initial interviews (n=4) to locate potential ideas for technical development. • suggestions needed to meet clinic goals, reflect interviewee requirements and follow local trust guidelines.

16. data analysis themes • theme 1 - living with diabetes • theme 2 - diabetes technology • theme 3 - in the clinic • theme 4 - obtaining information and support . • theme 5 - mobile technology • theme 6 - mobile apps and mobile health apps

17. prototype app ideas • in collaboration with the clinic, we were able to filter possible ideas for prototype development. • three ideas were created in prototype (around alcohol, illness and hypoglycaemia education), with one (alcohol) subsequently chosen by latter interviewees (n=5) to be taken forward for final development. • a number of innovative ideas not currently available to participants were suggested during the interviews. • these included possible technological enhancements in the areas of diet and calorie control, carb counting, local social networks (both private and public), mentorship, medication and health appointment tracking, blood sugar recording, enhanced alarm capabilities, additional supportive and entertaining video and audio information, a general type 1 diabetes directory, emergency information notification and a continually open online helpdesk.

18. diabetes and alcohol guide • drinking alcohol increases the risk of hypoglycaemia (low blood glucose levels) in patients with type 1 diabetes. • it is estimated that as many as one fifth of episodes of severe hypoglycemia are attributable to alcohol (nilsson et al. 1988). • interviewees suggested that they would find a guide about alcohol limits particularly useful on a night out which could then be accessed via a mobile device.

19. technology used • development initially undertaken on the iphone platform as this was deemed to be the most popular platform for developing and approving apps at the time of development commencing and would also have the most impact on the patients, based on discussions during interviews. • can be easily transferred to other operating systems (e.g. android, windows and blackberry) as the apps are developed using apache cordovaarchitecture. • apache cordova(2013) is an open source solution which allows users to author native apps using web technologies like html, css and javascript and then deploy them across multiple platforms on different app stores.

20. method • iteration #1 developed as prototype to show to latter interviewees (n=5) • information initially extracted from core u-cairmaterials - after they had been examined for consistency and currency by a dietitian at the clinic. • revised information was then ported directly onto the app development platform for individual screen design. • feb 2012: prototype apps were deemed to have been suitably developed for testing to start within the clinic - having successfully passed system testing criteria.

21. method (2) • percentage of the time allocated in latter interviews (n=5), concentrated on ascertaining from the participants their feelings on the prototype app most closely aligned to their particular area of interest - highlighted by other sections of the interview process - to provide deep, meaningful feedback on the prototype. • this is important as unstructured interviews - in terms of usability engineering - are able to provide a wealth of information that the interviewer might not anticipate (faulkner 2000). • for latter interviews it was possible to utilisenvivo 9 to highlight, record and segregate the differing positive and negative comments on theprototype apps described by interviewees. • to subsequently feed this back into the design process (bothfor the developer – look and feel and navigation - and for clinicalstaff – textual content and the quality of information provided).

22. method (3) • alongside the section of the qualitative interview which focused on garnering prototype app feedback, the researcher was also able to observe the interviewees (n=5) using the prototype apps for a short, concentrated period of time. • this assisted in demonstrating how they were using them and highlighting any problems that they might experience in selecting screens and working out how to use the apps and navigate them, which would not come across from either listening to an audio recording or reading a transcription of an interview.

23. method (4) • in each latter interview, out of the three prototypes available, the alcohol guide was chosen by each interviewee as the app most closely aligned to their lifestyle requirements, the one which they wanted to explore in more depth and the one which they viewed as being the most useful to them. • so that the researcher could ensure from a clinical perspective that anything developed met the goals of the clinic, a questionnaire was also distributed to clinic staff that had first had a chance to try out one of the prototype apps (this provided another useful feedback loop on what was being developed). • iteration #2 developed based on feedback from interviewees and questionnaire responses from staff. • new functionality was added to iteration #2 regarding a podcast about alcohol as interviewees had expressed a desire for this feature to be available; text was also amended as it had become apparent, once the information was displayed on a mobile screen that it needed to be reformatted to make it easier to read and understand.

24. method (5) • due to the current lack of nhs regulation, to ensure that the app met clinical validation standards we formally approached the local patient advice and liaison service (pals). • iterations #3 - #5 of the app were submitted to pals for their approval, as a part of the five-step process for standardised patient information. • the approval process highlighted several areas which needed to be amended prior to approval being granted. • post pals approval of iteration #5, the alcohol app successfully passed apple’s authentication process and was offered as a free download in december 2012. • a duplicate version was then ported to the google play store and approved as an android app in february 2013.

