Live from iHT2-San Francisco: What Are the True Barriers to Optimal Healthcare Mobile App Use?

A lively and incisive conversation about the introduction of consumer-facing mobile health apps dominated the first panel discussion on Monday morning at the Health IT Summit in San Francisco, being held at the Park Central Hotel here, and sponsored by the Institute for Health Technology Transformation (iHT2, a sister organization to Healthcare Informatics, under the Vendome Group LLC corporate umbrella).

Shadaab Kanwal, executive director, corporate services and digital technologies, at the Oakland-based Kaiser Permanente, led the panel discussion, titled “Mobility & Medicine.” He was joined by David Kagan, M.D., a practicing primary care physician and the co-founder and CMO of Circle Medical; Tim Needham, executive director, healthcare solutions delivery practice, for Burwood Group Inc.; and Spencer Hamons, the regional chief information officer for the western U.S., at NetApp Healthcare.

Near to the start of the discussion, Kanwal asked the audience if anyone had a statistic on how many mobile apps related to healthcare are in use now? Jukka Valkonen, R.N., P.H.N., director of health innovations strategies and solutions at Blue Shield of California Health Innovations and Technologies, and a speaker at the conference, answered that there are 170,000 mobile health apps now in use.

“A lot of the focus has been on health and fitness,” Kanwal said, regarding the consumer-facing apps that make up the vast bulk of the mobile health apps currently in use. “But now, those apps are starting to turn into workflows for our physician community. And when they become disruptive, and sometimes, physicians start creating those workflows. How do physicians cope with that?” he asked his fellow panelists. “And how are providers consuming those healthcare applications?”

“I had no idea about 170,000,” Dr. Kagan replied. “I use three to five. My patients use apps that help keep them motivated,” he reported. “MyFitnessPal is an example. And I can talk with my patients about what they’re actually eating. The data itself isn’t necessarily helpful on a static basis, but when I talk with them about what they’re doing and their activity level, it keeps them motivated.”

(l. to r.) panel: Kanwal, Hamons, Needham, Kagan

“Spencer, you have the opportunity to speak to CIOs,” Kanwal said. “How many things have been put in place?”

“From the CIO’s perspective, patient engagement is an important aspect, but not the most important,” Hamons replied. “I would much rather see us have 1,000 clinical projects that have IT components than 1,000 IT projects with clinical components. Over time, we can make the technology more meaningful.”

Needham noted that a number of patient care organizations are doing self-development around some mobile apps. “Providence [Health] is a good example” of that, he said. “There’s a lot of developer talent in Seattle, and they’re bringing it forward” in this area. Still, he conceded, the U.S. healthcare industry is early in its journey in this area of activity.

“Can you enlighten us on the apps that you’re using in your medical practice, David?’ Kanwal asked. “Are they outside your regular workflow?”

“I don’t think they’re disruptive, I think they’re helpful,” Kagan said. “What I would like to figure out, though, is how I can get the data from these apps in real time. If patients bring us information about their weight loss, etc.—‘I notice that you haven’t been exercising,’ ‘Your diet is off,’ etc., I’d like the technology to talk to us, rather than having to have the patient bring it to us.”

“There are close to 500 million smartphone users worldwide,” Kanwal noted, contexting mobility in a global framework. “And in the intervening years, we think the use of healthcare applications will increase, and probably more than 3.4 billion smartphone users will use an app in some way. So when I go in to see my physician and show him my watch, he says, that’s good! But it’s not part of my EMR. Everybody has a different device. I have both Apple and Android. How is this BYOD aspect affecting workflow? Do you think we’ll see ‘bring your own applications,’ also? Will the group of apps narrow down?”

“I think this is one of those areas where we’ll see an evolution,” Hamons said. “Meaningful use has actually stifled innovation, because everyone had to focus getting to a baseline” of implementation of clinical information systems, he contended. “As meaningful use wraps up, we’ll see more innovation, with an emphasis on integration. And I think we’ll see an evolution… with everything coming forward in a meaningful way.”

