There’s a medical app for that
Authors: Benjamin Jelle Visser, Jonathan Bouman
Publication date: 18 Apr 2012
Doctors should be wary when using medical apps, but a few questions can help sift the good from the bad
Increasing numbers of doctors and medical students are using smartphones and associated applications (apps) as a source of reference material in daily clinical care. Many mobile health apps are targeted at doctors as tools to improve and facilitate the delivery of patient care. Doctors and students can use apps in their day to day tasks—for example, to look up reference values, make a differential diagnosis, perform useful calculations, and look at a patient’s investigations (for example, chest radiographs).
In 2010, according to Research2Guidance, 500 million smartphone users worldwide will be using a healthcare application by 2015. A survey conducted by the General Medical Council demonstrated that 30% of doctors use a smartphone for medical apps. Another study concluded that this number will rise in 2012, where it is predicted that 83% of medical doctors will use a smartphone.
One explanation for increased use could be that health professionals are beginning to recognise the positive impact smartphone apps can have on patient safety, on outcomes, and on system efficiency. Medical apps have an enormous potential for improving our practice by providing a quick, comprehensive, and up to date overview of current clinical guidelines, which could help clinical decision making and change the way healthcare is delivered in the future (box 1).
Box 1: Fifteen recommended medical apps for smartphones
All recommended medical apps are targeted to an international audience and available for iPhone, Android, and Blackberry, unless stated otherwise.
Medscape—Free. Tops our list, with enormous content that grows continuously with each update. Find drug references, disease clinical references, clinical images, procedure videos, and more. This top reference tool has its real value in the disease and condition clinical references it provides
Prognosis—Free. Clinical case simulation game designed for doctors and medical students updated with a new case every week (available for iPhone and Android)
UptoDate—Free if you have an institutional subscription, otherwise prices for annual subscriptions range from $199 (£125; €150) for trainees and students to $495 for an individual subscription. The only clinical knowledge system associated with improved quality of care. Essential app for medical students (available for iPhone)
Micromedex—Free, easy to use, straightforward, and a reliable reference for medical prescriptions
Visual Body—$35.95. Learning for an exam or bored on public transport? Improve your anatomical knowledge at a time convenient for you (available for iPhone)
Oxford Clinical Handbooks—$50. As numerous in hospitals as stethoscopes; downloading them on your smartphone will save you many pounds of luggage in your white coat
Epocrates—Free. The number one mobile drug reference among US doctors, and a notable rival to the Medscape app
Merck Manual—$35.99. One of the best selling medical references in your pocket, for half the price of the hardcover version. Geared towards the US in terms of diagnostics and treatment decisions
Lexi-Complete—$175 a year (students) or $285 a year (doctors), Harrison and drug information at your fingertips. One drawback is that it is expensive
Student BMJ—Free. Download this and other articles and read them offline at your convenience (available for iPhone)
ECG Guide—$0.99. Also having troubles interpreting electrocardiograms? The largest electrocardiogram library available on the iPhone, with over 200 high resolution sample electrocardiograms with common and complex findings for easy reference
Differential diagnosis BMJ—$7.99. Your doctor or tutor will be astonished by your complete differential diagnosis (available for iPhone)
Oxford Medical Dictionary—$14.99. Quickly look up medical terminology with this app (available for iPhone)
iStethoscope—$0.99. Place the microphone on your chest and analyse, record, or share your heart rate with friends; solely for entertainment purposes
MedPageToday—Free. Keep up with the latest medical news
This potential has not gone unnoticed by app developers—Apple has more than 10 000 apps in the medical section, and Android features more than 3300 medical apps. It is uncertain, however, if many of these apps are reliable, evidence based, and developed without conflicts of interest. Additionally, most apps in the medical section are misclassified and are of no use. No reliable data are available regarding the number of “real” healthcare apps, and this is an ongoing problem for users.
Dangers of medical apps
The General Medical Council’s Good Medical Practice  states that “doctors and students must provide a good standard of practice and care” and keep their “professional knowledge and skills up to date.” Mobile medical apps will play a pivotal role in this process, but will apps provide the user with up to date evidence and the highest clinical standards for healthcare?
The advent and rapid growth of the medical app market has increased the risk of using an app that is unreliable, that is not evidence based, that is trivial, or that is even dangerous. It is only a matter of time before medical errors caused by unreliable apps emerge. A rheumatology calculator app from Pfizer has been recalled because it provides incorrect values for markers of disease activity.
