Patients’ use of mobile health applications: what general practitioners think

Patients’ use of mobile health applications: what general practitioners think Abstract Background Chronic disease patients are adopting self-management techniques, such as using mobile health applications (apps). As GPs are the main caregivers of chronic disease patients, obtaining GP perspectives regarding patient use of mobile health apps is vital in understanding longer term value and feasibility of these apps. Objective The aim was to determine GP perceptions of their current and potential roles in the use of health apps by their patients and how patient-focused apps affect patient management. Methods Ten GPs participated in semi-structured, face-to-face interviews, which focused on their perceptions of, and involvement in, the use of patient-focused health apps. Interviews were transcribed verbatim and thematically analysed by two independent reviewers. Results GPs found that apps complemented their role in patient management as additional sources of medical information of their patients. They perceived that patient-focused apps would be part of their future practices; however they noted that further work was required to incorporate them into their current practices. Currently, the main role of GPs was in promoting apps to patients. Suggestions for further engagement in mobile health included regularly reviewing patient data entered into health apps during consultations. Conclusion GPs view patient-focused health apps positively, particularly to support them in providing patient care. Discussing information recorded in apps during consultations and frequent promotion of apps are feasible ways to integrate apps into their current work practices. Further studies involving evaluations of apps in improving health care delivery and patient communication in general practice are required. Delivery of health care, general practice, general practitioners, mobile applications, patient participation, primary health care Introduction Chronic conditions, such as diabetes, obesity and gout, are rising in prevalence and placing great burden on patients and the health care system. Electronic self-management tools provide patients with a novel avenue to engage in management of their own health care. Self-management tools have been successfully used to help patients in self-care of chronic conditions such as diabetes and HIV (1–3). GPs are the main health care providers for patients with chronic conditions. Research indicates that patients would use an electronic self-management tool if it was recommended by their GP (4). Further, successful uptake of self-management tools is enhanced by GP promotion or suggestion and GPs’ participation in shared decision making with patients who use tools (4,5). As the use of mobile health applications (apps) by patients increases, it is important to understand the perspectives and potential roles of GPs in patient use of self-management apps. Primary care organizations are encouraging GPs to use electronic health technologies (6). This aligns with the observed rise in use of technologies in routine GP care, particularly of mobile technologies (7). GPs use health apps to aid in patient assessments, with the convenience of access to, and portability of, apps cited as encouraging their use. GPs also prescribe health apps to their technologically able patients (7). In some primary care populations, more than half of patients own a smartphone, and of these, 70% use mobile technology (8). A recent survey of Australian GPs regarding health technologies showed two-thirds of GPs had recommended a health app to a patient and nearly half had used mobile devices for patient-related work, such as engaging in patient education, or to access clinical calculators or guidelines (6). However, lack of knowledge of credible apps and their ability to provide patient benefits have been reported as barriers by GPs that prevent further adoption of mobile technologies. Increasing patient use of mobile health apps has the potential to change the way GPs deliver health care. The aim of this study was to ascertain GPs perceptions of current and potential roles in the promotion and implementation of patient-focused mobile health apps and their views on how app use can affect their workflows. Methods Recruitment GPs in metropolitan Sydney known to the research team and GPs with contact details posted on the Internet were contacted by telephone, email or fax. Approximately 120 GPs were invited to a short (20 minute) semi-structured interview about mobile health apps. Of these, 12 expressed interest in participating. Thematic saturation was achieved after 10 interviews. Participating GPs were reimbursed with a $100 gift card. Data collection Once consent was obtained, semi-structured face-to-face interviews were conducted with each GP (n = 10). Interview questions were designed to explore GP’s experiences of interacting with mobile health apps and to ascertain their current and potential roles in patient use of mobile health apps (see Supplementary Material). Interviews were audiotaped and transcribed verbatim. Investigators met periodically throughout data collection to discuss themes and reach consensus on any discrepancies. Analysis Thematic analysis was undertaken concurrently but independently by two investigators (ADN, LJF) to determine when thematic saturation occurred (9). After analysis of five transcripts, investigators convened to discuss emerging themes and developed a coding framework using an inductive approach, allowing for the most predominant themes to be identified. Emerging themes were categorized into GP perceptions of, and their role in, patient-focused health apps, perceived benefits and limitations of these apps, and potential implications for GPs of patient use of these apps. Results Participants Six female and four male GPs were recruited. The GPs practised in eight different medical practices located across four regions of Sydney, Australia. GP perceptions of mobile health apps for patients GPs stated that mobile health apps could be useful to patients, particularly those patients who actively searched for medical information and were interested in their health (Table 1). Table 1. Summary of GP perceptions of mobile health applications (apps) for patients GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs View Large Table 1. Summary of GP perceptions of mobile health applications (apps) for patients GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs View Large Perceived benefits of patient-focused apps GPs perceived that a large benefit of mobile health apps was their potential to support patients in keeping records of their own health and conditions. GPs noted that some patients were already monitoring their health using paper logs, such as handwritten medication lists. However, technological methods, such as spreadsheets, were more commonly used, with patients also reportedly using mobile apps. GPs reported that tracking menstrual cycles was the most common health reason for patients to use an app, as well as for monitoring blood pressure and blood glucose concentrations. A GP explained, ‘I find a lot of the women… monitor their menstrual cycle with apps… My hypertensive patients… they’re very obsessive people who bring spreadsheets to me’ (GP #2). Apps were perceived by GPs to be able to provide patients with useful and credible education that could improve patient knowledge about a condition. This was described by a GP as, ‘It’s a source of information that they can just go to the app for, rather than just numbers and “remember to take your medication”, it’s a bit more information… It’s a little bit more health promotion’ (GP #5). GPs said they would be more comfortable recommending an app that was evidence based and developed by a credible source. One GP described, ‘The only time I’ve ever prescribed an app is for my patients who have IBS and I suggest that they use the Monash University Low FODMAP app only because that’s the most thoroughly researched and something that is very evidence-based’ (GP #8). Perceived limitations of patient-focused apps Although GPs were generally positive about health apps, several limitations about their use were raised. Participants reported that technical difficulties, such as patients not being able to open apps due to technical faults, or apps that required Internet connection to access features were deterrents for maintaining app use. A GP described, ‘The only problem with technology is that I’ve had patients where they can’t open a certain application when they need to… I’ve had patients who say, “Oh I’ve got to show you this.” And they can’t open it and they try to. I guess it depends on reception and what’s happening with the Internet’ (GP #2). Another barrier to the wider adoption of health apps was reported to be the limited time available for patients to use apps. Also, GPs felt that the population of patients who would use and therefore benefit from apps was limited, stating that apps potentially self-selected for younger patients as they require technological knowledge. A GP explained, ‘If it’s easy to use and patients have a smartphone, then yes I think it would be quite useful, in the sort of younger population, because the older population… they’re not very computer smart… If you give them something, I don’t think the older generation would really know how to do it’ (GP #9). GPs also stated that younger patients who required help with improving their medication compliance would likely find apps more useful than older patients, as they possess the technological ability, as well as a need, to use them. Roles of GPs in patient-focused mobile health apps GPs said that while health apps have not changed the way they deliver care to their patients, apps were useful and complementary to their role as medical practitioners. In particular, GPs saw apps as a source of medical information about their patients. For example, when patients collect or track pathology results on an app, this enabled GPs to review patient results over time. A GP described, ‘Patients would record everything they have on their app, they can show it to you… Patients would take photos, which is very helpful, especially being a part-time GP, they can’t access me when they need to’ (GP #2), and another reiterated, ‘… I had seen them after six or 12 months and we wanted to have a look at all their readings, if there was a way to generate a summary for GP and then email it as a PDF, then we could scan that into their medical record, and that way the other GPs would be able to access it and make it useful’ (GP #8). GPs stated that currently their main role in the use