“I was visiting a 15-hospital health system very recently,” Needham said, “and the CIO said, ‘I know my physicians are going to have to care for twice as many patients as before, but with no time in their way.’ So any patient-provided data has to at least come into a dashboard of some kind. And not every type of data has to come into an EMR. In the next 12-18 months, we’ll see some significant innovations,” he predicted. “But in terms of more granular patient data getting into the EMR, we’re still somewhat at the mercy of interoperability. So I think I would focus attention on creating dashboards that can [ingest] patient-provided data.”

An audience member told the panel, “I’m very interested in the idea that there needs to be a physician dashboard, but I don’t see that happening. I see a lot of end-user dashboards. But not physician dashboards. Is that happening?” she asked.

“California has a problem” with regard to the business model issues involved, Needham noted. “The model here is dominated by independent physician practices. It can be difficult to achieve an enterprise standard.” Instead, he said, “Where I see things happening is in large integrated health systems in the Midwest. There’s an enterprise approach—they want to drive single applications. Eighteen months ago,” he noted, “HCA bought a company called PatientKeeper. They decided they wanted to buy a shop themselves. And in the next 18 months, some examples of a new model will emerge. I suspect we’re on the cusp.”

Also, Hamons said, “As data visualization becomes more prevalent, physicians will want to be able to do that, so some interest is being created.”

“So we’re still relying on our fragmented point-of-care solution,” Kanwal said. “And physicians are creating their own apps. Over time, those will circulate more widely,” and will spur the forward advance of the development of apps useful to physicians, he added.

Jukka Valkonen noted that, “When we were at Kaiser, we created a panel view. And when you start to look at solutions out there, they’re either using clinical data relevant to the physician, or health plan data related to HEDIS, etc., and the feedback I get from physicians is that the care gaps data is nice, but not necessarily the kind of data they will use during their day. Physicians are much more aware of hotspotting,” he said. “They’re interested in which patients to focus on. So my team is focusing on a hybrid of clinical and administrative data.”

One important, unresolved issue in all this, Needham, noted, is “data governance: do we trust the data coming from consumers/patients and their devices?”

Kanwal asked his fellow panelists how the current barriers can be overcome. “I think that we need to not allow the perfect be the enemy of the good,” Hamons insisted. “We need to foster innovation,” over time.

“David, do you like it when patients bring you data?” Kanwal asked. “What kind of data do you want from your patients?” “There are a couple of questions here,” Kagan responded. “First, what data do we want? I appreciate when they bring data in to show me, because it shows me that they’re interested in their health. So to me, it’s helpful to know the patients care enough to think about it. But I think we still need to figure out what kinds of data will actually help inform our models of care. So there’s still a lot of work that needs to be done in that respect.”

One audience member made a statement, followed by a question. “I’m quickly seeing we’re starting to move into overtreatment,” she said. “If every single person with an allergy to dust sends data into their physician, we’re starting to see over-testing and other issues. How do you address that as providers and IT people? How to address that huge amount of data, as providers?”

“I think it’s a conversation,” Kagan replied. “I think to be honest, more patients are disengaged than over-engaged. I do see young millennials overdoing it: I had a 24-year-old come in and say, I want a PSA test. And I’m like, you’re 24. But I’d rather have the patients be over-engaged than disengaged.

And you’re starting to see a level of engagement that you’ve never seen before. I’m not a millennial, but people of the millennial generation are really engaged, and they’re open to having an engaged conversation with providers. And as you look to the next generation, you’re going to see people who want to use apps to help them. They’re not coming in and saying, here’s all my food data; they’re coming in and saying, I want to lose weight, please suggest apps that will help me. And that creates space for engagement.”

Another audience member noted that, “Often, in population health, the people who are the hot spots are the least engaged. They’re not coming in with their number of steps or what they ate that day. So how can we engage those people?”

“I agree,” Kagan said. “I think it’s a combination of figuring out how to engage people (but not overdo it). They’ll need a more robust care team, and will need much more handholding, which we’re still going to need for years to come.”