Can you recall a smartphone app? You can remove the app from the app stores, but that only prevents new downloads. Most apps are downloaded on smartphones and used offline. The developer is not able to remove these apps from phones directly, so the users must do it. (In extreme situations, Apple and Android can remove them remotely.) Hence, there is a risk that recalled apps are still being used by doctors, with risks for patients’ health. No protocols exist on how to recall a malfunctioning or dangerous medical app to stop it being used.
As is the case with traditional medical devices, such as interpreting an electrocardiogram, medical apps can pose several potential risks to patients and public health because of the unique characteristics of the medium. For example, the interpretation of a chest radiograph on a smartphone could be negatively affected by the relatively small screen, low resolution, and uncontrolled light of the smartphone. In addition, users can neither dictate reports nor look at comparison films side by side. “You will not find a radiologist who wants to read a chest x ray on an Apple iPad. It’s not what it is meant for,” said a director of radiology informatics during the New York Medical Imaging Informatics Symposium last year. Note that he was commenting on an iPad, a mobile device with an even larger screen than a smartphone.
Last year the US Food and Drug Administration (FDA) approved an app that enables doctors to interpret and access imaging studies displayed on their smartphone.  “This important mobile technology provides physicians with the ability to immediately view images and make diagnoses without having to be back at the workstation or wait for film,” said William Maisel, chief scientist and deputy director for science in the FDA’s Center for Devices and Radiological Health.
One of the biggest concerns related to the use of smartphones in clinical care is the potential breach of patients’ confidentiality. The increasing usage of smartphone apps adds a new aspect to patient information security, which will require new security measures. When patient data, also called protected health information, are stored electronically, they become exposed to potential data breaches.
Last year the US government released federal regulations that deal with the way in which protected health information should be maintained; which steps should be taken to prevent a data breach; and how to act in such a case. Unfortunately, these regulations do not deal with issues related to storage of protected health information in medical apps, and no guidelines currently exist that indicate how these regulations apply to medical apps. Moreover, different legal regulations apply for different countries, which makes it complicated to create guidelines that are internationally applicable.
Despite the lack of proper security regulations, apps have been released that perform the functionality of an electronic health record system or that store patient data. By being mobile, there is an even greater risk for patient information to leave the hospital. Wireless devices allow remote access to healthcare systems and databases. Furthermore, it is easy to lose a smartphone, and you should know what to do when it is lost. You can erase all data from a distance on certain smartphones if you lose them. Most smartphones have basic security measures installed, but most do not have sufficient security measures such as proper encryption of data to ensure safety of patient information. Besides this, even if a smartphone is protected by the use of a personal password, the password could be cracked, which would compromise personal information as well as saved patient information. 
Clinical decision making
As medical apps are increasingly used to support diagnosis and management of diseases—for example, apps that allow the user to input patient-specific information along with reference material to automatically diagnose a disease or condition—facilitating proper use of information technology becomes essential. Hospitals and doctors need to ensure that they clearly designate and peer review apps that are evidence based, reliable, and up to date for use in daily clinical care, when such use is appropriate, and they should provide sufficient training to support this.
Conflict of interest
Doctors are affected by their interactions with the drug industry. 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. The drug industry is increasingly using medical apps for marketing, and it is often difficult to determine the origin of a medical app; whether it is funded privately or by a commercial company—for example, a drug company. Using apps developed by a drug company can raise substantial ethical issues. Such companies might use these apps for marketing purposes to influence treatment options, and they may display information in favour of their own drugs, all of which can affect patient care. Given the potential health implications and in light of the potential for biased clinical decision making, doctors and medical students should be cautious about using apps made or sponsored by drug companies.
A public debate over the regulation of these medical apps harks back to a different yet similar problem of regulatory issues—that of the publication of drug promotions in scientific medical journals, or of accepting money from a drug company. Multiple regulations and guidelines have been released containing strict regulatory rules. For example, the American Medical Association’s Seal of Acceptance programme in the first decades of the 20th century became the number one tool for regulating drug advertisements during that period. Medical apps that are emerging at the moment are far more complex. Given the potentially important consequences for clinical care of drug promotion in these medical apps, regulators and manufacturers will have to share the responsibility for any oversights. 
How to recognise a high quality medical app
There are many different medical apps, and it is hard to find out details about their production, authorship, development, and whether the app is evidence based and regularly updated. Everyone equipped with the skills to make a smartphone application could launch it on the medical app market, and no guidelines exist stating that rules or regulations must be met before this occurs. A few questions can help you decide which app to download (box 2).