25. diabetes and alcohol guide

26. diabetes and alcohol guide (2)

27. next steps • as of end of april 2013, the app has been downloaded 458 times worldwide (with 416 apple and 42 android downloads to date). • this means the user base is large enough to warrant further research on its use. • future research might concern any hrqolimpact that can be seen to be associated with the app locally, in other parts of the ukand overseas - and also investigate any benefits or problems, which have come from downloading and use of the app in a mobile environment. • it is also planned to continue development of the prototype app for hypoglycaemiaand take it through the same approval process as the alcohol app.

28. restraints: regulation • one specific area of concern with health apps is the current lack of any medical regulation for those released. • in 2011, the american food and drug administration (fda) released draft guidance on how it was planning to regulate apps and is now expected to release its final policy later in 2013 on which apps it will oversee. • appositely, in europeand the uk, there are currently no official guidelines for the production of apps to be used in health settings. • registered medical devices are required to carry the cemark and to date only one publically available health app hasbeen registered as a medical device(d4 research 2012). • this ever-changing landscape has prompted thenhscommissioning board to launch their healthapp library project in march 2013.

29. restraints: policy • the reasons for being unable to utilise particular forms of social media within some health environments is laudable, but also has the effect of stifling potentially life-changing ideas. • whilst acknowledging that use of blogging and other social networking websites by nhsstaff could expose their organisation to unexpected informational risks or liabilities, it is imperative that the nhsand dohadopt a more flexible approach for utilising these forms of communication rather than just banning them indiscriminately. • there is a frustratingly unclear picture of what exactly is possible from this aspect of technological innovation – especiallyif trying to work across multiple trusts.

30. which is a real shame……….health and twitter • twitter suggested as a tool which might benefit youngpeople with type 1 diabetes either used directly orthrough integration with apps. • a way to meet other people of a similar age with asimilar lifestyle. • emergency link for contacting people in the health servicewho could assist at a particular point in time. • receiving direct messages from clinical staff advisingon reminders about taking insulin,coming to appointmentsand taking blood sugar readings which could help to personalise diabetes care. • real time news feed for information on developments in diabetes such as new bloodsugar meters, stem cell research and development of an artificial pancreas. • (philbaumann blog: 140 health care uses for twitter, 2009)

31. restraints: security • an interesting conundrum, concerning what can be developed against what information is allowed to be recorded. • one of the biggest concerns relating to the use of smartphones in clinical care is the potential breach of patients’ confidentiality (nolan2011). • visserand boumannoted (2012) that the increasing usage of smartphone apps added a new aspect to patient information security, which would require new security measures. • when patient data is stored electronically it risks becoming exposed to potential data breaches and even if a smartphone is protected by the use of a personal password, this can be easily hacked, which could then compromise personal information as well as any saved patient information (bommissetty 2012).

32. restraints: interoperability • many devices, such as apps, sensors, and monitoring devices can now be used by patients and health professionals, but as wake and cunningham(2013) noted, many diabetes technology tools and systems currently operate in silos. • for example patients might use glucose monitors and diabetes apps to manage their diabetes at home but this information is never fully shared with their health care providers when they meet each other, missing an important opportunity for action and intervention. • also there is a real risk of duplicating existing functionality or apps…

33. restraints: conflict of interest • issues related to conflicts of interest include conscious and unconscious bias in prescribing habits, as well as the perception by patients and the public that doctors do not always consider the best interests of their patients when making prescribing decisions (visserand bouman2012). • using apps developed by a drug company raise substantial ethical issues as these companies might be using apps as a form of trojan horse– perhaps for marketing purposes to influence treatment options. • notably, again in the uk, there seem to be no guidelines currently available or in the process of being created which refer to the correct procedures to follow in these instances.

34. final thoughts vitally important that theoretical concepts such as empathetic understanding, reflection of the experiences of patients, thinking about ways of humanising healthcare and considering the patient voice are considered by clinicians and technological developers as innovative ways of finding out what patients would like to see developed for their own use and thinking about how they feel before and during the development process. then… utilising a suitable design approach – such as sociotechnical design - which is the best method for providing a solution satisfactory to all parties.

35. finalthoughts (2) • crucial that the patients who will be using technology for mental health issues are included in discussions regarding how they might best utilise it. • key that proactive practitioners start looking at the technology around them and seeing if they can apply it to their own practice rather than waiting for technologists to suggest what they could or should do with it. • If the clinical quality of some existing mental health applications is questionable, then it requires forward thinking psychiatrists in the uk to actively work on clinically accurate versions which could then be used in the mobile world. • It also requires prudent sensible strategic policy to avoid costly haphazard adoption of web 2.0 and mobile technology within the health sector without understanding why it is being implemented, what benefits it will bring and whether it is the right thing to be doing in the first place. mhisig connect newsletter (pulman 2010)

37. keeping in touch Andy Pulman the school of health & social care (hsc) @ Bournemouth University apulman@bournemouth.ac.uk @andy475ukandypulman@wordpress.com