Kathryn's Final Blog Post

My goal of this project was to look at how usable telemedicine apps were, particularly those with a video call feature to speak with/see a physician. I wanted to see if these apps lived up to being the "future of medicine" and how easy there were to use.

I downloaded all three of the apps I looked at to my phone (DoctorOnDemand, LiveHealth Online, and HealthTap). I was originally interested in this topic because of DoctorOnDemand, which I always heard about from watching the show The Doctors and Dr. Phil. This app, surprisingly, ended up being my least favorite because it didn't offer nearly as much as the other two I looked at. My findings of how usable each app were are summarized in the screen capture below of one of my Power Point slides. I looked at what I saw as the five of the most relevant usability characteristics: simplicity, flexibility, memory, undo and availability. I quantified this data by giving each characteristic a numerical rating then totaling each app's score in a matrix.

For the future, further analysis could be done with this matrix by giving each usability characteristic a weight then recalculating the app's score based on the weights. This project has shown me more about the advanced features of telemedicine apps. I was most impressed with HealthTap's artificial intelligence feature, which was like WebMD but way more accurate and less scary with the results. Telemedicine apps in the future may be able to replace websites like this because the diagnoses I've seen so far have been much more accurate and less extreme. Hopefully this project has shown others how fast and easy telemedicine apps make doctor's appointments, because it has made me clearly see how much of a time drain the traditional office visits can be. Overall, telemedicine apps I believe, will play an increasingly larger role in medicine's future because of their convenience.

Telemedicine For Psychiatry in Teens

Who has a smartphone?
A 2015 pew research study found that 73% of teens have a smartphone,in addition to 58% with tablet access and 87% with computer access. Early teens also have a lot of access with 64% of boys and 73% of girls 13-14 having access to a smartphone. Smartphones aren't just for high income households either, 65% of teens households with less then $30,000 income a year have a smartphone. Racial disparities are reversed when it comes to this as well, with 85% of non-Hispanic black teens having access, compared to 71% of non-Hispanic white teens. Those with mental health conditions have the highest percentage of smartphone ownership at 97%. The study also found that most patients are interested in using a mobile phone application to monitor their mental condition.
Who has a mental illness?
Half of lifetime mental disorders start in the mid teen's and three-quarters by the mid-20's. 52.4% of people age 18-29 experience any disorder and 22.3% are experiencing three or more disorders. Within this group, it was found that anxiety disorders were most common at 30.2%, followed by impulse control disorders at 26.8%.
Mobile Apps VS. Telepsychiatry
This article defines mobile apps as delivering interactive content, collecting information, informing users about insights based on findings, and enabling users to receive assistance when in crisis. Telepsychiatry is defined as linking the patient to a clinician (which is differentiated than a mobile app which doesn't require clinician involvement).
Hard Vs. Soft Benefits
Hard benefits are defined as direct benefits and result from the immediate expenditures and benefits tied  to a good or service. Soft benefits are defined as indirect benefits and result from the the activities and changes that are caused by the good or service. Both of these benefits are used to gauge the return on investment for mobile apps and telepsychiatry (summarized in the table above).
Direct Benefits of Mobile Applications
Mobile apps for mental health create savings from the substitution of other forms of care as content delivered through an app is less expensive than the same care delivered in person. Building an app has a high sunk cost, but after that the incremental costs are almost zero. In a multi-site study by the National Institute of Mental Health-funded, it was found that with CBT (cognitive behavior therapy), therapists typically spent 16.6 hours with a patient, but with a combination of a computerized program the same reduction in depression scores could be achieved. By prerecording CBT instructions, it eliminates much of the time therapists need to spend on repetitive tasks. The CBT cost is now reduced to a third.
Another benefit is that high -acuity situations can be prevented because apps provide anonymity and convenience. People who would not normally seek psychiatric help are more willing to complete a diagnostic questionnaire through an app. The US Prevention Services Task Force recommends screening all adults for depression and this app is a good confidential way to get adults the care they need. Early recognition is also helped with mobile apps because adolescents cannot get live therapeutic help and apps bridge this gap.
Self-identification through the app may drive some to seek professional help, which increases the demand for psychiatry services.
Apps are often supported by ad revenue, fees for purchase, or fees for use; all of which provide these app developers and operators a revenue source.
Indirect benefits of Mobile Applications
Poor mental health can lead to poor physical health, which is costly and it can also lead to poor performance at work/school, which is again costly. Early recognition and treatment of mental illness, results in great cost savings due to improved physical health. Mortality is also increased for those with mental health conditions because after a stroke, for example, these conditions lead to an increased rate of mortality.
 Mental health affects how adolescents perform in and out of the classroom. Those who score higher on the Children's Depression Inventory, have a higher rate of absenteeism and lower academic performance. This affects university performance because high school performance affects college admissions and college selectivity is found to affect future earnings.
As an adult, depression affects overall output and the productivity loss impacts the individual and surrounding society. Since mobile apps can diagnose and treat, this reduces the impact of present and future financial consequences.
Direct Benefits of Telepsychiatry
Geographic barriers are removed with telepsychiatry, which makes those in rural areas or who are bed bound, able to access these services. The transportation costs is also eliminated with a video conference appointment. This increases access to those with limited time, money, or access to  transportation, so that those in rural areas have access to adequate care. For those not in rural areas, this allows continuity of care while traveling.
Telepsychiatry increase the ability of patients to receive care when they need it urgently. A survey found that primary care physicians who referred patients for psychiatric care are satisfied with the telepsychiatry care received. It is useful as a supplement when a patient can't reach his/her primary psychiatrist in a time of need.
Telepsychiatry services expand the market reach of a psychiatrist, which helps fill his/her schedule.Patients are less likely to miss appointment because of the elimination of the transportation barrier and telepsychiatry services allow a psychiatrist to fill in holes for last minute cancellations. Psychiatrists can increase revenues while giving patients access to care at a lower cost.
Indirect Benefits of Telepsychiatry
Telepsychiatry appointments reduce the need for caregivers to assist a patient in getting to an appointment, which lowers costs for patients. This also holds true for children and adolescents that need someone to take them to their psychiatry appointments.
Psychiatrists can save on staff and office space, as telepsychiatry doesn't require a waiting room or physical forms. This also eliminates the insurance required for physical visits, like slips ad falls. In addition, there are savings on utilities,tissues, water, couches, rugs, etc. All that is required for a telepsychiatry appointment is a laptop with a camera, a smartphone,and a broadband connection.
Telepsychiatry produces the same indirect benefits as mobile apps in terms of improved mental health, potential improvements in school as well as present and future earnings since mental illness amplifies costs for physical illness.