Box 2: Questions to ask before downloading an app
Clinical decision making
Is it produced by a medical publisher? For example, apps adopted by a medical journal or publisher
Is it regularly updated?
Is it properly referenced?
Are the authors listed?
Is it possible to give feedback?
Is the content peer reviewed?
Has it been recommended by your tutor, university, or healthcare institution?
Is the app’s primary purpose to inform the health professional (and not patients)?
Does the app require you to input patient specific data, and could this compromise patients’ privacy?
Conflicts of interests
Do you know where the app is from? Is it produced by a drug company or a non-commercial organisation?
Draft US FDA guideline for mobile medical applications
In the past, the mobile medical apps sector primarily focused on producing new apps and encouraging doctors and medical students to use them. But before the healthcare industry adopts medical apps, problems such as patient privacy, clinical decision making, and conflicts of interest need further consideration.
Initiatives focusing on the connectivity and data integration of mobile apps have enormous potential for improving patient care and facilitating medical research possibilities. Many mobile medical devices, such as apps, sensors, and monitoring devices can be used by patients, doctors, and other health professionals. At the moment, they are not connected to each other, but in the future these devices might become integrated—from decision support tools to personal electronic medical records.
Another rapidly developing area is telemedicine—for example, remote monitoring of patient specific data. It can be convenient for a doctor to evaluate blood glucose levels, blood pressure, and other vital signs from a distance. By using smartphones to catch problems early, doctors can avoid drastic and costly interventions such as rushing someone to hospital for a long stay. Consequently, unnecessary hospitalisations can be prevented.
One study showed that the number of home health monitoring devices in use with embedded cellular connectivity increased from 420 000 in 2010 to about 570 000 in 2011, and is expected to hit 2.47 million in 2016. In Palms West Hospital, Florida, an app was developed that allowed doctors to monitor on their smartphones the vital signs of women in labour. This app delivers patient specific information, including fetal heartbeat and maternal contraction patterns, in virtual real time directly from the hospital labour and delivery unit to a doctor’s smartphone. This app allows doctors to monitor patients when they have to leave the labour and delivery unit.
More evidence is emerging that shows the routine adoption of smartphones can improve efficiency in communication among doctors and other healthcare professionals, which is often hampered by systems such as the use of pagers.
It is unclear how apps are regulated and who is responsible for this process. Because of the wide variety, it will be an immense task to review every medical app on the market. Not every app needs regulation. Apps used only as reference guides or mnemonics do not need strict regulation, but an app that changes a smartphone into a medical device or is used to control existing medical devices needs strict regulation and critical appraisal.
Two things are going to change in the near future. Firstly, the FDA will start regulating potentially dangerous medical apps. Secondly, experts will start peer reviewing medical apps, reviewing not only usability, design, and layout, but also the content of the app. 
Last year, the FDA proposed draft guidelines (figure ) for the regulation of mobile medical apps. It argued that the intended use of a mobile app determines whether it meets the definition of a “medical device.” Apps that are used as an accessory to a medical device or that transform a smartphone into a regulated medical device will therefore face strict regulation by the FDA in the future. Other apps, such as those that are solely “copies” of electronic textbooks or apps that do not require the input of patient specific data to output a patient specific recommendation, diagnosis, or treatment, are not considered as a “mobile medical app” and are therefore not regulated. It is expected that a final guidance will be launched in the first half of 2012.
Because of the huge number of apps and the lack of proper good quality indicators, specialised app markets will now be stepped up. Commercially orientated companies are trying to solve this problem by creating their own medical app market and “app certification programs” (for example, Happtique—www.happtique.com). Their app stores are now in development, and a few are already accessible. It is still uncertain if such app stores will hit the critical mass needed to become a serious alternative to regular app stores. Furthermore, app stores regulated by a commercial third party might have conflicts of interest about which apps get published.
Addition to the first aid kit
With all the potential dangers of current apps you might wonder if you should use them at all, but you can select good quality and reliable apps. It is expected that smartphones will soon join stethoscopes in the doctor’s first aid kit. Medical apps have the potential to make clinical practice more efficient, and they are revolutionising the way healthcare is delivered, by improving communication and healthcare efficiency and supporting clinical decision making. Remember, though, when you use medical apps don’t take them at face value—make sure you critically appraise them.
Thanks to Wilgert Velinga (information and communications technology specialist) for his comments on the revision of the manuscript.
Competing interests: None declared.
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Benjamin Jelle Visser final year medical student
Jonathan Bouman final year medical student Academic Medical Centre, University of Amsterdam, The Netherlands