October 2013 - Patient Apps for Improved Healthcare

October 2013

Patient Apps for

Improved Healthcare

From Novelty to Mainstream

Introduction

Apps have become ubiquitous in many aspects of our lives over the past ve years, fueled by the

widespread availability of tablet computers and smartphones. Tens of thousands of health, wellness,

and medical apps are now available for download to Apple or Android devices from online stores.

Harnessing the potential power of apps for healthcare has become a focal point of innovation,

in particular those apps which can be used by consumers or patients as part of their wellness,

prevention or treatment regimens.

While there is a great deal of interest in apps and enthusiasm for their use, they have yet to reach the

mainstream of healthcare provision, and indeed in many respects are still viewed as a novelty.

In this report, we share the results of a study we have undertaken to look more closely at the

consumer healthcare apps that are currently available, including an objective assessment of

their type, role, and functionality. We also look at the barriers to apps being more broadly and

systematically used by healthcare providers and patients or caregivers, and approaches that are

being taken to address these impediments.

The movement toward digital therapeutics is clear. Our intention is that this report provides some

objective and balanced perspective on how consumer apps can play a larger and more meaningful

role in the prevention and treatment of disease – resulting in improved health measures and

outcomes, and a more ecient healthcare system.

The study was undertaken independently by the IMS Institute for Healthcare Informatics as a public

service, without industry or government funding. The contribution of Carolyn Gauntlett to this report

is gratefully acknowledged.

Murray Aitken

Executive Director

IMS Institute for Healthcare Informatics

IMS Institute for Healthcare Informatics, 11 Waterview Boulevard, Parsippany, NJ 07054 USA

info@theimsinstitute.org www.theimsinstitute.org

Find out more

If you want to receive more reports

from the IMS Institute or be on our

mailing list please click here

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Find out more

Acknowledgements

The contributions to this report of Carolyn Gauntlett, John MacCarthy, Matthew Tindall,

Stephen Buck, Glenn Connery and many other colleagues at IMS Health are gratefully

acknowledged.

The authors would like to express sincere gratitude to people who have given their time

and expertise toward the development of this report. These individuals have participated

in interviews, roundtable discussions, chapter reviews and provided methodology

guidance.

Priyanka Agrawal, MD (University of California, San Francisco)

G. Caleb Alexander, MD, MS (Johns Hopkins Bloomberg School of Public Health)

Sameer Badlani, MD, FACP (University of Chicago Hospitals)

Jonathan Birnberg, MD (North Shore University Health System)

Philip Chan, PharmD (Pharmacist)

James Cunnar, MD (DuPage Family Medicine)

Michael Docktor, MD (Boston Children’s Hospital)

Israel Green-Hopkins, MD (Boston Children’s Hospital)

Alan Greene, MD, FAAP (Pediatrician)

James Homan, PharmD (St. Jude Children’s Research Hospital)

Cheng-Kai Kao, MD (University of Chicago)

Leslie Kernisan, MD, MPH (Geriatrician and caregiver educator)

Howard Landa, MD (Alameda Health System)

Elliot Levine, MD (Illinois Masonic Medical Center)

Creagh Milford, DO, MPH (Massachusetts General Physicians Organization)

Alisa Niksch, MD (Tufts University School of Medicine)

Kevin Patrick, MD, MS (University of California, San Diego)

Jordan Shlain, MD, FACP (HealthLoop Inc.)

Shannon Sims, MD, PhD (Rush University Medical Center)

Randall Staord, MD, PhD (Stanford University)

Lee Vermeulen, MS, RPh (University of Wisconsin Health)

Contents

EXECUTIVE SUMMARY

__________________________________________________

BACKGROUND

_________________________________________________________

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

_____________

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

_______________________

CALL TO ACTION

_______________________________________________________

CONCLUSION

__________________________________________________________

METHODOLOGY

________________________________________________________

REFERENCES CITED

_____________________________________________________

ABOUT THE AUTHORS

___________________________________________________

ABOUT THE INSTITUTE

_________________________________________________

transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without express written

consent of IMS Health and the IMS Institute for Healthcare Informatics

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Executive Summary

Little is currently understood about the diverse array of healthcare apps available to consumers,

their role in healthcare, the barriers to increasing their recommendation and support from

providers, and the requirements for mobile apps to move into the mainstream of healthcare.

This study includes the analysis of the 40,000+ healthcare apps available for download from the

U.S. Apple iTunes app store and an assessment of the potential value they provide throughout a

patient’s journey. This clearly demonstrates that to date most eorts in app development have

been in the overall wellness category, with diet and exercise apps accounting for the majority

available. Further an assessment of functionality of available apps nds that healthcare apps

available today have both limited and simple functionality - the majority do little more than

provide information.

There is a signicant skew in download volume for healthcare apps, with more than 50% of

available apps achieving fewer than 500 downloads. Conversely, 5 apps account for 15% of all

downloads in the healthcare category. The reason behind the limited downloads, and hurdles

to improved uptake, span all stakeholders. Patients currently face a dizzying array of healthcare

apps to choose from, with little guidance on quality or support from their doctors. Some eorts

are underway to help provide professional healthcare guidance in both the U.S. and the U.K.

but these are limited in scope and impact to date. Furthermore, apps developed to date do

not t well with the greatest areas of spend in healthcare – those patients facing multiple

chronic diseases and typically over the age of 65. These patients are likely to be among the top

healthcare spenders but smartphone penetration is lowest among this group, with only 18% of

the U.S. population using them, compared to 55% of those aged 45-54 years.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

EXECUTIVE SUMMARY

Physicians can see the potential benets of mobile healthcare apps but remain wary of formally

recommending apps to patients without evidence of their benet, clear professional guidelines regarding

their use in practice, and condence in the security of personal health information that may be generated

or transmitted by the app. Payers and employer wellness programs also want clear evidence of benet

before considering reimbursement or promoting the use of apps.

Over time, the app maturity model will see apps progress from being recommended on an ad hoc basis

by individual physicians, to systematic use in healthcare, and ultimately to an end goal of being a fully

integrated component of healthcare management. There are four key steps to move through on this

process: recognition by payers and providers of the role that apps can play in healthcare; security and

privacy guidelines and assurances being put in place between providers, patients and app developers;

systematic curation and evaluation of apps that can provide both physicians and patients with useful

summarized content about apps that can aid decision-making regarding their appropriate use; and

integration of apps with other aspects of patient care. Underpinning all of this will be the generation of

credible evidence of value derived from the use of apps that will demonstrate the nature and magnitude

of behavioral changes or improved health outcomes.

Meeting these preconditions will accelerate the movement of apps use from that of a novelty into the

mainstream of healthcare – and realizing their full potential in the years ahead.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Background

Recent years have seen a gradual shift in the relative importance of dierent healthcare

stakeholders - between physician, payer and patient. Although the patient will never have the

tools to replace the roles of the physician and the payer, patients are encouraged to take a more

active interest in their overall wellbeing and understand the consequences of poor health in

later life. By having the patient aligned with the importance of wellness programs and sickness

prevention, health systems can hope to realize savings – especially from a lower burden of

multiple chronic conditions. As such, there are more frequent examples of healthcare payers

and/or governments pushing increasing responsibility for healthcare onto the patient, whether

that be by providing incentives to patients to stay healthy (eectively targeting preventive

measures) or for adhering to treatment regimes that are prescribed.

Figure 1: Evolution of Healthcare Stakeholders

In an attempt to rein in health care costs from chronic health conditions associated with

unhealthy behaviors, the Patient Protection and Aordable Care Act in the U.S. includes a

provision stating that beginning 2014 employers can use up to 30% of the total amount of an

employee’s health insurance premium to provide outcome based wellness incentives.

Bonuses

for health-related behavior in Europe are a key feature of private health insurance systems such

as in the U.K.

Recently in Dubai, local government ocials announced a 30-day challenge

(to coincide with Ramadan) in which it promised to pay participants a gram of gold for every

kilogram of weight lost.

Original Stakeholder: Physician

Previously Now Future

Key Stakeholder:

Payer now as important

as Physician

New Stakeholder:

Patient more involved in

healthcare decision making

and choices

In the past physicians were

key stakeholders acting as

gate keepers to healthcare

information and treatment

options

As the key budget holders,

payers have the most

inuence today over

healthcare treatments and

patterns and evaluation of

outcomes results

With the rise of the internet

and all its healthcare

information, patients are

better informed and enabled

to participate in the healthcare

decision making process

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

BACKGROUND

This push for the general population to have a higher awareness of - and be more involved in -

managing their health is occurring at the same time that technology is enabling the quick and

easy access of information. Websites such as WebMD, MDadvice, MedicineNet and NetDoctor all

oer patients medical advice and information for managing conditions. In 2013 the Pew Internet

and American Life Project released the latest Health Online survey which found that more than

half of all Americans have looked online for health information in the last year, and more than

one-third have used the internet to self-diagnose a condition.

The Global Observatory for eHealth (GOe) within the World Health Organization (WHO) denes

mobile health or mHealth as “medical and public health practice supported by mobile devices,

such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other

wireless devices”. mHealth involves the use of voice and short messaging service (SMS) as well

as more complex functionalities such as 3G systems, global positioning systems (GPS), and

Bluetooth technology.

The advent of smartphones has taken the potential for mHealth to a new level. The advanced

computing capability of smartphones that are typically optimized for internet usage means that

individuals can access information and advice from anywhere at any time. They also provide

functionality that is not available via a laptop such as the ability to capture information from sensors

on the move and the addition of GPS and camera functions. There are now estimated to be more

than 1 billion smartphones and tablets globally; some sources estimate that this will reach 2 billion

by 2014. In 2012 China overtook the U.S. to become the key smartphone market by volume, and

other key emerging economies are forecast to see strong growth rates for these devices too.

A mobile application (or mobile app) is a software application designed to run on smartphones,

tablet computers and other mobile devices. They are usually available through application

distribution platforms, which are typically operated by the owner of the mobile operating system,

such as the Apple App Store, Google Play (Android), Windows Phone Store, and BlackBerry App

World.

Across geographies the majority of smartphone users have more than 20 apps on their

device at present; in many cases this is closer to 30 apps.

Gaming apps and social media apps

such as Facebook remain the categories commanding most of users’ time.

Not all apps that have been developed in healthcare are widely available to consumers on their

mobile platform stores. Some of the most advanced medical apps are the 100 apps already

approved by the FDA and these are not necessarily designed to target general consumers.

Some apps have been designed for healthcare practitioners, others are for patients but require a

prescription, and others are intended for only a small subset of the population and hence are not

added to the general app stores.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

This report focuses only on the healthcare apps that are widely available to the general public

to aid in their everyday healthcare management in conjunction with their physician or other

healthcare professional. While apps are essentially without geographic boundaries, this report is

primarily focused on the use of apps in the context of the U.S. healthcare system. However, the

perspectives and considerations for more extensive use of apps are globally relevant.

BACKGROUND

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Proling widely available

consumer healthcare apps

Development and use of healthcare related apps is growing rapidly but the current

level of functionality is limited and use is mostly for prevention and wellness

• Despite the large number of healthcare apps developed, the majority have only simple

functionality; however mobile apps can be used for remote monitoring providing potential for

extra data collection to aid healthcare management

• Almost 50% of healthcare apps available to consumers can be downloaded for free and are

produced by a variety of types of developer

• Apps are available across the full spectrum of the patient journey, although healthy living apps

dominate the space, whereas self-diagnosis, lling prescriptions and medication compliance

have the lowest numbers of apps developed to date

• Some apps cover the full patient journey and are therapy area specic or demographic specic

but there are still signicant areas of unmet need to be lled

With increasing interest in the use of mobile apps in healthcare, this study sought to undertake

the most comprehensive analysis of the 43,689 mobile healthcare apps available to the general

consumer through the English language U.S. iTunes store as of June 2013, assessing their

functionality, placement on the patient journey map and areas where unmet need still exists.

Every app categorised under “health and tness” or “medical” was reviewed. In seeking to focus

on apps that are purely related to patient health and treatment, examination of the content of

these apps led to the exclusion of 20,007 apps from further analysis since these were considered

not truly related to healthcare (e.g. salons, apps which use gimmicks with no real health benets)

(see Figure 2). Of the remaining 23,682 apps considered genuine healthcare apps, further content

analysis categorized 7,407 apps as healthcare professional (HCP) oriented, and the remaining

16,275 apps as consumer/patient oriented (see Figure 3). A full functionality analysis was

conducted on each of the apps targeting consumers/patients.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Figure 2: App count methodology

Figure 3: Distribution of healthcare apps

43,689 “Healthcare and Fitness” or “Medical”

23,682 Apps genuine healthcare related

20,007 Mis-categorized or only

loosely healthcare related on App Store

• Fashion and beauty (e.g. salons)

• Apps intended for members of specic

clubs/universities

• Veterinary apps

• Apps which use gimmicks with no real health

benet (eg apps which make the user sound sick,

or demonstrate how the user would look if they

were obese)

• Apps related to health issues but which do not

focus on health (e.g. fertility)

• Product presentation apps for use by sales

reps/retailers

• Apps believed to have meaningless claims

e.g. “gives you a beautiful way to keep track of your

body's biorhythms”

Source: IMS Health analysis of widely available healthcare apps

16,275

Consumer

7407

HCP

Apple Store - Number of apps by customer

• IMS Analysis on all apps present in

App Store to June 2013 showed 23,682 apps

in the apple store related to healthcare

• More than 2/3 related to consumer

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Assessment of app functionality

Although the number of healthcare apps is large and growing, there is signicant variation in

capabilities of the current apps, with most having only simple functionalities built into them.

