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If the vibrancy of an industry is judged by its output, digital health apps are thriving. When assessed instead by uptake and value, progress appears more hesitant.
On the Apple store alone, there are now more than 165,000 health-related apps available, offering everything from early stage prevention to advanced medical consultation and monitoring. Yet just 5 per cent register any significant number of downloads.
“There’s something new every day,” says Karen Taylor, director of the UK centre for health solutions at Deloitte. “But I think there is a degree of hype. It’s difficult to pull out the reality.”
There is little doubt about the underlying trend, and capacity, for digital health services. The fast-growing reach of the internet, big data analysis and ever wider availability of smartphones has provided expanding access to more sophisticated tools and information. A study by BCC Research estimated that by 2018, the mobile health industry overall would be worth $21.5bn.
The technological capacity of such services offers speed, convenience, anonymity and potentially greater effectiveness. The trend towards “gamefication” and nudging in order to gently change individual behaviours provides new approaches and motivations which are increasingly being tapped in health.
A poll in February by PwC concluded that “people are demanding more convenient care, more access and a bigger say in decisions about them and their care … They’re willing to have their care in non-traditional settings, from non-traditional players.”
Brian Pomering, a PwC partner specialising in healthcare, says: “I think we’re getting to a critical turning point where citizens are not going to accept the status quo.”
The majority of health-related apps and online services focus on prevention: systems to inspire, encourage and monitor healthier lifestyles, led by fitness, wellness and nutrition. Many incorporate movement indicators, allowing effortless monitoring of distance walked or heights climbed.
A newer twist has come in “brain health”, with tools such as Peak, designed to stimulate improvements in memory, numerical and verbal reasoning; or Wizard, to help the memory in people with schizophrenia. More broadly, services such as the Big White Wall provide a way to express concerns about depression and seek support. Others offer cognitive behavioural therapy.
Other types of health app assist with medicines, home monitoring of medical conditions and sharing of information, which can help with diagnosis, offer guidance and assistance, and even be tapped to help recruitment into clinical trials. The growing use of artificial intelligence — such as IBM’s Watson — offers far greater scope for diagnosis and treatment in the future.
Uncertainties lie ahead. One question is how far many health apps measure the right things. As a report from the Vitality Institute, a think-tank within the South African health insurance company Discovery, cautioned this month: “Despite the benefits to health of such interventions, companies … often entirely neglect to integrate scientific or behavioural evidence into their devices.”
The UK’s National Health Service has responded with a library showcasing health apps. The European Commission is exploring the prospect of establishing “kitemarks” of quality for apps.
Another concern is whether devices measure reliably. Integrated movement indicators, for instance, will only work so long as the wearer is attached to them. They are open to manipulation for those seeking to overstate their physical activity — a temptation in the case of apps linked to incentives offered by health insurers and other providers.
The US Food and Drug Administration has stepped up regulatory scrutiny of apps which directly affect patients. Among services requiring its approval are apps that monitor heart wave function irregularities, emit light used for examining patients and control medical devices and machinery.
One factor prompting worry among doctors is whether self diagnosis risks triggering greater misdiagnosis. “Who has clinical responsibility if something goes wrong?” asks Mr Pomering. “People can always find the worst and rarest of rare diseases in themselves, and miss things.”
There is also the matter of how far apps reach those most in need. While smartphones are increasingly widespread even in lower income countries, people with access and who are motivated to use health apps are often those who are less in need. The focus on consumer health products for people who are healthy may need to be shifted to devices that actually help the sick and assist healthcare professionals.
A report by the Nuffield Trust in February argued: “To date, there has been a real focus on apps and devices to improve wellness — such as step and calorie counters — as well as those focused on a single disease. There has been less of a focus on tools for complex costly patients.”
Privacy is an important issue. While few cases of the misuse of personal health data have been identified — leading to discrimination in health insurance or employment — there are calls for more transparency and tougher standards of encryption and for the removal of personal identities from sensitive information.
An NHS health apps library survey last year showed two-thirds of apps which sent identifying information over the internet did not use encryption. There were an estimated 7,000 data breaches in the NHS in 2011-14.
“The genie is out of the bottle,” says Ms Taylor at Deloitte, nonetheless, on the subject of app use. “Even if there is scepticism among health providers and disadvantages, patients want to use them, are asking about them and buying them themselves.”
Providers, healthcare professionals and regulators will have to adapt.