of health apps was promotion of them to patients, with most saying they have previously promoted an app or would promote one if it were applicable to their patient. Potential implications for GPs of patient use of mobile health apps GPs stated that mobile health apps were the way of the future for health care, with one GP saying, ‘It’s going to be more and more incorporated in our [GP] practice. Personally, it’s more so being ahead, as well as being able to provide the best care that is contemporary’ (GP #5). However, it was noted that mobile health technologies were yet to be integrated into their workflow. More regular promotion of health apps to patients was suggested as an area that GPs could expand. One GP elaborated, ‘You’re going to have patients bringing in their information [on apps] and discussing results with you – it’s just what’s going to happen, so we [GPs] need to be aware of that rather than fighting it’ (GP #3). Additionally, most GPs commented that they would be amenable to more regularly reviewing data entered by patients into a mobile health app during medical consultations. A GP explained, ‘If they were achieving their goals and they were reaching their targets… a summary could be made so that they can give it to their GP when they attend for review’ (GP #8). However, GPs stated that helping a patient to set up an app during consultations would be too time-consuming. When asked about whether they would like independent access to patient information stored on health apps, GP responses were divided. Some noted that it would be beneficial to track multiple patients through a single remote portal. However, others cited limited time and additional responsibilities outside of work hours as barriers to accessing health app data independently. Using an app to improve communication between GPs and patients was raised, with GPs being in favour of information from apps being fed back to them through non-urgent communication channels, such as email. A GP explained, ‘That is definitely going to become more useful and more important in the future – patients having those records themselves… And maybe some way to link in so that you could give them some information and they could give you some information… You could somehow email the patients their results to put in their [app]… Some sort of way of linking’ (GP #4). Other GPs elaborated, ‘If it’s something that we introduce – they use it, they really liked it, then it becomes a connection or a link that if they have any questions there’s an opportunity for them to ask… It can potentially facilitate that working together thing through a virtual thing’ (GP #5), and, ‘I wouldn’t have much time to see them, track the patient. This is a big medical centre. Patients can see a lot of different doctors… You can send [patient information from apps] to the medical centre. Then at least it will be in the patient’s file’ (GP #1). To engage GPs further in the use of mobile health technologies in their routine care, GPs were asked about their preferences for receiving information and training in this area. Most GPs said that online tutorials were preferable, as they could access and complete these in their own time. A GP explained, ‘Just a link to how to use it properly, and I’ll just do it on my own phone and see what happens. I’m sure it’s pretty simple, a simple app’. (GP #10). However, some GPs preferred face-to-face training in their practice. Discussion Obtaining the perspectives of GPs on patient use of mobile health apps is vital in understanding the long-term feasibility of these electronic tools for patients’ self-management. GPs were receptive to the idea of patients using mobile apps to keep records of their health, viewing apps as complementary to their role in patient management. However, apps are yet to become a common component of routine health care delivery in primary care. This study showed that promotion of health apps to patients, such as informing patients of the availability of potentially useful apps, is currently the primary role for GPs in engaging with mobile health. However, this finding is not reflected in a recent study that showed <10% of general practice patients reported their health app use was due to promotion by their GP (8), with another survey revealing that no patients had received an app recommendation from their GP (10). GPs in this study reported that patients with a vested interest in actively monitoring their health, such as women who were trying to conceive, utilized apps. Therefore, GPs are likely to only promote apps to patients presenting with a particular need, such as a chronic condition, that could be assisted by the ‘prescription’ of a health app. In addition, app credibility and inclusion of evidence-based information increased the confidence of GPs in promoting apps to their patients, with apps viewed as a method to educate patients, as seen in other studies (7). This may be due to the potential for information recorded in health apps to prompt changes to treatment regimens (11). Health apps should therefore be rigorously evaluated before dissemination, and GPs should be made aware of, and trained in the use and benefits of, credible apps. This could enhance the role of GPs in app promotion. In addition to app promotion, GPs postulated that regular review of ‘patient-entered’ app data during medical