An analysis of healthcare apps available to consumers through the iTunes app store resulted in

categorization of apps based on whether they could:

• Inform: Provide information in a variety of formats (text, photo, video)

• Instruct: Provide instructions to the user

• Record: Capture user entered data

• Display: Graphically display user entered data/output user entered data

• Guide: Provide guidance based on user entered information, and may further oer a

diagnosis, or recommend a consultation with a physician/a course of treatment

• Remind/Alert: Provide reminders to the user

• Communicate: Provide communication with HCP/patients and/or provide links

to social networks

It should be noted that there are mobile medical apps which are not available directly to the

public through the iTunes app store, including some of the mobile medical apps that have been

approved by the FDA, such as the BlueStar app from WellDoc which requires a prescription.

These apps do have signicant functionality components but as they are not available to the

general browsing public they are excluded from the functionality analysis below.

The most common capability of widely available consumer healthcare apps is the ability to

provide information - 10,840 consumer apps have this feature, or approximately 2/3 of all

consumer targeted apps. Fewer apps have other functionalities, for example, 5,823 can provide

instructions, 5,095 capture data entered by the user and 1,357 apps have a remind/alert function

built into them. About 10% of the consumer healthcare apps reviewed, 1,622 apps, have none

of these capabilities at all, and include apps such as those to help with relaxation and sleep,

and baby monitors. Although there is a subset of apps with impressive functionality (e.g.

electrocardiogram (ECG) readers, blood pressure monitors, blood glucose monitors) it is clear

that most of the healthcare apps available today are only simple in design and do little more than

provide information. This is echoed by an assessment of multi-functionality: although two-thirds

of healthcare apps can display information, only half of these can also provide instructions, and

only one-fth could track or capture user entered data (see Figure 4).

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Figure 4: Assessment of consumer healthcare app functionality

Some mobile apps enable the remote monitoring of vitals that can be communicated back to the

healthcare practices. This oers the potential to enhance the value of provided care by taking

advantage of this patient reported data and embedding it into the clinical care plan:

if patients are regularly collecting health data they can, in consultation with their physician/nurse

practitioner, use that information to modify their behavior and better manage their condition.

As such, healthcare apps have the potential to bring eciencies into healthcare systems by

reducing the frequency and cost of direct interventions by healthcare professionals with patients.

Monitoring of vitals can be done remotely, and communication with healthcare professionals

– including pharmacists, physicians and nurse practitioners – can be done without the patient

having to physically meet with them.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Source: IMS Health analysis of widely available consumer targeted healthcare apps

Information Inform + Instruct

Information Inform + Record

Inform

10,000

5,000

10,000

5,000

Instruct

Record

Display

Guide

Remind/alert

Communicate

Number of apps Number of consumer apps

Individual Functionality Multi-Functionality

Less than ½ of apps

which provide

information also

provide instructions

Approx ⅕ apps which

provide information

also track/capture

user data

10,840

4,697

2,249

10,840

5,823

5,095

2,302

1,434

1,357

395

10,840

Patient uses app to

collect health data either

by choice or on physician

recommendation

Patient can transmit

data to physician or take

phone along to appt to

show physician

Patient and physician

together evaluate

the data

Necessary interventions

made: behavioral or

medication changes

Collect data Share data Evaluate data Intervene

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Analysis of the widely available consumer healthcare apps on the iTunes app store shows that at

present there are 159 apps which link to sensors. However these are dominated by tness and

weight apps which monitor pulse rates when exercising and measure weight and body mass

index (BMI). Fewer than 50 of these 159 apps relate to actual condition management or provide

tools and calculators for users to measure their vitals. There is therefore considerable room for

growth in this sector.

IMS Health functionality scoring system

The IMS Health score for app functionality considers the results of 25 individual criteria assessed

during the app review process. These criteria include, but are not limited to, the type and

quantity of information provided by the app, how the app tracks or captures user data, the

communication processes utilized by the app, and the quantity of device capabilities included in

the app. In addition to looking at this result, weightings are applied specic to the category of the

app. For example, in a condition management app there will be a higher value placed on results

that focus on doctor communications than there would be for a reference app.

This scoring system was used for all consumer oriented healthcare apps with at least one

assessed level of functionality as dened in Figure 4, and conrmed that the majority of apps

have only simple functionality. This scoring system is based on our independent and objective

assessment of the app functionality and does not reect patient/user evaluation, physician

evaluation, or evidence that users benet from their use from an outcomes perspective.

The maximum score achievable is 100. As illustrated in Figure 5, the distribution of the 16,275

reviewed apps skews toward the low end of the 100 point scale, with more than 90% of the apps

receiving a score of 40 or less.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“I am really interested in feedback loops and how instant data can change behavior. I think apps

give an opportunity for patients to have instant access to themselves”

Jim Cunnar, MD – DuPage Family Medicine

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Figure 5: IMS Health App functionality score distribution

In looking across all apps at their individual functionality score (each of which has a maximum

score of 100), the highest average scores accompanied the most prolic functionalities:

information and instructions (see Figure 6). Despite the thousands of apps with these

functionalities, few scored an excellent on this rating; instead average scores were only 40 out of

a possible 100. This reects the level of complexity of the app: the information score was assessed

based on whether the app provided text, photo and video formats, and how the level of detail

ranged from oering tips to detailed references. Therefore even though two-thirds of apps oer

some form of information, for the majority this is simple content in a simple format. There are,

however, signicant scoring dierences depending on the designed purpose of the app. Overall,

when considering all 16,000+ apps, reminder functions only achieved an average score of 5 out

of 100; however this varied dramatically. Those apps which are designed specically as reminders

to aid medication compliance and have a narrow purpose in this arena, saw scores reach as high

as 100 for this marker.

Functionality score

<50 6-10 16-20 26-30 46-50 56-60 61-65 65-70 71-75 76-80 86-90 91-9581-85 96-10011-15 21-25 31-35 36-40 31-45 51-55

3,000

2,500

1,500

2,000

1,000

500

Number of apps

Source: IMS Health analysis of widely available consumer targeted healthcare apps

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Figure 6: IMS Health App scores by type of functionality

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Reminders Tracking/Guidance

InstructionsCommunications

Phone functionality Information

All Apps with functional information

Source: IMS Health analysis of widely available consumer targeted healthcare apps

One of the most advanced apps for condition management and remote monitoring,

approved by the FDA, is the WellDoc Diabetes Management software available through

the app store with partner AT&T. In the initial clinical trial of WellDoc (a 3 month non-

blinded randomized controlled trial of 30 T2D patients aged 18-70 years old) the

average decrease in A1c values for intervention patients was 2.03% compared to

0.68% (P<0.02, one-tailed) for control patients. Of the intervention patients 84% had

medications titrated or changed by their HCP compared to controls (23%, P = 0.002).

The WellDoc group also demonstrated improved self-care in diet, medication, and

exercise compared to that achieved by control patients receiving usual HCP care.

A key component

of the software is the Guided Compliance™ tool which directs patients to test their blood glucose

at optimal times to generate data for pattern analysis. The software also acts as a coaching tool

suggesting medication and lifestyle/self-management changes to patients (all suggested changes

are also communicated to the HCP). A follow-on trial consisted of a 12-month cluster-randomized

study with 163 participants. The trial demonstrated that the average decrease in A1c values for

intervention patients was 1.9% compared to 0.7% in the standard care control group (P<0.001). The

study therefore demonstrates that it is possible to improve treatment outcomes with mobile phone

and web portal communications when used by both patients and their HCPs.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Business models for apps

The healthcare apps that are available to consumers today are produced by a variety of developers,

from individuals with a novel idea to address unmet need, to large organizations with a commercial

strategy involving an app. As such there is a wide range of scale, investment, and return in the

current business models supporting consumer apps.

Examples of healthcare app developers:

Table 1: Developers of mobile healthcare apps

Developer Motivation Typical app functionality Example apps

Individual app

developers/

academic

research groups

• Initially start out with small

development to address unmet

need out of interest or with

ambitions to attract investment

Simple functionality designed for

specic need

• Living Proof: Breast Cancer

Survivor Stories

• Fat Burning Zone Calculator for

Fitness

Patient

organizations/

charities

• Creation of app products

which aid users in condition

management and provide

emotional support and other

patient success stories

Typically provide limited

functionality, oering

information, social media

connections and physician

recommendations

• Diabetes GPS

• Diabetes UK Tracker

• MyCancerManager

• PCR tracker

Corporate/

investment

backed app

developers

• Medium- to long-term nancial

returns as user base expands

and revenue model grows

May span the full range of

functionality:

• Display • Record

• Diagnose • Remind/Alert

• Communicate

• Calorie Counter by

MyFitnessPal

Pharmaceutical

manufacturers

• Increase awareness of

condition

• Increase adherence to

prescribed treatment

• Display health information

• Explain drug mode of action

and side eects

• Remind/alert

• Ab Educator

• Hoop4Diabetes

• MyBETapp

Large consumer/

retailing brands

• Link app to present oerings,

typically links to website

• Reach extended audience

• Display health information

• Record user entered data

• Provide reminders of service

renewal

• Weight Watchers Mobile

• Walgreens

• Watsons Asia

Health insurance

groups

• Inform members with general

healthcare advice/condition

management

• Enable HCP/facility search

• Display health plans

• Symptom checkers

• Physician locators

• Submit and monitor claims

• Medibank Australia symptom

checker

• Singhealth HealthBuddy

• BUPA Mobile

National health

systems

• Reach larger audience

to inuence healthcare

management

• Lessen burden on clinical

services

• Symptom checkers

• Physician locators

• Appointment reminders

• NHS Choices

• NHS Symptom Checker

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

With such a variety of backing to apps development, there is unquestionably a range of

nancial models, which in turn aects the pricing of the available apps. Of the 16,275 consumer

healthcare apps available in the Apple app store, 7,717 are free, 7,689 are priced in the range

$0.99 - $4.99, and 869 are more than $5 (of which 23 are more than $100). Despite initial

appearances, many of the 7,717 free apps oer paid content within the app. In many cases, the

free app is just a sample and the user needs to buy an upgrade or a subscription.

Investment funding can be signicant in the healthcare app space. In August 2013 it was

announced that Calorie Counter by MyFitnessPal, the most popular free calorie counter and

tness tracker on Google Play in the U.S. and the #2 on Apple App store in the U.S.

, with

both a website and mobile app covering 40 million users, had attracted $18 million of venture

capital nancing. The app, which has always been free to users, achieved protability through

successfully advertising tness and weight loss products and with the majority of revenues

coming from desktop use. Future growth in revenue through partnerships with hospitals or

health insurers is the aim and focus of the recent investment. Underpinning this investment by

venture capital rm Kleiner Perkins Caueld & Byers and Accel Partners is a belief that insurers will

pay for this app, or corporations will oer it as part of their employee health plans.

Apps placement on the patient journey

An entire continuum of healthcare needs can be addressed via apps, broadly in two main focus

areas for healthcare organizations across the patient journey:

• Changing consumer/patient behavior in areas that aect health, particularly exercise and diet

• Improving the implementation of prescribed treatment regimens

• Understanding physician instructions

• Ensuring polypharmacy is appropriately managed

• Medication compliance or adherence to physician instructions

A further detailed analysis of the consumer focused apps places them along a patient journey,

consisting of overall wellness, diagnosis, HCP visit, further information, prescription lling and

compliance. A total of 14,243 apps were placed on the patient journey, including those specic

to a particular demographic group or disease area, which can be distributed across the full

journey steps as displayed in Figure 7.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Figure 7: Consumer healthcare app placement along patient journey

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

The Patient Journey

Therapy Area Specic: 1,980

Demographic Specic: 1,440

Prevention/Healthy Lifestyles

Healthy living, diet and exercise,

addiction quitting, stress, relaxation, and sleep

8,786

Self-diagnosis

Symptom checker and self diagnosis

304

Finding a HC profession or facility

Doctor reviews and referrals

Second opinions

931

Compliance

Persistence, Compliance

225

Filling prescription

Finding a pharmacy, availability,

price and insurance coverage

200

Diagnosis/ Education

Medical information, condition management

information, emotional support post-diagnosis

562

Number of apps

Source: IMS Health analysis of widely available consumer targeted healthcare apps

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Table 2: App placement on the patient journey

Patient journey stage Description No. Functionality Example

Prevention/Healthy Living Focus on factors associated

with overall wellness:

• Healthy eating

• Weight management

• Fitness

• Tips for healthy living

• Smoking cessation

• Stress management

• Sleep

8,786

apps

• Display information

• Display pre-loaded

instructions for diet &

tness

• Record and display user

entered data

• Track weight

measurements over time

• CalorieCounter

• NikeTrainingClub

• OneSportsMan

• Weight and BMI diary

Symptomatic/

Self-diagnosis

• Reference for common

symptoms/conditions

• Diagnosis based on

data inputted/question

answered

• Communication with

medical professionals

304

apps

• Display reference

information

• Record users answers

and display appropriate

guidance

• Communication interface

between patient and

physician

• NHS Health and Symptom

Checker

• SingHealth Health Buddy

• Medibank Symptom

Checker

• Melanoma Visual Risk

Checker

• Am I depressed?