Powell, A., PhD, Chen, M., PhD, & Thammachart, C., MA. (2017). The Economic Benefits of Mobile Apps for Mental Health and Telepsychiatry Services When Used by Adolescents. Child and Adolescent Psychiatric Clinics of North America,26(1), 125-133. doi:http://doi.org/10.1016/j.chc.2016.07.013
Link

Telemedicine Apps Population Survey

In a survey of 4144 Germans over 35 in order to see the extent of smartphone and health app use; sociodemographic, medical, and behavioral correlations to smartphone and health app use; as well as associations of the use of apps.

61.25% (2538/4144) used a smartphone and those who did, tended to be younger, did more internet research, were more likely to work full time and have a university degree, engaged in more physical activity, fewer had a low fat diet, and had a higher health-related quality of life and health knowledge. Among the smartphone users, 20.53% (521/2538) used health apps.

The health apps focused on quitting smoking 44.5% (232/521), healthy dieting 38.6% (201/521), and weight loss 23.2% (121/521). The apps focused on planing 50.7% (264/521), reminders 36.1% (188/521), motivation 34.4% (179/521), and health information 33.6% (175/521).

The study finds that a significant portion of the population isn't engaged and the disparities in the use of this technology is age-related, socioeconomic-related, literacy-related, and health-related. In order to make telemedicine apps more engaging, app developers should take into account the needs of the elderly, those with chronic conditions, and those with low health-literacy.

Ernsting C, Dombrowski SU, Oedekoven M, O´Sullivan JL, Kanzler M, Kuhlmey A, Gellert P

Using Smartphones and Health Apps to Change and Manage Health Behaviors: A Population-Based Survey

J Med Internet Res 2017;19(4):e101

Link

The Doctor Will Skype You Now

The Time magazine article, The Doctor Will Skype You Now, gives an overview of DoctorOnDemand and HealthTap and how useful they will be in the future to replace non-emergency visits. 

The article begins with the story of Vivek Soddera, age 30, who woke up with a swollen knee after a night out with friends. He knew he had to see a doctor about it, but he was unable to  move from his couch (because of his knee); and didn't want to pay a cab fare to/from the hospital on top of the visit cost. He turned to DoctorOnDemand and after entering his symptoms and snapping some photos, he was paired with a specialist who immediately recognized it as a dislocated knee and had an MRI scheduled for Soddera. The visit cost $40 and doesn't require insurance either. Apps like HealthTap and AskMD allow users to get text-questions answered by multiple doctors for free.

Telemedicine apps were typically only reserved for the rich and those in remote areas, but this is all changing. These apps are a cheap, easy alternative for non-emergency consultations. And is beneficial to doctors as well because it allows them to build their patient base and make some money in their downtime. Murray Aitken, the executive director of the health care consultancy IMS institute, says "we are going to see a major shift in how  medicine is practiced and where". 