consultations and tracking patients through a remote portal outside clinic visits were potential avenues for future growth in health app interactions. However, GPs explained that they were time poor; therefore, incorporating additional app-related tasks into their workflow would be challenging. Potential involvement of allied health practitioners such as practice nurses, especially those trained in chronic disease management, and/or community pharmacists, in app promotion and helping patients set up apps, needs to be investigated. In addition to the clinical usefulness of health apps, they can also provide a communication platform between patients and health care providers. Some GPs in this study were amenable to an app feeding back patient data to them through email or directly to their practice. Increasingly, GPs work in medical practices that have multiple GPs on site (12). Consequently, patients may not see the same GP at each practice visit, which can reduce the capacity of GPs to be personally aware of patients’ complete histories. Patients have been reported to share information gathered in health apps with GPs via printouts or using smartphones (7). Providing a structured communication channel, such as linking data entered into a health app with electronic patient files, could provide a means of ensuring GPs have access to all relevant patient data, regardless of their direct interactions with the patient. In the case of patients with chronic diseases, health apps can record medical information, such as symptoms and pathology results, between GP visits. This additional source of information would provide a more complete picture of a patient’s health status for health care providers and could lead to more personalized decision making. This would be of particular benefit to patients who live in remote areas, where GPs are not readily accessible, with apps acting to prompt GPs to provide suitable care in real time. The potential for data linkage between patient apps and medical record systems was viewed positively by GPs in this study. However, it should be noted that security issues surrounding confidential patient data could arise (10). Encryption of linked data, appropriate GP training and legislation changes may be required before data linkage between apps and GP medical software becomes routine practice (13,14). Research has shown that apps developed with patient input are more clinically effective and have better patient satisfaction ratings (15–19). The main barriers to the usefulness of apps raised by GPs were associated with technical issues. There was a perception that younger, ‘tech-savvy’ patient populations would find health apps more useful. It is important that these issues are addressed, perhaps by increased education for patients and GPs, as well as co-development of future health apps to ensure that all target populations have their needs addressed within the app, and that technical issues are identified during development. Co-development can improve longer term app utilization and effectiveness, with user-centred design employed to develop mobile health apps that are effective in chronic self-management of diabetes, asthma and cardiovascular disease (16–20). As GPs take on a larger role in patient-focused mobile health, their input into the design of apps is important. For example, feedback from GPs regarding the ease of accessing patient data on apps for review during consultations would be useful in designing a health app. Limitations This study had several limitations. GPs were only recruited from Sydney, Australia. Therefore, the results might not be generalizable to other GP populations, especially those with different health care systems. Additionally, the participants were a self-selecting sample. GP responses to the advertisement likely reflect higher levels of interest in technology-assisted health behaviour change. Also, information on GPs’ attitudes towards mobile health or their personal use of any forms of apps was not collected. Conclusions GPs continue to be encouraged to adopt health technologies into their routine practice. GP involvement in frequent and targeted promotion of health apps to patients was viewed as a feasible method to facilitate the integration of health apps into routine GP workflows. Further studies examining how health apps can improve health care delivery and patient communication in general practice are required. Information recorded by patients in their health apps could be used to improve patient–doctor communication and provide an additional source of data for GPs to use during routine consultations. GP-specific training, as well as consulting GPs in app development, may help overcome barriers to GP use and promotion of health apps. Further, understanding of how apps could complement and improve the role of GPs in patient management will facilitate the development and implementation of patient-focused mobile health apps in routine care. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: This research was funded by a National Health and Medical Research Council (NHMRC) Program Grant #1054146 and the Lexy Davies Bequest at St Vincent’s Hospital, Sydney. The funding bodies were not involved in the design and data collection of the study, or review and approval of the manuscript for publication. Ethical approval: Ethical approval for the study was obtained from The University of New South Wales Human Research Ethics Advisory Panel (reference # HC16384). Conflicts of interest: Authors declare no conflict of interest. References 1. Quinn CC , Clough SS , Minor JM , et al. WellDoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction . Diabetes Technol Ther 2008 ; 10 : 160 – 8 . Google Scholar CrossRef Search ADS PubMed 2. Swendeman D , Farmer S , Mindry D , Lee SJ , Medich M . HIV care providers’ attitudes regarding mobile phone applications and web-based dashboards to support patient self-management and care coordination: results from a qualitative feasibility study . J HIV AIDS 2016 ; 2 ( 4 ). 3. Holtz B , Lauckner C . Diabetes management via mobile phones: a systematic review . Telemed J E Health 2012 ; 18 : 175 – 84 . Google Scholar CrossRef Search ADS PubMed 4. Jordan JE , Osborne RH . Chronic disease self-management education programs: challenges ahead . Med J Aust 2007 ; 186 : 84 – 7 . Google Scholar PubMed 5. Rees F , Hui M , Doherty M . Optimizing current treatment of gout . Nat Rev Rheumatol 2014 ; 10 : 271 – 83 . Google Scholar CrossRef Search ADS PubMed 6. The Royal Australian College of General Practitioners . Views and Attitudes Towards Technological Innovation in General Practice: Survey Report 2016 . https://www.racgp.org.au/download/Documents/e-health/RACGP-Technology-Survey-2016-Results.pdf (accessed on 31 October 2017) . 7. Lippman H . How apps are changing family medicine . J Fam Pract 2013 ; 62 : 362 – 7 . Google Scholar PubMed 8. Bauer AM , Rue T , Keppel GA , et al. Use of mobile health (mHealth) tools by primary care patients in the WWAMI region Practice and Research Network (WPRN) . J Am Board Fam Med 2014 ; 27 : 780 – 8 . Google Scholar CrossRef Search ADS PubMed 9. Braun V , Clarke V . Using thematic analysis in psychology . Qual Res Psychol 2006 ; 3 : 77 – 101 . Google Scholar CrossRef Search ADS 10. Urs-Vito A , Kambiz A , Kristin I , et al. Expectancy, usage and acceptance by general practitioners and patients: exploratory results from a study in the German outpatient sector . Digit Health . 2017 ; 3 : doi:32055207617695135 . 11. Robinson PC , Taylor WJ , Dalbeth N . An observational study of gout prevalence and quality of care in a national Australian general practice population . J Rheumatol 2015 ; 42 : 1702 – 7 . Google Scholar CrossRef Search ADS PubMed 12. Bryan A . General practice: does size really count ? Med J Aust 2012 ; 197 : C7 – 8 . Google Scholar CrossRef Search ADS 13. Mohammed EA , Slack JC , Naugler CT . Generating unique IDs from patient identification data using security models . J Pathol Inform 2016 ; 7 : 55 . Google Scholar CrossRef Search ADS PubMed 14. Mandl KD , Szolovits P , Kohane IS . Public standards and patients’ control: how to keep electronic medical records accessible but private . BMJ 2001 ; 322 : 283 – 7 . Google Scholar CrossRef Search ADS PubMed 15. Cafazzo JA , Casselman M , Hamming N , Katzman DK , Palmert MR . Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study . J Med Internet Res 2012 ; 14 : e70 . Google Scholar CrossRef Search ADS PubMed 16. Lyles CR , Altschuler A , Chawla N , et al. User-centered design of a tablet waiting room tool for complex patients to prioritize discussion topics for primary care visits . JMIR Mhealth Uhealth 2016 ; 4 : e108 . Google Scholar CrossRef Search ADS PubMed 17. Matthew-Maich N , Harris L , Ploeg J , et al. Designing, implementing, and evaluating mobile health technologies for managing chronic conditions in older adults: a scoping review . JMIR Mhealth Uhealth 2016 ; 4 : e29 . Google Scholar CrossRef Search ADS PubMed 18. McCurdie T , Taneva S , Casselman M , et al. mHealth consumer apps: the case for user-centered design . Biomed Instrum Technol 2012 ; 46 (suppl): 49 – 56 . Google Scholar CrossRef Search ADS PubMed 19. Schnall R , Rojas M , Bakken S , et al. A user-centered model for designing consumer mobile health (mHealth) applications (apps) . J Biomed Inform 2016 ; 60 : 243 – 51 . Google Scholar CrossRef Search ADS PubMed 20. Woods L , Cummings E , Duff J , Walker K . Design thinking for mHealth application co-design to support heart failure self-management . Stud Health Technol Inform 2017 ; 241 : 97 – 102 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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Patients’ use of mobile health applications: what general practitioners think

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Abstract

Abstract Background Chronic disease patients are adopting self-management techniques, such as using mobile health applications (apps). As GPs are the main caregivers of chronic disease patients, obtaining GP perspectives regarding patient use of mobile health apps is vital in understanding longer term value and feasibility of these apps. Objective The aim was to determine GP perceptions of their current and potential roles in the use of health apps by their patients and how patient-focused apps affect patient management. Methods Ten GPs participated in semi-structured, face-to-face interviews, which focused on their perceptions of, and involvement in, the use of patient-focused health apps. Interviews were transcribed verbatim and thematically analysed by two independent reviewers. Results GPs found that apps complemented their role in patient management