• HealthTap

Finding a Physician • Locate most appropriate

physician or healthcare

facility and nd contact

information

• Rate and review

physicians

• Appointment reminders

931

apps

• Display search results

• Display location information

(and connect to GPS)

• Connect to phone function

• Display reviews

• Remind appointments

• BetterDoctor

• US Hospitals Lite

• Patient fusion

• Doctor visit manager

Education post-diagnosis Provide health reference

material:

• Drugs/medication

information

• Emergency and rst aid

information

• Condition management

information

562

apps

• Display drug information

• Display condition

information

• Record user entered data

• Can connect to healthcare

professionals or

emergency services

• Drug Guide for Consumers

• Family Drug Guide

• Pill identier by drugs.com

• Health Handbook

• Emergency Info 4Family

• Medical Facts+

Filling prescription • Finding pharmacy

• Price scans for

medications/special oers

• Relling of prescriptions

• Drug interactions and

side eects

200

apps

• Display search results

• Display location information

(and connect to GPS)

• Connect to pharmacy

systems to register

prescriptions

• Oer discounts on

medications

• CVS Pharmacy

• Walgreens

• LowestMed Mobile

Compliance Assisting the patient to

act within the prescribed

interval and dose of a

dosing regimen:

• Pill reminders

• Medication trackers

• Alert support network if

dose not recorded

225

apps

• Provide reminders

• Display information

• Record user entered data

(e.g. register dose was

taken)

• Communicate with

support network

• Medicine Reminder HD -

with Local Notications

• MediSafe – virtual pillbox

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

The most dominant category on the journey is healthy living, while the least populated are self-

diagnosis, lling prescriptions, and compliance.

Healthy living: Earlier this decade Mokdad et al found that 40% of all premature deaths have to

do with health behaviors. Specically, the leading causes of death in the year 2000 were tobacco

(435,000 deaths; 18.1% of total U.S. deaths), poor diet and physical inactivity (400,000 deaths;

16.6%).

Since then employee wellness programs in the U.S. have claimed that 70% of all healthcare

costs are the direct result of behavior and have designed healthcare plans that reward healthy

behavior. For example at Safeway, employees are tested for tobacco usage, healthy weight, blood

pressure and cholesterol levels and receive discounts o a “base level” premium for each test they

pass.

As a result of encouraging healthy behaviors, the company saw its per capita healthcare costs

remain at while most American companies’ costs increased by 38% over the same period.

With almost 9,000 apps available to help the population lead healthy lives there is a real

opportunity to make an impact on overall health and wellbeing. By far the largest category

within this grouping of apps is diet and tness, with more than 5,400 of these apps solely

designed for the purpose of counting calories or tracking calorie consumption, providing tness

routines and monitoring weight or body mass index (BMI). It has already been demonstrated that

self-monitoring of physical activity and dietary intake are key components of behavioral weight

loss programs.

Thus the variety of apps in this space could act to provide signicant support

and guidance for individuals to achieve their health targets and lessen the burden of behavior on

overall healthcare costs.

Self-diagnosis: Although many apps provide symptom guidance and information, few propose an

actual diagnosis to the end user and it is essential that those which do are approached with caution

as not all are connected to a HCP. Recent research evaluated smartphone apps that claim to detect

cancer based on a picture of a mole.

Only one of the apps sent the picture of a suspected mole to a

dermatologist. It was correct 98% of the time. Three others may have serious medical repercussions

since they missed melanoma between 30% and 90% of the time, according to the report.

The FDA released its guidance document on mobile medical apps on September 25, 2013. One

of the areas that the FDA has been clear they intend to regulate is when mobile medical apps

transform a mobile platform into a regulated medical device. As stated in the FDA guidelines

“When the intended use of a mobile app is for the diagnosis of disease or other conditions… the

mobile app is a device”

This means that apps which clearly serve the purpose of providing a

diagnosis will be subject to FDA clearance as a medical device. This should lead to a higher

standard of diagnosis accuracy from the apps, and potentially increase the numbers of apps in

this category now that developers have clear guidelines to work within.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Filling prescriptions: In the U.S., pharmacy apps provide weekly deals along with price

comparisons, allowing pharmacists to attract customers. These apps typically provide pricing

information for drugs sold at major retailers, and are intended to help both insured and uninsured

consumers nd the best deal on prescriptions by including pricing information for proprietary

brands and generic drugs across the most commonly prescribed medicines.

These apps have

the opportunity to be extended to the large audiences in emerging markets where smartphone

penetration is growing rapidly, and where out-of-pocket costs are such a high proportion of

healthcare expenditure and hence aordability is a key hurdle for access. As such there is likely to

be an increased number in this app category as target audience expansion occurs.

The U.S. market is also the most advanced market for chain pharmacy mobile apps. Walgreens has

developed an app which can be used to rell prescriptions and to remind patients when to take

their medications; they claim the most popular feature of the app is the “Rell by Scan function”,

allowing patients to scan the bar codes on their prescription vials to order rells. This accounts for

more than 40% of all online rells and generates more transactions than any other Walgreens app

feature.

Similarly an app from CVS Caremark also enables patients to manage their prescriptions,

with functionality that allows patients to ll prescriptions, access their prescription history, and

transfer prescriptions between dierent CVS/pharmacy locations.

The company claims the app

is used 1,000 times per day. If these apps can be linked to improved medication adherence and

customer loyalty, more extensive use of these sort of apps can be expected.

Medication compliance: This may be dened as “the extent to which a patient acts in

accordance with the prescribed interval and dose of a dosing regimen”.

To date there are no

public studies published in academic journals or whitepapers which demonstrate eective use

of apps for improved compliance. Indeed the only notable results have been released by app

developers themselves. For example MediSafe Project has released a statement claiming that its

mobile pillbox health app produced compliance rates of about 80% for patients taking type 2

diabetes medications, leading them to state that compliance was more than 26% higher for type

2 diabetic users when they used mobile technology. However, neither the compliance rates for

these individuals prior to using the app, nor the characteristics of this particular patient group,

are reported for comparison.

It remains to be seen whether randomized trials of mobile apps

for medication compliance can demonstrate a clinical benet resulting from the use of these

tools and hence show their value in the reduction of the multi-billion dollar non-adherence costs

to the healthcare system. Such a demonstration of evidence of value would likely drive a surge of

apps in this category.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Apps specic to a demographic group or disease

Chronic diseases – such as heart disease, stroke, cancer, diabetes, and arthritis – are among the

most common, costly, and preventable of all health problems. Seven out of ten deaths among

Americans each year are from chronic diseases, with heart disease, cancer and stroke accounting

for more than 50% of all deaths.

About 1/4 of people with chronic conditions have one or more

daily activity limitations.

Arthritis is the most common cause of disability, with nearly 19 million

Americans reporting activity limitations.

In addition to suering early mortality, patients with chronic diseases also incur signicant avoidable

costs to the healthcare system through non-adherence to treatment. In a recent IMS Institute report

on avoidable healthcare costs in the U.S., it was demonstrated that six disease areas (congestive

heart failure, HIV, osteoporosis, hypertension, diabetes and hypercholesterolemia) accounted for

$105 billion in annual avoidable costs from non-adherence to medication treatment

(see Figure 8).

Figure 8: Non-adherence avoidable costs by disease, US$bn

Source: Avoidable Costs in U.S. Healthcare, IMS Institute for Healthcare Informatics, 2013

Avoidable costs by disease, US$Bn

Congestive

heart failure

HIV Osteoporosis Hypertension Diabetes Hypercholesterolemia

15.5

1.8

1.0

18.6

24.6

44.0

105.4

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Of the 1,980 apps developed to date which relate to specic therapy areas, chronic conditions

dominate. However the areas of focus of these apps are highly concentrated and not related to

leading causes of mortality or non-adherence. The largest category of apps for specic therapy

areas is in mental health and behavioral disorders – with autism, anxiety, depression and

attention decit hyperactivity disorder (ADHD) making up 2/3 of apps available in that area

(see Figure 9). Mental health and behavioral disorder apps also command some of the highest

prices for apps. Of the 23 apps commanding prices in excess of $100, 16 of these are categorized

under mental health and behavioral disorders, with autism again ranking highest with 12 of the

16. These apps are predominantly communication solutions to aid with speech and provide

pre-recorded messages.

Figure 9: Breakdown of apps by therapy area

Eyes & Hearing

Mental Health &

behavioural disorders

Endocrine, nutritional

& metabolic diseases

Heart /

Circulatory System

Autism

Anxiety

Others

Cancer

Musculoskeletal system/

connective tissue

ADHD

Depression

Source: IMS Health analysis of widely available consumer targeted healthcare apps

1,980

558

537

171

196

115

139

270

284

558

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

For other chronic disease areas, diabetes apps (categorized within endocrinology) account for

230 apps to date; 139 apps relate to the heart/circulatory system (of which only 12 target stroke)

and there are only 77 apps for the other leading cause of death - cancer. Despite the fact that

arthritis is the most common cause of disability, only 11 apps target rheumatoid arthritis, and 5

apps target osteoarthritis. It would therefore appear that there is still unmet need in the therapy

area space for apps which provide better condition management for patients living with the

most disabling chronic diseases, such as cancer, stroke and arthritis. These apps could provide

information for optimal condition management, the ability to track patient health levels over

time (and record improvements in wellbeing or condition), and the ability to communicate with

caregivers or other patients for motivation and the sharing of best condition management – the

latter is likely to be particularly important in emotive diseases such as cancer. One of the challenges

will be how to motivate app developers to address these areas. Although a higher proportion of

condition management apps are paid for than, for example, diet apps, only a small number cost

more than a few dollars. As such, unless there can be paid content within the apps there is little

nancial incentive to address these key areas of unmet need and the duty is likely to fall back on

pharmaceutical companies or healthcare providers themselves to generate the content.

Of the 1,440 apps categorized as being intended for demographic-specic target groups, women

and children’s health dominate. Within women’s health almost 80% of the apps are pregnancy

oriented (see Figure 10).

Senior Health is at present a very small category, accounting for only 27 apps. The main target

audience within these apps however is not directly the patient, but the caregiver, with most

of these apps targeting the carer network, enabling family members and friends to plan and

coordinate their caring activities and tasks. The 65+ age category is at present the group with

the lowest penetration of smartphones according to the latest Pew Internet and American Life

Project report on smartphone ownership.

It is therefore reasonable that apps directly targeting

the patient within the senior health category would be lowest in number, and that instead the

apps are designed for the caregiver base which is typically made up of younger, smartphone

using family members. In future years as smartphone penetration in the 65+ category increases

there should be a concomitant increase in apps for this target audience.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Figure 10: Consumer healthcare apps breakdown by demographic target groups

IMS Health ranking of top apps

Functionality scores were calculated for all apps which fall along the patient journey. However,

recognizing that the best apps have not only strong content, but are also user friendly and oer a

positive user experience, the functionality score was combined with a user score. The user score

considers the number of reviews that an app has received in addition to its star rating. As app use

increases, and new sources of evaluation become available, rating scores will inevitably evolve

beyond functionality and user scores. In particular, it will be essential to also include physician

evaluations and evidence of app ecacy in future scoring systems.