There are some concerns raised with telemedicine apps, however. They are not meant to replace in-person exams, they should only replace visits for a cold/flu and minor injuries like Soddera's dislocated knee. The Aitken also points out that it isn't ideal to have someone who isn't a patient's primary care doctor prescribe medications without seeing the patient's electronic medical-record history. He wants to see a balance, telemedicine apps should be used to replace unnecessary doctor visits to save space for patients that need an in-office visit.

Overall this article shows that telemedicne apps have a very bright future, if they're used in the right way. 

Sifferlin, A. (2014). The doctor will Skype you now. Time, 183(1), 12.  /  Link

Project Update

We have decided to focus solely on mobile apps, like DoctorOnDemand, Health Tap, and  LiveHealth Online.  We want to gather data on the usability of these apps and what the future is for them. Below is our original project proposal, expanded on.

How Treating Healthcare Like a Game Can Save Lives

Gamification can be difficult to achieve in the long run, however, as pointed out by Frank Lee, leader of “Serious Games for Health”. It’s hard to get patients hooked on a game, it’s not just about nice graphic and earning virtual trophies, even financial (dis)incentives stop working after a while. For example, a daycare started fining parents who were late for pick-up, but the number of offences doubled as parents saw this as paying a few for an extra service. The same applies to penalizing patients for smoking, they may wonder if the pleasure of smoking is really worth the $20 and it might be. A Gartner study found that 80% of apps that aim to gamify healthcare would disappear due to poor design (Rubin). These apps are tricky enough to make accurate, and when traditional incentives don’t work and game requirements are so high, the likelihood of a gamification of healthcare begins to diminish. The potential gamified healthcare apps have though may be enough to outweigh all the negativity of failed apps along the way.

Accenture reported seven key gamification elements: status, milestones, competition, rankings, social connectedness, immersion reality and personalization. Dr. Joseph Kim, a physician technologist, believes that applying this to healthcare can lead patients to be more curious about their condition, medications, and eventually self-care. Patients use role-playing games and see what happens if they do not adequately manage their conditions. This will hopefully kick start individuals and encourage them to set goals, measure their progress, reach milestones, and compare their performance to benchmarks; all elements of gamification. Gamification will also motivate patients to receive ongoing feedback, reminders, and status updates about their progress. Gamification can save lives, especially those of children (see On Alert for Pain story). Overall, gamification leads to more actively engaged and healthy patients and this is just the beginning of how gamification is shaking up the delivery of healthcare (Kim).

Source: SearchHealthIT "Gamification in healthcare isn't just about playing games" and US News "The Health Benefits of Gamification"

Are Wearable Fitness Trackers Killing Your Doctor Bills or You?

There are two positions on wearable technology, the yes and no side. This technology has the power to disrupt healthcare by proving more patient than ever before in a relatively inexpensive, yet accurate matter. However, some point out than wearables in fact are making people fatter.

On the “yes” side is Dr. Peter Weiss, co-founder of Rodeo Drive Women’s Health Clinic. Even if wearable technology doesn’t directly make users more healthy; wearable technology will create new industries and businesses built around health. He believes that these technological advancements will end up benefitting patients if they are willing to use the technology and share their results with their physicians, as this can help physicians modify a patient’s everyday routine. This helps a physician see where a patient is really at and make more data-guided recommendations based on the wearable results (Weiss & Brulte). For example, in an office visit, a physician can recommend that a patient takes 10,000 steps a day. But if the patient is only taking 5,000 a day that goal may seem impossible to accomplish, but with wearable data a physician can set a lower goal like 6,500 steps then build it up based on data. Although there is strong evidence for wearables creating healthier patients, even indirectly, there is still a “no” side that believes wearables are hurting more than helping.

Apple Watch: Track fitness and order pizza

On the “no” side is Dr. Mitesh Patel, an assistant professor of medicine at the University of Pennsylvania who believes assigning someone wearable technology will make that big of a difference overall. He bases this statement on a study done by John Jalicic of the University of Pittsburg, where 470 patients were put on a low-calories diet and told to exercise more for two years. Half were given a fitness tracker to monitor progress. After two years, both were equally active, but the group with wearables lost less weight. The reason for this is patients becoming discouraged by not meeting fitness goals set by their wearables or believed they could eat more based on the exercise their wearable reported (Ross). Although some patients may be more motivated to lead a healthy lifestyle with the use of a wearable, it may have the opposite effect.

Source: NPR "Weight Loss On Your Wrist? Fitness Trackers May Not Help"