Combining the currently available functionality scores with the user scores provided an IMS

Health App Score which has been used to identify the top apps in each category. As such the IMS

Health top apps by classication on the patient journey are listed here. These apps have strong

functionality combined with ease of use.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Demographic Specic Women’s Health

OtherChildren’s Health FertilitySenior Health Pregnancy BreastfeedingWomen’s Health

1,440

689

562

724

Source: IMS Health analysis of widely available consumer targeted healthcare apps

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Table 3: Top apps by classication on the patient journey

Patient Journey: Prevention/Healthy Lifestyles

App Name Developer Description

Calorie Counter

and Diet Tracker by

MyFitnessPal HD

MyFitnessPal.com Diet app featuring large calorie counting database and features such as

food tracking, exercise and weight goals and links to friends

Calorie Counter PRO by

MyNetDiary

MyNetDiary Inc. Diet app featuring large calorie counting database and features such as

food tracking, exercise and weight goals

Chest Trainer :

Fitness Buddy

Azumio Inc. Weight training and tness application which claims to mimic having a

personal trainer in the home, requires no equipment

Cycle Tracker Pro -

TrainingPeaks GPS

Peaksware, LLC Converts phone into a GPS-enabled cycling computer, with a wide

range of workouts, providing custom readouts and activity reports

Quit It 3.0 - stop

smoking

Tommy Kammerer A stop smoking motivational program, supporting and encouraging

smokers to quit smoking, helping ex-smokers to stay quit; keeps track of

the cigarettes not smoked and how much money saved as a result

Quit Smoking Now HD

- Hypnotherapy with

Max Kirsten

Max Kirsten A four week quit smoking program with personal hypnotherapy

sessions

Patient Journey: Finding a HCP or facility

Healow eClinicalWorks Lets patients communicate with their doctor’s oce and access up-to-

date health records, includes visit summaries and appointment reminders

Vitals – Your top 10

doctors!

Vitals Provides customized lists of the best local doctors, as rated by their

patients, allowing for searches by symptom, condition or medical

specialty

ZocDoc - Doctor

Appointments Online!

ZocDoc Tool to nd and book doctor’s appointments based on zip code

searches

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Patient Journey: Diagnosis/Education

App Name Developer Description

HealthTap - free doctor

answers to medical and

health questions

HealthTap Provides health answers and healthy tips on any symptom, condition,

medication, health concern, or even wellness topics from 47,000 U.S.

doctors; provides current and vetted health information

iTriage Healthagen LLC Provides clear, concise, and useful information covering thousands of

medical symptoms, diseases, conditions, procedures, medications and

drugs

WebMD for iPad WebMD Provides mobile-optimized health information and decision-support

tools including WebMD’s Symptom Checker, Drugs & Treatments, First

Aid Information and Local Health Listings

Patient Journey: Filling Prescription

GoodRx GoodRx GoodRx compares prices for prescription drugs and provides prices,

coupons and savings tips for more than 6,000 drugs at most pharmacies

in the U.S.

MyRell Rx Intelecare

Compliance

Solutions, Inc.

Order medications straight from the phone and get them delivered to

the door, as well as medication reminders and appointment reminders

Walgreens Walgreen Co. Rell by Scan function, Points for Rells, Pill Reminders, Transfer

Prescription feature, Rell Reminders, Health Reference encyclopedia

Patient Journey: Compliance

Dosecast Montuno Software,

LLC

Flexible medication reminder with customizable dose amounts and

instructions, a large drug database and the ability to support multiple

users

Pill Monitor Free –

Medication Reminders

and Logs

Maxwell Software Prescription reminder that alerts the user every time they need to take

a prescription. Allows user to enter all prescriptions, set up reminders,

and track when they have been taken

RxmindMe Prescription

/ Medicine Reminder

and Pill Tracker

RxmindMe, LLC Prescription reminder that alerts the user every time they need to take

a prescription. Allows user to enter all prescriptions, set up reminders,

and track when they have been taken

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

In addition to apps that relate to a specic step in the patient journey, apps with the highest

IMS Health App Scores in specic therapy areas are as follows.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Table 4: Top apps by therapy area

Therapy Area Specic : Diabetes

App Name Developer Description

Daily Carb -

Carbohydrate, Glucose,

Medication, Blood

Pressure and Exercise

Tracker

Maxwell Software Tracks daily nutrition intake of food, carbs, ber, fat, tracks quantity of

water intake, readings of glucose, HbA1c, blood pressure, heart rate,

weight, exercise, medications and insulin

Glucose Buddy -

Diabetes Logbook

Manager w/syncing,

Blood Pressure, Weight

Tracking

Azumio Inc. Designed as a data storage utility for people with diabetes. Users can

manually enter glucose numbers, carbohydrate consumption, insulin

dosages, and activities

GoMeals Sano-Aventis

U.S. LLC

Food, activity and glucose tracker designed to aid the user make healthy

lifestyle choices

Therapy Area Specic : Mental health & behavioral disorders

ADHD Angel Daniel Anderton Reminders to take medication, a process for sending reports ahead of

physician visits, ADHD information/reference, advice on the 8 main ADHD

'Tipping Points'

Live OCD Free Pocket Therapist,

LLC

Claims to reduce OCD symptoms by 34% in 8 weeks; includes video

tutorials as well as extensive user guide

T2 Mood Tracker The National

Center for

Telehealth and

Technology

Allows users to monitor their moods on six pre-loaded scales (anxiety,

stress, depression, brain injury, post-traumatic stress, general wellbeing).

Custom scales can also be built

Therapy Area Specic : Musculoskeletal system and connective tissue

Oce-Fit Medicus 42

GmbH

Provides exercises against work-related pains and stress

WebMD Pain Coach WebMD Oers a holistic approach to balancing lifestyle with chronic pain

conditions. In particular provides help for those suering from back

pain, neck pain, nerve pain, bromyalgia, migraine, osteoarthritis and

rheumatoid arthritis

Zimmer Arthritis 411 Zimmer, Inc Patient education resource for people who suer from osteoarthritis. Can

be used at home to learn more about arthritis pain and treatment options

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Therapy Area Specic : Oncology

Dr K's Breast Checker Lingopal

Holdings Pty Ltd

Designed to help women keep track of change in breasts using

interactive tools, provides practical information and reminders

PCR Tracker Cheryl-Anne

Simoneau

Specically designed by CML patients for CML patients, allows user to

track and graph results from lab tests, treatment reminders, understand

treatment milestones, access educational tools and videos, reference to a

glossary of terms used

SkinKeeper The Health Safari

Pty Ltd

Enables user to monitor moles, capture important personal and family

skin cancer risk factors, and share this information with their doctor

Therapy Area Specic : Nervous system

Noteness (Multiple

Sclerosis)

Martin Hartl Is a multiple sclerosis diary app. Monitors injections and symptoms, and

provides reminders

Parkinson Diary Health Wave

Signals, LLC

App for patients and caregivers to record, report and review symptoms

easily. Features symptom logger, graphical representation of changing

symptoms, animation to visually see how symptoms have changed over

time

Young Epilepsy Young Epilepsy Designed for young people with epilepsy, and parents or carers of a child

with epilepsy. Contains an up-to-date information portal, video and diary

that helps track and manage seizures and symptoms

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

PROFILING WIDELY AVAILABLE CONSUMER HEALTHCARE APPS

Top-rated apps that are specic to women’s health or children’s health are as follows:

Table 5: Top apps by demographic

Demographic Specic : Women’s Health

App Name Developer Description

Ovulation Calendar

Ladytimer Free

Vipos.com Tracks and predicts menstrual cycle days, helping women to become

pregnant or avoid pregnancy

Period Diary (Period,

Fertile & Ovulation

Tracker)

nanobitsoftware.

com

Fully animated period and ovulation tracker. Monitor menstrual

symptoms, body weight, temperature, and add notes

Pregnancy Tracker from

WhatToExpect.com

Everyday Health, Inc. Guides women through pregnancy day-by-day. Based on entered

due date user receives personalized content, gets access to the latest

parenting news and health information, and can be connected to a

community of other expecting moms

Demographic Specic : Children’s Health

Baby Connect (Activity

Logger)

Seacloud Software Baby tracking application which provides graphical reports and

trending charts, weekly averages, medicine, vaccine and growth

tracking, timers, notications, reminder alarms

Baby Food Pee Poo

Free

Colorful Drop Combines baby logger/tracker, reminders (feeding, diaper change,

and sleep) with built-in alarm sound or human voice, as well a white

noise recorder/player

Total Baby ANDESigned Baby logging and tracking function which covers: Diapers, Nursing,

Pumping, Bottles, Solids, Sleeping, Bath, and Other (timing and

tracking), Diary, Milestones, Doctor Visits, Growth, Vaccines, and

Allergies (logging)

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Achieving greater uptake of healthcare apps

Patients, physicians and payers all face obstacles in accessing or supporting

the use of apps, providing barriers to their greater use and usefulness across

healthcare

• Despite the thousands of healthcare apps available, downloads are heavily skewed toward a

small number of apps

• Barriers to wider uptake and use of healthcare apps span all stakeholders

• Patients currently face a maze of healthcare apps with little guidance on quality although this is

starting to be addressed in the U.K. and U.S.

• The demographic skew of smartphone users makes it more dicult to reach those who are the

most expensive users of the healthcare system

• Physicians see six key hurdles to the widespread recommendation of apps to patients

• Payers expect to see evidence of improved outcomes and reduced hospitalizations before they

will reimburse mobile apps

Assessment of app functionality

Installs data from the Google Play (Android) app store shows the skew in download volumes for

healthcare apps. The majority of these healthcare apps receive very few downloads: more than

50% of the apps in this category receive less than 500 downloads, with only 2% receiving more

than 100,000 downloads. In fact, 5 apps account for 15% of an estimated 660 million downloads

in this category (see Figure 11).

It would therefore appear that despite the choice available the

market is already very concentrated and consumers are consistently choosing the same apps.

Since analysts’ estimates for downloads of apps in 2013 across all geographies and categories

range from 56 to 82 billion, this shows the current limitation of healthcare app use.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Figure 11: Android healthcare apps installs from the Google Play store

There are many reasons for both the skew and the limited number of downloads observed, and

they span all stakeholders. These barriers result in a current lack of incentive to recommend and

use mobile apps in healthcare and hence the full potential of apps is far from being reached:

• Patients have to navigate a maze of healthcare apps with little guidance, meaning those apps

with the most downloads are considered best and continue to receive the most downloads

– a self reinforcing cycle

• The demographic skew of smartphone users makes it harder for the most expensive healthcare

system users – the elderly suering multiple chronic conditions - to be targeted

• Prescribers are faced with the same widespread choice of apps as patients and with limited

information regarding app performance and benets may be wary to choose an app to

recommend to their patient

• Payers are unwilling to consider providing reimbursement for mobile apps without

evidence that they bring clinical or cost benet - and to date there are minimal studies

demonstrating ecacy

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

30%

501-10k

28%

51-500

29%

1-50

11%

10k-100k

85%

33,247 apps

15%

5 apps

2% >100k

100% = 33,252 apps 100% = est 660m downloads

Number of installs obtained

Google Play App Store: Health/Fitness and Medical Apps:

Share of installs volume

Source: IMS Health analysis of installs data

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Challenges for patients using healthcare apps

With more than 16,000 healthcare apps in the Apple app store alone to choose from, the choice

for consumers is confusing. Healthcare app developers include pharma companies, retailers,

national health systems, insurance companies, as well as small businesses and individuals. There

is a recognizable split between those apps which are developed as part of a commercial strategy,

and those which are developed simply to try and cover an area of unmet need. For a consumer

approaching an app store, at rst glance it would appear that healthcare apps are in a state of

chaos with little structure or order to help the patient determine the optimal app out of the

thousands available for their particular needs.

In March 2013 the National Health Service (NHS) Commissioning Board in the U.K. unveiled a

library of NHS-reviewed health apps intended to help people manage their health. The apps are

produced by a variety of developers and then reviewed by the NHS to ensure they are clinically

safe. At present the library is a working project with more apps being added over time. Apps in

the library to date include those which provide advice on specic medical conditions (such as

mental health or diabetes), allow users to book repeat prescriptions, access test results, and nd

the most appropriate NHS service. The library has been designed by the NHS to put patients

in control, in the hope that giving patients easy access to information will encourage them to

participate in their care. This initiative by the NHS is also in response to the large number of apps

available that are of varying levels of quality with respect to the medical advice provided. It is

intended to provide an NHS stamp of approval so users know the apps are safe.

Progress is also being made in the U.S. HealthTap has developed a product called AppRx, which

enables its 40,000 physician users to evaluate health and medical apps. Doctors in the network

review the apps on a high level, based on three questions.

• Is the app medically sound?

• Is the app useful?

• Is the app easy to use and understand?

Doctors have the option to write a review to explain their choice, and their reviews do not enter

the system until at least 30 reviews have been made and the HealthTap medical review board has

approved them. These reviews are then available to all of HealthTap’s non-doctor customers –

patients will be able to see the reviews and see how many/which doctors recommended the app.

Separately, patients will also be able to recommend the app with the “applaud an app” function.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

More recently in the U.S. the “Go You Cigna Marketplace” was launched providing a landing site

for members that features certied health and wellness apps. As development continues the aim

is to certify additional health improvement apps that receive positive customer feedback.

These rst steps towards healthcare app-verication are essential for consumers to have trust in

the app they are using. Without such measures consumers are reliant on numbers of downloads

and individual reviews as a guide to usage by the wider public, and hence become involved in a

self-reinforcing cycle of most downloads continuing to inspire further downloads.

Smartphone penetration vs healthcare expenditure

The 2012 Pew Internet and American Life Project report on cell phone activities showed that 31%

of cell phone owners in the U.S. use their phone to look for health/medical related information.

With the increasing number of healthcare apps and their uptake by the general population,

technology is providing the opportunity for individuals to be at the heart of their own healthcare.

In moving to a situation where patients/consumers have increasing personal responsibility for

their own health, there is the potential to move towards a society focused on overall wellness and

preventive measures rather than reactive measures.

However, it is important to recognize that apps are not a panacea and optimal deployment does

not mean for every individual, in every situation.

Although for many people apps in healthcare have progressed from being a novelty to a

mainstream tool the fundamental question remains: can healthcare apps really improve

healthcare eciency and lessen healthcare costs? In the U.S. it is estimated that 5% of the

population account for 50% of all healthcare expenditure; 20% of the population account for 80%

healthcare expenditure

(see Figure 12). The pertinent issue then is whether apps can really turn

the dial for the 20% of the population who are the nation’s top users of healthcare services.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“There is a tendency among certain populations to over analyze… there is always a limitation when

you’re designing an app of how much raw data you want the consumer to know versus having

a built-in back end where there is somebody with a medical background, some kind of structure

or framework, where the data that’s being collected can be interpreted and analyzed for the

consumer.”

Alisa Niksch, MD – Tufts University School of Medicine

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Figure 12: Percent of total healthcare expenditures for percentiles of the U.S. population

The elderly (age 65+) are much more likely to be among the top healthcare spending percentiles. A

principal reason for this is that a much higher proportion of the elderly than the nonelderly have

expensive chronic conditions. However, those over the age of 65 are least likely to own a smartphone or

to have downloaded an app, according to recent surveys (see Figure 13).

Figure 13: Smartphone penetration and app download by age group

30,36

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Source: IMS Lifelink Health Plan Claims Database, Dec 2010

Distribution of spending in the privately insured

Percent of health plan members, ranked by healthcare spending ($)

25.6% 50.6% 65.2% 74.3% 80.7% 85.4% 96.9% 3.1%

Top 1%

> $44,957

Top 5%

> $14,947

Top 10%

> $8,528

Top 15%

> $5,773

Top 20%

> $4,169

Top 25%

> $3,130

Top 50%

> $874

Bottom 50%

< $874

Sources: Pew Internet and American Life Project: Smart phone ownership June 2013, Cell phone activities Nov 2012

18-24

25-34

35-44

45-54

55-64

18-29

Age group

34-49

50-64

65+

Smartphone Penetration by age group (%), USA % US phone owners who have downloaded an app

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Methods for increasing smartphone penetration and app downloads amongst the elderly are

essential to unlock the full potential of mobile apps in healthcare eciency improvements. An

alternative approach is to consider family and caregivers of the elderly and the role they can play,

supported by specic apps. For example, the hundreds of apps developed to help patients nd an

appropriate medical professional/facility can also be used by family; obtaining a prescription rell

simply by scanning the current product barcode can be done by friends and family members who

can ensure from a single visit to the patient that their medications remain well stocked. When it

comes to medication adherence, several apps serve not only as pill reminders, but allow the patient

to nominate a “support network” who will also receive notications if a medication dose has been

missed or not entered into the system. In this way the carer network is using healthcare apps to

become or remain involved with healthcare management plans for elderly patients.

In the case of older patients with multiple medical problems, it would not necessarily be benecial

to use apps that are narrowly focused on one disease area, and instead it would be optimal for these

patients to be supported in taking their multiple medications that their physician has prescribed,

and to be supported in remembering the combination of diet tips suggested as a reasonable t

for their preferences and combination of medical conditions. The burden on the patient if every

specialist seen decided to recommend or prescribe their own preferred app for adherence would

quickly lead to app overload, similar to that experienced by patients receiving uncoordinated

guideline-recommended care for multiple co-existing chronic conditions.

38,39

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“There’s a group [of patients] who each have several medical problems and often they have several

specialists, all making recommendations. It’s often overwhelming for the patient and for the

caregiver. They get overwhelmed by the number of pills and the number of recommendations that

they have been given, so I feel that if everybody starts prescribing apps it could quickly lead to app

overload”

Leslie Kernisan – Geriatrician and caregiver educator

“The challenge we face as practicing physicians is that we have an aging population who can be

very savvy with a smart phone and tablets but may not view these technologies as an essential part

of their life. And then you have the millennials who were born after the internet was created, and

that is the life they know, the connected life. So, from an enterprise standpoint, we have to gure

out a way to engage both these patient groups”

Sameer Badlani, MD – CMIO, University of Chicago Medicine

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

It is feasible that with increasing smartphone penetration amongst the elderly – the 18% of

Americans age 65+ who now own a smartphone compares to only 13% in 2012

, and high

smartphone penetration amongst the younger generations who are likely to make up the

caregiver base, mobile healthcare apps can begin to make an impact on healthcare eciency in

the highest healthcare-spending group.

Finding appropriate medical attention promptly, enabling caregivers and family members to

access further detailed information on the condition, order prescription rells and receive their

own notications if the patient has not taken their medication, enables a more solid support

network than might otherwise be envisioned and can lead to avoidance of costly complications

arising from delayed access to healthcare or non-adherence to treatment. However it is important

to note that most patients and families have only limited time available for daily healthcare

management tasks and while apps can help people to manage a medical plan, not all patients

or carers will be willing to try, or will respond, to mobile apps. Technology is an enabler, but the

challenge remains in changing a patient’s behavior.

In fact it is changing a patient’s behavior that may well hold the key to healthcare savings in the

future. Younger people are prolic users of apps on smartphones and apps related to diet/tness/

weight management account for half of all apps on the healthcare app store and are the top

ranking apps within the category. Over time, the positive inuence these apps have in changing

behavior and attitudes toward wellness, exercise, diet and health could potentially have a very

signicant impact on future levels of chronic disease and the associated healthcare burden.

Six key hurdles for widespread physician app recommendation

At present, physicians do not recommend apps as standard practice, though they show strong

interest and the current level of activity looks set to change in the near future as the infrastructure

and evidence for use becomes more widespread. The pioneer in this space is Dr. Erik Topol MD,

a practicing cardiologist with Scripps Clinic, who has said in interviews that he prescribes

more apps than pills.

A near-term opportunity exists for other physicians globally to become

condent in going beyond an ad hoc assessment of the ratings of individual apps and actually

recommend or even prescribe to their patients the use of such a tool to monitor behavioral

patterns, to access information and to monitor their treatment remotely or provide extra data to

the healthcare professional.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

In-person discussions with leading physicians and opinion-leaders in the U.S. suggest a diverse

set of hurdles for widespread app-prescribing currently exist (see Figure 14):

• Choice of apps and evidence behind them

• Infrastructure for app prescribing

• Regulations

• Data privacy and security

• Reimbursement

• Liability

Figure 14: Hurdles to widespread physician recommendation of apps

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“I conceptually love the idea of apps in engaging our patients. As a physician, if I could get this

fantastically digestible data that allows me to better care for them, that’s the Holy Grail. But I think

we’re, as we all know, a long way from there”

Michael Docktor, MD – Boston Children’s Hospital

How can a physician

be condent in

prescribing an app

to a patient?

Choice/

Ratings

Data privacy/

Security

Legal

Reimbursement

Regulations

Infrastructure

to prescribe

Which apps are the most relevant

for my patients and can I trust

they are good?

How do I go about

recommending /prescribing

an app to my patient?

What are the regulations for mobile

apps: am I safe to recommend an

app without FDA clearance?

Are these apps endorsed by my

institution with legal agreement?

If there are any repercussions

from app use am I liable?

How will my patient pay for

the app I recommend unless

it is free? Will they have to pay

themselves or will insurance

reimburse the cost?

If I am prescribing an app to my

patient can I be condent that all of

their health data is secure and stored

in a HIPAA compliant manner?

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Choice of apps/lack of evidence: In the same manner that the sheer volume of available apps

can be confusing to patients, physicians face the same challenge. When a patient is seeking a

recommendation, the physician has limited resources to help guide their choice and may fall back

on personal preference or peer recommendation rather than the specic needs of the individual

patient. Physicians more than patients are likely to look for evidence that apps work and can

demonstrate improved outcomes, hence apps which have evidence to demonstrate their ecacy

are more likely to stand out and be recommended.

Some physicians also expressed a downside potential in that apps may create “data overload” that

leaves a physician awash in data but nothing fundamentally useful to make important decisions.

If apps start overwhelming physicians with data to interpret, there will be a need for “data triage”

to separate the important signals from the noise of information overload. There is a risk in the

short term that recommending a patient use an app could lead to longer, not necessarily shorter

and more meaningful patient encounters.

Infrastructure to recommend: At present, the infrastructure necessary for physicians to formally

recommend apps to patients is limited and many instead resort to writing down an app name

and giving it to the patient during their consultation. To address this challenge for physicians,

in 2012 testing of an app formulary was undertaken by Happtique, but to date there has been

no public release of results from that test.

App formularies could be a signicant asset to

physicians if they contain simple functionality such as grouping apps by type, rating their

functionality and ease of use as well as their medical content, and displaying the frequency of

recommendation so that physicians can see which apps are recommended the most by others in

their profession. Formularies will need to be designed such that physicians can directly send the

app recommendation securely to the patient’s phone for them to download and be able to follow

up as to whether the app was in fact downloaded.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“It goes without saying that 40,000 apps within any store is the denition of poor design, because

you know that 90% of them are terrible designs and I would say that’s the number one cause of lack

of adoption”

Israel Green-Hopkins, MD – Boston Children’s Hospital

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Seamless integration with other health information technology systems including electronic

health records (EHR) will be a necessity for any system designed to provide a means for

physicians to recommend apps to their patients, as they – or the chief information ocer of

their provider organization - will likely resist a stand-alone IT system at a time when so much

eort and attention is being placed on implementing or upgrading EHR systems. Large

provider networks or integrated delivery systems are also likely to require apps to contribute to

patient engagement, consistent with the Meaningful Use requirements under the 2009 Health

Information Technology for Economic and Clinical Health (HiTech) Act. The overall goal of the

Meaningful Use program is to promote the widespread adoption of EHR systems, ultimately

creating an infrastructure that improves the quality, safety and eciency of patient care.

To qualify for Meaningful Use incentive payments, eligible providers must not only adopt an EHR,

but also show that they are “meaningfully using” their EHR by meeting a number of objectives

patient care.

Regulations: The FDA recently released its guidelines for mobile medical apps stating clearly that

the two groups of apps it will regulate are those which are intended to be used as an accessory

to a regulated medical device and those which transform a mobile platform into a regulated

medical device. To date, the FDA has approved about 100 mobile medical apps - including

40 in the last year - most of which are focused on chronic condition management including

diabetes, asthma, and blood pressure management.

However the FDA has also made clear

that it intends to exercise discretion in regulating apps that provide patients with simple tools

to organize and track their health information, such as apps that enable patients with specic

conditions or chronic diseases to log, track, or trend their events or measurements and share this

information with their HCP as part of a disease-management plan, and also apps that provide

or facilitate supplemental clinical care, by coaching or prompting, to help patients manage their

health in their daily environment. With the issuance of this guidance, physicians can be condent

going forward that the apps they are likely to be recommending to their patients are receiving

appropriate levels of regulatory scrutiny.

Data privacy and security: It is essential that there is both transparency and awareness of how

data entered into the app is used and that patient consent is obtained for use of that data.

If a healthcare app collects, stores, and/or transmits information that constitutes Protected Health

Information (PHI) it is essential that it does so in full compliance with the Healthcare Information

Portability and Accountability Act (HIPAA), and any other applicable laws or regulations of

the country concerned. Any app that is intended to connect to an Electronic Health Record or

Personal Health Record (PHR), enabling users to send and retrieve patient information between

a mobile device and the EHR/PHR, must do so in a secure manner and all stakeholders involved

must accept their stewardship role for protecting the data contained within.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Reimbursement: How the patient will pay for the app is a concern for many physicians.

Although almost half of healthcare apps available to consumers can be downloaded for free, the

other half range in price from $0.99 to more than $100. In particular, therapy area specic apps

are more likely to only be available with a patient charge. At present patients need to cover the

cost of the app directly although as evidence emerges for ecacy there is likely to be a push for

reimbursement. WellDoc’s BlueStar diabetes management system is now available to employees

at a number of Fortune 500 companies who have decided to oer it as a reimbursed program

for their employees and their dependents with diabetes.

The product is on prescription benet

plans, requiring a healthcare professional to prescribe BlueStar to one of these employees before

they can use it. WellDoc is pursuing a new path to condition management with its reimbursed

mobile software and it is likely that this will be mirrored by other developers in the future.

Reimbursement for physicians to review remotely generated patient data via apps is also seen as

a consideration prior to recommending such an app, particularly for physicians operating on a fee

for service basis.

Legal: Discussions with leading physicians make clear that taking the leap from recommending

an app to a patient to ocially prescribing an app would add a whole new dimension to

the process. Chief medical information ocers (CMIO) would recommend the prescription

of a subset of apps by that institution’s physicians to their patients only after receiving the

endorsement of their organization’s legal team. Liability from any medical repercussions as a

result of app use is also a concern for physicians.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“Doctors have to be able to trust the app and the data that it’s collecting and distributing”

Creagh Milford, DO, MPH – Massachusetts General Physicians Organization

“When an individual physician says ‘I like this app, you should use it’, it is very dierent from the

CMIO or the Associate CMIO saying ‘These are the endorsed apps from the organization, we have

evaluated the app and physicians are welcome to use them’. Now you are putting an institutional

stamp on an app and you have to have supporting evidence for use, liability, and technical support

amongst many aspects.”

Sameer Badlani , MD – CMIO, University of Chicago Medicine

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Payer requirements for app reimbursement

Before payers will be willing to reimburse mobile apps, encouraging uptake by both patients

and physicians, there will be a need for evidence which shows the benets of using apps as part

of standard healthcare management. The evidence requirements will vary depending on the

intended utility of the app (see Figure 15).

Figure 15: The app evidence divide

Self-diagnosis apps: These apps are likely to require the highest level of evidence and the

results from evaluating several apps intended to diagnose melanoma suggest this is an urgent

and critical need.

Diagnosis apps may be less likely to be reimbursed by payers in mature

markets where there is an expectation that a HCP will be undertaking the diagnosis, but the FDA

will be regulating such apps as medical devices and hence will be expecting to see evidence of

their utility before approval. There is a strong likelihood of self-diagnosis apps becoming widely

used in emerging markets where access to physicians can be severely limited in remote locations,

and yet where smartphone penetration is continually increasing. As such patients should be

reassured of the accuracy of such applications through thorough testing and regulation by the

FDA or other agencies.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Critical need for evidence

Clinical trials to demonstrate ecacy Regulation to verify safety of diagnosis

Need for evidence to demonstrate benets to all stakeholders

Observational studies to demonstrate ecacy Need for regulation when apps link to device or sensor

Need for evidence for reimbursement

Observational studies necessary to improve uptake No foreseen need for regulation

Download popularity/3rd party ratings suce

Ranking by professionals likely to aid

consumer condence

Download volume likely to be inuencing

factor for choice

Self-Diagnosis

Apps

Condition

Management

Remote

Monitoring

Prevention/

Healthy Lifestyle

Compliance

Rx lling

Finding HCP

Education

post-diagnosis

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

Condition management/remote monitoring apps: The largest trial carried out to date in the

condition management/remote monitoring area is the WellDoc diabetes management software

trial.

11,12

As well as demonstrating improved A1c levels in patients, feedback from physicians was

also very encouraging. The product is now reimbursed by several large corporations’ healthcare

plans. However reimbursement for other medical apps, including others approved by the FDA,

has not been secured and many questions remain for reimbursement. For condition management

medical apps, payers are likely to expect to see evidence of a dened improvement in specic

outcomes measures, whether this be therapy area specic measures such as A1c levels or blood

pressure levels or an overall dened improvement in adherence to prescribed treatment as a

result of remote monitoring, medication reminders and healthcare task management.

Wellness apps: A recent RAND report estimated that approximately 50% of employers with

more than 50 employees oer wellness programs. Although only about half of all employers

oer wellness programs, more than 75% of employees working for companies with more than

50 employees have access to a wellness program, because large employers, who account for a

greater share of the workforce, are more likely to have such programs.

With many corporations

in the U.S. and Europe enrolling employees in wellness programs, and with measures such as

those in the Aordable Care Act encouraging employers to set aside premiums for wellness

based incentives, there is growing interest in how apps may support patients in this manner.

It is likely that to fully realize this potential, payers of wellness programs will want to see

meaningful evidence of the ecacy of relevant apps. Evidence for apps in a wellness setting is

much more likely to come from real world use than an randomized clinical trial, and to date few

studies have analyzed this. A pilot study by Carter et al followed 128 overweight volunteers over

a time period of 6 months, comparing the outcomes of a group of patients randomized to self-

monitor weight management via a mobile app against patients using either a website or a paper

diary.

The pilot trial was not statistically powered to detect change in anthropometric measures;

however trial retention was 40/43 (93%) in the smartphone group, 19/42 (55%) in the website

group, and 20/43 (53%) in the diary group at 6 months. Adherence was statistically signicantly

higher in the mobile app group with a mean of 92 days (SD 67) of dietary recording compared

with 35 days (SD 44) in the website group and 29 days (SD 39) in the diary group (P<.001).

Larger scale real-world trials such as this are likely to be conducted in the future to satisfy the

requirements of payers in a wellness setting. However it remains to be seen if there will be a

“class eect” and whether one large trial with a specic calorie counting app or a tness app will

be seen as sucient to cover all calorie counting and tness apps, or whether ease of use and

individual functionalities of the app will lead to a more individual evidence scenario. If that is

to be the case then there will inevitably be a fall out from the smaller app developers who are

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

ACHIEVING GREATER UPTAKE OF HEALTHCARE APPS

unable to aord such an extensive analysis of their user base. Evidence that is collected by the

use of apps in such Wellness programs could also be used by physicians and payers looking for

outcomes evidence before widely adopting such technology.

Finding a HCP/healthcare information apps: These apps serve to provide the consumer

with information on relevant healthcare services and their condition management/medication

regimen “on the go”, providing a convenience factor, and do not sit on a part of the patient

journey that is ever likely to see reimbursement or recommendation. As such apps are

downloaded on the basis of consumer interest, and download popularity or reviews from other

users are likely to suce, formal evidence of utility is unlikely to be required in the future.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

CALL TO ACTION

Call to action

For mobile apps in healthcare to move along the maturity curve and become

a fully integrated component of healthcare delivery, all stakeholders must be

engaged and evidence developed

• The app maturity process will be driven by four key elements which involve all stakeholders

- Payer and provider recognition of the potential role of apps in healthcare management

- Creation of a standard benchmark for security/privacy guidelines that protects PHI globally

- Curation and evaluation of healthcare apps

- Integration of apps with other health IT systems

• Systematic development of credible evidence of the value derived from using healthcare apps

will also be necessary

For app use in healthcare to evolve across the maturity spectrum from present day novelty factor

and ad hoc use, to become a fully integrated component of healthcare delivery with widespread

recommendation by healthcare professionals and reimbursement from payers, there are four key

issues to address on the model to app maturity (see Figure 16). There are a range of stakeholders

which form the “app ecosystem” and each of the four steps requires collaboration between these

stakeholders: the app developer, the regulator, the provider, the patient and the payer (see Figure 17).

Additionally underpinning the entire maturity model will be increasing evidence of app eectiveness.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

CALL TO ACTION

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Promoting Adoption

Process is underscored by increasing evidence of healthcare benets

Implementation

Recognition of apps

Security/Privacy guidelines

Curation and evaluation of apps

Integration with health IT systems

Level of maturity of app prescribing

Time

Fully integrated delivery of healthcare

Apps have a fully integrated role in the

delivery of healthcare

Systematic use of mobile apps in healthcare

Systems and policies in place to enable

widespread use of apps in healthcare

Individual physician recommendation

A small number of progressive physicians

are recommending apps to their patients

Stakeholder dened

unmet need

Stakeholder

Collaboration

App

developer

Regulator

Provider

Patient

Payer

Figure 16: The app maturity model

Figure 17: Stakeholders in the app maturity model

CALL TO ACTION

Recognition of the potential role for apps: Apps should not be used as a replacement for

human care, rather they should provide a strengthening of the care provided. Across the patient

journey mobile apps have the potential to empower patients to live a healthier lifestyle, and to

ensure adherence to prescribed treatment.

In the U.S. the Patient Protection and Aordable Care Act is driving dramatic changes in

healthcare. Improving the quality of care and treatment outcomes is one of the priorities of

healthcare reform. Delivery of care changes center on the patient and creating connections

between all settings of care; an additional component of healthcare delivery reform is

preventative healthcare. Payers and providers should recognize the potential of mobile apps in

this setting. A key benet to the physician in charge of the patient’s healthcare management

is the remote monitoring of vitals which can be communicated back to the healthcare practice.

Alongside patient logging of healthcare activities this can help to improve continuity of care

in cases where there is a transition of care management after hospital discharge, avoiding

the penalties that will be introduced for hospital readmissions. Public health literacy can be

improved through use of informational apps and patient awareness of preventative healthcare

services can also be targeted.

A further aim of the healthcare reform is to encourage the meaningful use of EHRs in order to

enable information-sharing between healthcare stakeholders and across settings of care. Apps

also have a potential role here with providers oering apps from which patients can directly

access their EHR, and with the potential for patient-reported healthcare measures being

transferred from the app to the EHR.

For providers and payers to recognize the potential value of apps to healthcare eciencies they

will also be looking for evidence that the patient is actively engaging with the technology (see

Figure 18).

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“There is a big desert that you enter once you leave the hospital or the doctor’s oce. So that is

where I really see a lot of opportunity and personal excitement around using an app as a tool to

help ll that space”

Jonathan Birnberg, MD – North Shore University Health System

CALL TO ACTION

Figure 18: Evolution of evidence of app implementation

Security/Privacy: The main risks posed to data protection by apps at present stem from the

consumer’s lack of awareness or understanding of the types of data collected and a failure to

obtain the consumer’s consent for the processing, storing or accessing of any personal data on their

smartphones. As such, a typical privacy policy for mobile applications (not specic to healthcare)

would contain as a minimum four published elements:

• The categories of personally identiable information (PII) collected and the types of third

parties with whom the information is shared

• A description of the process for users to review and request changes to their PII that has

been collected

• The process by which material changes to the privacy policy will be communicated

• The eective date of the policy

With healthcare apps it is essential that any information that constitutes PHI is treated in full

compliance with HIPAA, and any other applicable laws or regulations of the country concerned.

The challenge for app developers today is there is no published standard which shows that an app

is in fact HIPAA compliant and dierent regions globally are at dierent stages of mobile app privacy

guideline design.

In a time of rapidly evolving technology, industry self-regulation is the most eective way to

maintain the balance between consumer condence in privacy and continued innovation. As such

the mobile healthcare apps industry should itself dene a standard which ensures that all healthcare

apps adhere to the highest privacy standards. This standard should include, but not be limited to,

the following points:

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Today: Adhoc patient use

Short to Medium Term:

Systematic patient use

Medium to Long Term:

Integrated healthcare component

• Patients are downloading apps

• Patients are using apps

• Patients are using apps eectively

• Patients are receiving clinical benet

• Patient Reported Outcomes

CALL TO ACTION

• App developers should request consent before the app starts to collect data from the device or

place data on the device: this consent should be informed and specic

• Apps should only collect data that is strictly necessary for the app to perform the desired

functionality

• Developers should dene a reasonable period of time for data retention. Dormant apps should

be treated as expired and the data should be deleted

• HIPAA standards should be translated into a global benchmark which forms the basis for

privacy and security of all PHI data transmission, encrypting data and making eorts to de-

identify user data before sharing it with another party

Once mobile healthcare app developers have designed their global privacy standard, providers

and patients can be reassured of the benets of apps in healthcare rather than detracted by their

concerns over protection of personal information.

Curation and evaluation: Systematic curation and evaluation of apps that can provide both

physicians and patients with summarized content to aid decision-making regarding the appropriate

app choice will be an essential step towards promoting the widespread adoption of healthcare

apps. There are initial steps being taken in the U.S. and the U.K. but new services with widespread

medical endorsement that ensure this information is made available in the proper format and

context to support patient care will be required in future.

Evaluation services must group apps by functionality, and contain user evaluations, physician

evaluations and evidence to support the use of the app in the context for which is was designed.

Professional healthcare societies, such as the American Medical Association or other similar

organizations, should be involved in the process endorsing the apps with the highest evaluation

rating for use by their members since credibility and trust are a strong factor in who curates.

Integration of apps: The integration of mobile apps with other aspects of patient care including

use of electronic health records and patient portals requires the least collaboration between

stakeholders but will be one of the pivotal steps on the app maturity journey to facilitate the

widespread prescription of mobile healthcare apps. This requires consideration by provider

organizations, EHR software vendors, and the support of the Oce of the National Coordinator for

Health Information Technology (ONC) and CMS regarding meaningful use.

Stakeholder collaboration: Across these four steps dierent stakeholders have dierent roles to

play. In addition to the main stakeholders there are professional service enablers who also need to

contribute to the process.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

CALL TO ACTION

Table 6: Stakeholder call to action

Recognition Security/Privacy Curation/

evaluation

Integration

App Developer

✔ ✔ ✔ ✔

Regulator (Approver)

✔

Provider

✔ ✔ ✔ ✔

Patient

✔ ✔

Payer

✔

The call to action is therefore clear: app developers and healthcare providers need to be the main

drivers of progress for app maturity. As the key starting point in the process, app developers have

the power to drive recognition through the design of apps which a) satisfy key areas of unmet need

(such as condition management in leading chronic diseases or disabling conditions), b) clearly

address elements of healthcare reform, c) have a clear value proposition backed up by evidence

of eectiveness which can be used in the evaluation of the app and d) which respect the data

protection rights of the user and ensure all sensitive information is handled appropriately. App

developers must also be willing to work with other developers of healthcare IT system infrastructure

to ensure that there can be a seamless integration of systems.

A fundamental challenge here is the range of app developers. App developers range from National

Health Systems and large retailing brands with sucient resources to tackle all of the above calls

to action, to individual app creators with no nancial backing and no resources available to collect

outcomes evidence. A consortium of app developers needs to be formed which represents equally

the interests of all app developers, and which lays out a clear plan to overcome the hurdles on the

app maturity curve. Providers also need to work together to share best-practice on app policies and

to design national guidelines for the systematic use of mobile apps in health delivery.

App developers and providers must then work together to ensure maximum benet and cost

eciencies for the healthcare system.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

CALL TO ACTION

Evidence

There is a pressing need for credible evidence of value derived from the use of healthcare apps

that will meet the needs of physicians and payers. This evidence will inevitably evolve and become

more sophisticated over time. Although at present observational studies are accepted as the best

available, it will be essential that over time randomized trials are conducted with the long-term goal

being outcomes based evidence.

There are at present opposing sides of the debate as to the necessity of conducting randomized

clinical trials (RCT)with mobile apps but these arguments tend to be based more on logistics than

evidence requirements. Those against performing randomized trials typically argue that the cost

would prevent small app developers from conducting them, and that the time taken to generate

results is too slow considering the pace at which technology evolves. It is also argued that since

multiple medical devices marketed with FDA approval do not have randomized trials to back them

up simply because they are unlikely to cause harm, there is no reason for apps to be treated any

dierently, especially now that the FDA has stated it is likely to exercise discretion for the majority of

mobile apps.

However, these arguments are looking at the process of the randomized clinical trial purely from a

development and approval perspective. The call to action for evidence generation from randomized

trials and outcomes based results is based on the belief that without this evidence there will not be

widespread uptake by providers and payers, making apps a fundamental component of healthcare

delivery and instead skepticism will remain amongst these key stakeholders. Since at present there

is almost no scientic evidence published in peer-reviewed journals regarding dened benets of

mobile app use, it is necessary to approach the evidence evolution in stages.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“Patient reported outcomes, or whatever term you want to use - those will be the future that we, as

providers and health systems, will be measured on”

Creagh Milford, DO, MPH – Massachusetts General Physicians Organization

“I am not aware of any scientic literature that proves the benet [of mobile apps]. While there are

a lot of industry sponsored white papers we really need to see randomized control studies - which

is the gold standard for calling an intervention evidence based. Even a prospective case control or

cohort studies would be a good start.”

Sameer Badlani, MD - CMIO – University of Chicago Medicine

CALL TO ACTION

Observational studies are appropriate for comparing the eectiveness of apps within a given

classication (e.g. diet and tness, compliance) and for encouraging uptake, whereas RCTs should

be used to demonstrate improved healthcare outcomes from an mHealth strategy (hence not app

specic). In the future since providers will be measured on patient reported outcomes, it will be

essential to have data providing evidence conducive to outcomes based results (See Figure 19).

Figure 19: Evolution of evidence development for ecacy

Observational studies: Although observational studies may not be the gold standard when it

comes to making statements of fact about safety, ecacy, or eectiveness, they provide valuable

data on “real world” use and practice, and help formulate hypotheses to be tested in subsequent

studies. In the current situation where there is a complete absence of evidence, beginning with

observational studies which are feasible and aordable to push on what is known in the world of

mobile health apps is a strong start, and these observational studies will be a useful way to generate

empirical evidence for testing in RCT.

Randomized Controlled Trials: In the short to medium term, work needs to commence on the

design and recruitment for an RCT to demonstrate the overall health outcomes associated with

using mobile apps. To design such a trial there needs to be a consensus on the criteria for evaluation

of apps, with researchers, clinicians, and entrepreneurs freely sharing and debating their work.

A 3-4 year RCT as seen in the development of drugs is wholly unnecessary for mobile apps, but

evidence of behavior change or change in dened health measures in an appropriate time scale are

essential to ensure the eectiveness of the mHealth approach. The trial must be designed with the

appropriate power to isolate the impact of the app from other variables such as the quality of the

patient-physician interaction.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Today: Observational Studies

Short to Medium Term:

Randomized Trials

Medium to Long Term:

Outcomes based results

• Observational studies demonstrate

improved adherence to weight loss plans,

increased adherence to treatment (through

timely Rx lls and medication trackers)

• Several academic papers question ecacy

of apps

• Prospective case control studies of use of

apps at large medical groups

• Multiple randomized control trials which

have sucient power to isolate the impact

of the app from other variables such as

patient-physician interaction

• Widespread demonstration of dened

patient outcomes in a real world setting

• Professional societies base guidelines for

app recommendation on clinical

outcomes data

• Steady stream of peer reviewed mhealth

app publications and clinical trial results

CALL TO ACTION

Further it must be recognized that a patient may be using their own online tools regardless of

physician recommendation and hence if one arm is the “app intervention” arm and the other a

“current care” control arm, the control arm must acknowledge that people are likely to passively

use open websites and mobile tools themselves. The key is to know how information, support, and

communication impacts on the patient’s wellbeing and, as such, these longer term RCTs should be

formulated in terms not of a specic app but in terms of a functional assessment of what is needed,

for example, dierent ways of providing information, support and communication.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

“Right now there is scant scientic evidence that apps work. The main, respectable journals have

not published any ‘interesting ‘ peer-reviewed and reproducible results. When they do, you will

have the attention of the medical community. We are taught to trust our journals. Sadly, medical

research has not embraced the technologies that are out there and continue to focus on basic

research and meta-analysis studies - which they should. Doctors are not techno-phobic, they’re

just afraid of new applications without a demonstrable ROI on time and outcomes.”

Jordan Shlain, MD, FACP – HealthLoop Inc.

Conclusion

As evidenced by the most detailed analysis of widely available consumer healthcare apps

to date, there has been a tremendous development of mobile apps to assist consumers

and patients in every step of their healthcare management - from preventive measures that

encompass overall wellness, through to adhering to a prescribed treatment regime.

The apps developed to date are supported by a wide range of backers and have very

dierent business models and propositions. They also vary widely in their functional

capabilities.

One of the main challenges stemming from the wide variety of mobile healthcare apps

available is the confusion amongst consumers regarding the most appropriate app to

meet their needs, resulting in a signicant download skew whereby the most downloaded

apps continue to receive the most installs as a result of high review numbers and ratings.

Physicians face the same challenge when they try and recommend an app to a patient.

For healthcare apps to move through a maturity cycle from being an ad hoc

recommendation to a systematic, integrated component of healthcare delivery, all

stakeholders will need to work together. Healthcare payers and providers will increasingly

recognize the potential benet apps can bring, app developers will ensure privacy and

security of patient data, and a concerted eort will be made to evaluate healthcare apps

and to integrate them with other health IT oerings. Moreover, signicant investment

will be made in evidence generation to demonstrate that mobile apps can lead to dened

improvements in health outcomes. Many of these steps will require considerable upfront

investment – meaning there must be an incentive to move apps towards maturity.

One such incentive in developed markets is the ongoing shift to patient centered care

models. Stakeholders need to see patients as responsible and capable partners in

healthcare management - and patient engagement through mobile apps is an exemplary

rst step in this process. Some of the areas where substantial gains can be made in the

healthcare system involve exciting an interest in healthy lifestyles through diet and tness

apps, combined with the potential for remote monitoring and patient collected data being

used to develop the healthcare management program. This could lead to fewer people

contracting chronic conditions and actively adhering to treatment recommendations -

improving patient outcomes at lower overall cost.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Methodology

Count of widely available consumer healthcare apps

All 43,689 apps available for download from the Apple iTunes App store as of June 2013

were scraped from the store and analyzed. A thorough examination of the content of

these apps led to the exclusion of 20,007 apps from further analysis since these were

considered not truly related to healthcare (e.g. salons, apps with gimmicks). Of the

remaining 23,682 apps considered genuine healthcare apps, further content analysis

categorized 16,275 apps as consumer/patient oriented and 7,407 apps as HCP oriented.

A full analysis was only conducted on those apps targeting consumers/patients.

The intention of this analysis was to categorize apps along the full patient journey,

as opposed to other reports which simply grouped apps based on target audience

(women’s health, tness etc). As such a further detailed analysis of the 16,275 consumer

focused apps sought to place them along a patient journey consisting of overall wellness,

diagnosis, HCP visit, further information, prescription lling and compliance; recognizing

also that some apps cover the full patient journey and are intended for specic groups of

patients (demographic specic or therapy area specic).

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

43,689 “Healthcare and Fitness” or “Medical”

23,682 Apps genuine healthcare related

20,007 Mis-categorized or only

loosely healthcare related on App Store

16,275 Consumer/Patient Oriented

7,407

HCP oriented

• Fashion and beauty (e.g. salons)

• Apps intended for members of specic

clubs/universities

• Veterinary apps

• Apps which use gimmicks with no real health

benet (eg apps which make the user sound sick,

or demonstrate how the user would look if they

were obese)

• Apps related to health issues but which do not

focus on health (e.g. fertility)

• Product presentation apps for use by sales

reps/retailers

• Apps believed to have meaningless claims

e.g. “gives you a beautiful way to keep track of your

body's biorhythms”

METHODOLOGY

A further 2,032 apps were therefore excluded at this point, although they relate to healthcare

they would not sit on a patient journey (e.g. nding an optician or dentist, specic tness centers

class timetables, cosmetic surgery). This left 14,243 general consumer healthcare apps which

belong on a typical patient journey.

Quality control was built into the mobile app review process. After each app was reviewed,

it underwent a second round of examination by a separate group of reviewers, verifying the

results of the rst review, even if the app was rejected initially. A smaller random set of apps

were selected for a weekly or monthly review. Since each app’s reviewer and date of review was

recorded, any misclassication trends uncovered during the reviews were linked to a specic

individual or time frame and these aected apps were sent for reclassication in their entirety.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

16,275 Consumer/patient targeted genuine healthcare related apps

14,243 Apps can be placed on patient journey

2,032

not

patient health

specic*

Overall Wellness

• Diet and Nutrition

• Fitness and Exercise

• Weight/BMI tracking

• Stress, relaxation and sleep

• Cognition IQ and memory

• Addiction quitting

Diagnosis

• App has built in

functionality to provide

diagnosis based on user

inputted information/

answers

Finding HCP

• Directs user to nearest

HCP/medical facility

• Review and create

ratings for HCPs

• Appointment

reminders

Is it intended for a specic group of

consumers / patients or their caregivers?

• Women’s Health

• Children’s Health

• Senior Health

• Therapy Area Specic

Finding Information

• Healthcare education

and information

• Drug information

• Medical information

• Emergency care

Finding Information

• Healthcare education

and information

• Drug information

• Medical information

• Emergency care

Prescription lling

• Finding a pharmacy

• Prescription rells

• Price checkers

• Polypharmacy

management

Compliance

• Medication reminders

• Medication trackers

• General patient

calculators

* cosmetic surgery, alternative care, opticians,

dentists and specic tness centers

METHODOLOGY

Functionality assessment score for consumer healthcare apps

The IMS app functionality score is calculated for the 6 key areas of information, instruction,

tracking and guidance, reminder, communication and use of phone functionality. Each app

undergoes a rigorous assessment for each function. Apps are assessed within use case.

The following criteria are considered:

Information

• Level of detail of information

• Provides information as text

• Provides information as picture

• Provides information as video

• Provides audio information

Instruction

• Provides instructions to the user

Tracking and guidance

• Ability to track and capture user entered data

• Graphically displays user entered data

• Outputs user data

• Can link to sensor

• Provides guidance based on entry

Reminder

• Built in reminder function

Communication

• Uses email

• Uses SMS

• Provides secure communication

• Provides link to social networks

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

METHODOLOGY

Phone functions

• Use of phone’s GPS

• Use of phone’s camera

• Use of phone’s scanner

• Use of phone’s voice recorder

The user rating score considers both the number of reviews the app has received on the iTunes

app store and the Google Play store, and the star rating assigned to the app.

Android data download analysis

Data for downloads of Android apps was purchased from AppMonsta in July 2013. This data

provided information including AppID, App name, Category, App URL, Description, Publisher,

Release Date and Downloads, where downloads were quoted in the following ranges: 10 million

to 50 million; 5 million to 10 million; 1 million to 5 million; 500,000 to 1 million; 100,000 to

500,000; 50,000 to 100, 000; 10,000 to 50,000; 5,000 to 10,000; 1,000 to 5,000; 500 to 1,000; 100 to

500; 10 to 50; 5 to 10; 1 to 5.

The median number of downloads was therefore taken for each range from which a total number

of downloads was estimated.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

1 Volpp, KG et al. Redesigning employee health incentives –

lessons from behavioural economics. N Eng J Med, 2011; 365 (5).

2 PruHealth UK Vitality Program. Accessed Sept 2013 at

http://pruhealth.pruhealth.co.uk/individuals/live ‐well/about-

pruhealth-vitality

3 Subramanian, C. The Ultimate Weight-Loss Incentive: Dubai

Will Pay Dieters in Gold. Time Newsfeed, July 2013. Accessed at:

http://newsfeed.time.com/2013/07/18/the-ultimate-weight-

loss-incentive-dubai-will-pay-dieters-in-gold/#ixzz2bwy4AdHJ

4 Fox, S and Duggan, M. Health Online 2013. Pew Internet and

American Life Project, 2013

5 mHealth: New horizons for health through mobile

technologies. Global Observatory for eHealth series, 2011.

Volume 3.

6 Gordon, ME. India, China, and the Map to Two Billion

Connected Devices. Flurry Blog. June 2013. Accessed at http://

blog.urry.com/bid/97962/India-China-and-the-Map-to-Two-

Billion-Connected-Devices

7 Wikipedia contributors. “Mobile app.” Wikipedia, The Free

Encyclopedia, 25 Sep. 2013. Accessed Oct 2013 at http://

en.wikipedia.org/wiki/Mobile_app.

8 Our mobile planet: Presented by google. Accessed August

2013 at http://www.thinkwithgoogle.com/mobileplanet/en/

graph/?wave=2013&age=all&gender=all&active=country

9 Khalaf, S. It’s an App World. The Web Just Lives in It. Flurry

ve year report. Apr, 2013. Accessed at http://blog.urry.com/

bid/95723/Flurry-Five-Year-Report-It-s-an-App-World-The-Just-

Web-Lives-in-It

10 Adapted from Center for Technology and Aging, Technologies

for Remote Patient Monitoring for Older Adults, April 2010

11 Quinn et al. WellDoc Mobile Diabetes Management

Randomised Controlled Trial: Change in clinical and

behavioural outcomes and patient and physician satisfaction.

Diabetes Technology and Therapeutics, 2008; 10 (3), 160-168

12 Quinn et al. Cluster-Randomised Trial of a Mobile Phone

Personalised Behavioural Intervention for Blood Glucose

Control. Diabetes Care, 2011; 34, 1934-1942

13 App Annie app store stats. Retrieved Sept 2013 at http://

www.appannie.com/top/iphone/united-states/health-and-

tness/

14 Dembosky, A. Venture capitalists weigh in on MyFitnessPal.

Financial Times. August 2013

15 Mokdad et al. Actual Causes of Death in the United States,

2000. JAMA, 2004; 291(10):1238-1245

16 How Safeway is cutting healthcare costs. Wall Street Journal.

2009. Accessed august 2013 at http://online.wsj.com/article/

SB124476804026308603.html

17 Burke LE et al. Self-monitoring dietary intake: current and

future practices. J Ren Nutr, 2005; 15, 281–90

18 Ferris et al. Diagnostic Inaccuracy of Smartphone

Applications for Melanoma Detection. JAMA Dermatology,

2013; 16, 1- 4

19 http://www.kaiserhealthnews.org/stories/2013/june/18/

doctors-patients-smartphone-apps.aspx

20 Mobile Medical Applications: Guidance for Industry and

Food and Drug Administration Sta. FDA document, Sept 25th

2013

21 http://www.eweek.com/c/a/Health-Care-IT/New-

Mobile-App-Allows-Consumers-to-Compare-Drug-Prices-at-

Pharmacies-132014/#sthash.1KkNf2sD.dpuf

22 http://drugtopics.modernmedicine.com/drug-topics/

news/drug-topics/chains-business/mobile-apps-managing-

health?page=0,0) http://mobihealthnews.com/22686/

walgreens-nds-mobile-customers-to-be-better-customers/

23 http://drugtopics.modernmedicine.com/drug-topics/

news/drug-topics/chains-business/mobile-apps-managing-

health?page=0,0) http://blog.arizonacollege.edu/2013/06/

pharmacy-apps/

24 Cramer et al. Medication compliance and persistence:

terminology and denitions. Value Health, 2008;11(1):44-7

25 Eweek and drug store news http://www.eweek.com/

mobile/mobile-pillbox-app-promotes-diabetes-medication-

adherence-Report/ http://drugstorenews.com/article/

medisafe-project-app-boosts-adherence-rates

26 Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data

for 2005 National Vital Statistics Reports 2008; 56(10). Available

from: http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.

pdf

27 Anderson G. Chronic conditions: making the case for

ongoing care. Baltimore, MD: John Hopkins University; 2004.

References Cited

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

REFERENCES CITED

28 Centers for Disease Control and Prevention. Prevalence of

doctor-diagnosed arthritis and arthritis-attributable activity

limitation—United States, 2003–2005. MMWR 2006;55:1089–

1092

29 Aitken, M.; Valkova, S. Avoidable Costs in U.S. Healthcare:

The 200 Billion Opportunity from Using Medicines More

Responsibly. IMS Institute for Healthcare Informatics, June

2013

30 Pew Internet and American Life Project: Smart phone

ownership, June 2013

31 AppMonsta, data purchased June 2013. See methodology

section for analysis description

32 Mobithinking: Global mobile statistics 2013 Section E:

Mobile apps, app stores, pricing and failure rates

33 NHS Commissioning Board launches library of NHS-

reviewed phone apps to help keep people healthy. Accessed

at http://www.england.nhs.uk/2013/03/12/nhs-apps/

34 HealthTap takes on app curation, prescribing,

Mobihealthnews, May 2013. Accessed at http://

mobihealthnews.com/22707/healthtap-takes-on-app-

curation-prescribing/

35 Wicklund, E. Cigna’s new marketplace helps members pick

the right health and wellness apps. mHealthNews, Oct 2013

36 Pew Internet and American Life Project: Cell Phone

Activities Nov 2012

37 Aitken, M et al. Healthcare Spending Among Privately

Insured Individuals Under Age 65. IMS Institute for Healthcare

Informatics, Feb 2012

38 Kernishan, L. How should apps be prescribed? Accessed at

http://thehealthcareblog.com/blog/2013/03/13/how-should-

apps-be-prescribed/.

39 Boyd et al JAMA. 2005;294(6):716-724

40 NBC News Rock Center, Jan 2013: The key to better

health care may already be in your pocket... and it’s not

your wallet. Accessed at http://rockcenter.nbcnews.com/_

news/2013/01/24/16677207-the-key-to-better-health-care-

may-already-be-in-your-pocket-and- its-not-your-wallet?lite

41 Happtique to test its health app prescription

platform, Mobihealthnews, May 2012. Accessed at http://

mobihealthnews.com/17300/happtique-to-test-its-health-

app-prescription-platform/

42 Examples of MMAs the FDA has cleared or approved.

Accessed Sept 2013 at http://www.fda.gov/MedicalDevices/

ProductsandMedicalProcedures/ConnectedHealth/

MobileMedicalApplications/ucm3 68784.htm

43 Moukheiber, Z. Trailblazer WellDoc To Sell First Mobile

Prescription Therapy. Forbes. June 2013. Accessed Sept 2013

at http://www.forbes.com/sites/zinamoukheiber/2013/06/14/

trailblazer-welldoc-to-sell-rst-mobile-prescription-therapy/

44 Mattke et al. Workplace wellness programs study. RAND

Health sponsored by the US Dept of Labor, 2013

45 Carter et al. Adherence to a Smartphone Application for

Weight Loss Compared to Website and Paper Diary: Pilot

Randomized Controlled Trial. J Med Internet Res 2013;15(4):e32

46 California Online Privacy Protection Act

47 Adapted from EU Article 29 Working Party Opinion on Apps

on Smart Devices and its Implications

48 Payne, P. Do mHealth apps require randomized controlled

trials– panel discusses at mHealth Summit. iMedicalApps, Dec

2012

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

Authors

Murray Aitken

Executive Director, IMS Institute for Healthcare Informatics

Murray Aitken is executive director, IMS Institute for Healthcare Informatics, which provides

policy setters and decision makers in the global health sector with objective insights into

healthcare dynamics. He assumed this role in January 2011. Murray previously was senior vice

president, Healthcare Insight, leading IMS Health’s thought leadership initiatives worldwide.

Before that, he served as senior vice president, Corporate Strategy, from 2004 to 2007. Murray

joined IMS Health in 2001 with responsibility for developing the company’s consulting and

services businesses. Prior to IMS Health, Murray had a 14-year career with McKinsey & Company,

where he was a leader in the Pharmaceutical and Medical Products practice from 1997 to 2001.

Murray writes and speaks regularly on the challenges facing the healthcare industry. He is editor

of HealthIQ, a publication focused on the value of information in advancing evidence-based

healthcare, and also serves on the editorial advisory board of Pharmaceutical Executive. Murray

holds a Master of Commerce degree from the University of Auckland in New Zealand, and

received an M.B.A. degree with distinction from Harvard University.

Carolyn Gauntlett

Senior Consultant, European Thought Leadership

Carolyn is a researcher and project manager in the IMS Health European Thought Leadership

Team, leading the development of reports and analyses focused on biopharmaceuticals and

healthcare in Europe and globally. Carolyn’s primary and secondary market research experience

spans therapy areas including diabetes and oncology, emerging markets, and the yearly

pharmaceutical strategic management review. Carolyn joined the Thought Leadership team

at IMS Health in 2011 and has supported both the North Europe and Central Europe business

units. Prior to IMS Health, Carolyn was a research chemist working both in academia and biotech.

Carolyn began her consulting career at OC&C Strategy Consultants in London, working across

a range of consumer, retail and media projects. Carolyn holds a MA and PhD in Chemistry from

Cambridge University and was a postdoctoral Fulbright Scholar at Stanford University.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

About the Institute

The IMS Institute for Healthcare Informatics leverages collaborative relationships

in the public and private sectors to strengthen the vital role of information in

advancing healthcare globally. Its mission is to provide key policy setters and

decision makers in the global health sector with unique and transformational

insights into healthcare dynamics derived from granular analysis of information.

Fullling an essential need within healthcare, the Institute delivers objective,

relevant insights and research that accelerate understanding and innovation

critical to sound decision making and improved patient care. With access to

IMS Health’s extensive global data assets and analytics, the Institute works in

tandem with a broad set of healthcare stakeholders, including government

agencies, academic institutions, the life sciences industry and payers, to drive a

research agenda dedicated to addressing today’s healthcare challenges.

By collaborating on research of common interest, it builds on a long-standing

and extensive tradition of using IMS Health information and expertise to

support the advancement of evidence-based healthcare around the world.

ABOUT THE INSTITUTE

Research Agenda

The research agenda for the Institute

centers on ve areas considered vital to the

advancement of healthcare globally:

The eective use of information by healthcare

stakeholders globally to improve health outcomes,

reduce costs and increase access to available

treatments.

Optimizing the performance of medical care

through better understanding of disease causes,

treatment consequences and measures to

improve quality and cost of healthcare delivered

to patients.

Understanding the future global role for

biopharmaceuticals, the dynamics that shape

the market and implications for manufacturers,

public and private payers, providers, patients,

pharmacists and distributors.

Researching the role of innovation in health

system products, processes and delivery systems,

and the business and policy systems that drive

innovation.

Informing and advancing the healthcare agendas

in developing nations through information and

analysis.

Guiding Principles

The Institute operates from a set of

Guiding Principles:

The advancement of healthcare globally is a vital,

continuous process.

Timely, high-quality and relevant information is

critical to sound healthcare decision making.

Insights gained from information and analysis

should be made widely available to healthcare

stakeholders.

Eective use of information is often complex,

requiring unique knowledge and expertise.

The ongoing innovation and reform in all aspects

of healthcare require a dynamic approach to

understanding the entire healthcare system.

Personal health information is condential and

patient privacy must be protected.

The private sector has a valuable role to play in

collaborating with the public sector related to the

use of healthcare data.

Patient Apps for Improved Healthcare: From Novelty to Mainstream. Report by the IMS Institute for Healthcare Informatics.

IMS Institute for Healthcare Informatics, 11 Waterview Boulevard, Parsippany, NJ 07054 USA

info@theimsinstitute.org www.theimsinstitute.org