as additional sources of medical information of their patients. They perceived that patient-focused apps would be part of their future practices; however they noted that further work was required to incorporate them into their current practices. Currently, the main role of GPs was in promoting apps to patients. Suggestions for further engagement in mobile health included regularly reviewing patient data entered into health apps during consultations. Conclusion GPs view patient-focused health apps positively, particularly to support them in providing patient care. Discussing information recorded in apps during consultations and frequent promotion of apps are feasible ways to integrate apps into their current work practices. Further studies involving evaluations of apps in improving health care delivery and patient communication in general practice are required. Delivery of health care, general practice, general practitioners, mobile applications, patient participation, primary health care Introduction Chronic conditions, such as diabetes, obesity and gout, are rising in prevalence and placing great burden on patients and the health care system. Electronic self-management tools provide patients with a novel avenue to engage in management of their own health care. Self-management tools have been successfully used to help patients in self-care of chronic conditions such as diabetes and HIV (1–3). GPs are the main health care providers for patients with chronic conditions. Research indicates that patients would use an electronic self-management tool if it was recommended by their GP (4). Further, successful uptake of self-management tools is enhanced by GP promotion or suggestion and GPs’ participation in shared decision making with patients who use tools (4,5). As the use of mobile health applications (apps) by patients increases, it is important to understand the perspectives and potential roles of GPs in patient use of self-management apps. Primary care organizations are encouraging GPs to use electronic health technologies (6). This aligns with the observed rise in use of technologies in routine GP care, particularly of mobile technologies (7). GPs use health apps to aid in patient assessments, with the convenience of access to, and portability of, apps cited as encouraging their use. GPs also prescribe health apps to their technologically able patients (7). In some primary care populations, more than half of patients own a smartphone, and of these, 70% use mobile technology (8). A recent survey of Australian GPs regarding health technologies showed two-thirds of GPs had recommended a health app to a patient and nearly half had used mobile devices for patient-related work, such as engaging in patient education, or to access clinical calculators or guidelines (6). However, lack of knowledge of credible apps and their ability to provide patient benefits have been reported as barriers by GPs that prevent further adoption of mobile technologies. Increasing patient use of mobile health apps has the potential to change the way GPs deliver health care. The aim of this study was to ascertain GPs perceptions of current and potential roles in the promotion and implementation of patient-focused mobile health apps and their views on how app use can affect their workflows. Methods Recruitment GPs in metropolitan Sydney known to the research team and GPs with contact details posted on the Internet were contacted by telephone, email or fax. Approximately 120 GPs were invited to a short (20 minute) semi-structured interview about mobile health apps. Of these, 12 expressed interest in participating. Thematic saturation was achieved after 10 interviews. Participating GPs were reimbursed with a $100 gift card. Data collection Once consent was obtained, semi-structured face-to-face interviews were conducted with each GP (n = 10). Interview questions were designed to explore GP’s experiences of interacting with mobile health apps and to ascertain their current and potential roles in patient use of mobile health apps (see Supplementary Material). Interviews were audiotaped and transcribed verbatim. Investigators met periodically throughout data collection to discuss themes and reach consensus on any discrepancies. Analysis Thematic analysis was undertaken concurrently but independently by two investigators (ADN, LJF) to determine when thematic saturation occurred (9). After analysis of five transcripts, investigators convened to discuss emerging themes and developed a coding framework using an inductive approach, allowing for the most predominant themes to be identified. Emerging themes were categorized into GP perceptions of, and their role in, patient-focused health apps, perceived benefits and limitations of these apps, and potential implications for GPs of patient use of these apps. Results Participants Six female and four male GPs were recruited. The GPs practised in eight different medical practices located across four regions of Sydney, Australia. GP perceptions of mobile health apps for patients GPs stated that mobile health apps could be useful to patients, particularly those patients who actively searched for medical information and were interested in their health (Table 1). Table 1. Summary of GP perceptions of mobile health applications (apps) for patients GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs View Large Table 1. Summary of GP perceptions of mobile health applications (apps) for patients GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs GP perceptions of mobile health apps for patients Benefits Limitations Implications to GP roles and practices • Support patients in monitoring and record keeping of their health • Source of educational materials to improve patient knowledge • App use requires technological knowledge • Time demands for patients to use apps • Technical difficulties with apps • Promotion of apps to patients is GPs’ main role currently • Apps are useful and complementary to GP health care delivery, being a source of patient medical information • Mobile health apps are the way of the future for health care, but not yet integrated into GP workflows • Potential areas for further implication into GP work practices include: - More regular promotion of health apps to patients - Regular review of data in health apps during consultations - Tracking multiple patients through a remote portal - Improving communication between GPs and patients by feeding back information entered in apps to GPs View Large Perceived benefits of patient-focused apps GPs perceived that a large benefit of mobile health apps was their potential to support patients in keeping records of their own health and conditions. GPs noted that some patients were already monitoring their health using paper logs, such as handwritten medication lists. However, technological methods, such as spreadsheets, were more commonly used, with patients also reportedly using mobile apps. GPs reported that tracking menstrual cycles was the most common health reason for patients to use an app, as well as for monitoring blood pressure and blood glucose concentrations. A GP explained, ‘I find a lot of the women… monitor their menstrual cycle with apps… My hypertensive patients… they’re very obsessive people who bring spreadsheets to me’ (GP #2). Apps were perceived by GPs to be able to provide patients with useful and credible education that could improve patient knowledge about a condition. This was described by a GP as, ‘It’s a source of information that they can just go to the app for, rather than just numbers and “remember to take your medication”, it’s a bit more information… It’s a little bit more health promotion’ (GP #5). GPs said they would be more comfortable recommending an app that was evidence based and developed by a credible source. One GP described, ‘The only time I’ve ever prescribed an app is for my patients who have IBS and I suggest that they use the Monash University Low FODMAP app only because that’s the most thoroughly researched and something that is very evidence-based’ (GP #8). Perceived limitations of patient-focused apps Although GPs were generally positive about health apps, several limitations about their use were raised. Participants reported that technical difficulties, such as patients not being able to open apps due to technical faults, or apps that required Internet connection to access features were deterrents for maintaining app use. A GP described, ‘The only problem with technology is that I’ve had patients where they can’t open a certain application when they need to… I’ve had patients who say, “Oh I’ve got to show you this.” And they can’t open it and they try to. I guess it depends on reception and what’s happening with the Internet’ (GP #2). Another barrier to the wider adoption of health apps was reported to be the limited time available for patients to use apps. Also, GPs felt that the population of patients who would use and therefore benefit from apps was limited, stating that apps potentially self-selected for younger patients as they require technological knowledge. A GP explained, ‘If it’s easy to use and patients have a smartphone, then yes I think it would be quite useful, in the sort of younger population, because the older population… they’re not very computer smart… If you give them something, I don’t think the older generation would really know how to do it’ (GP #9). GPs also stated that younger patients who required help with improving their medication compliance would likely find apps more useful than older patients, as they possess the technological ability, as well as a need, to use them. Roles of GPs in patient-focused mobile health apps GPs said that while health apps have not changed the way they deliver care to their patients, apps were useful and complementary to their role as medical practitioners. In particular, GPs saw apps as a source of medical information about their patients. For example, when patients collect or track pathology results on an app, this enabled GPs to review patient results over time. A GP described, ‘Patients would record everything they have on their app, they can show it to you… Patients would take photos, which is very helpful, especially being a part-time GP, they can’t access me when they need to’ (GP #2), and another reiterated, ‘… I had seen them after six or 12 months and we wanted to have a look at all their readings, if there was a way to generate a summary for GP and then email it as a PDF, then we could scan that into their medical record, and that way the other GPs would be able to access it and make it useful’ (GP #8). GPs stated that currently their main role in the use of health apps was promotion of them to patients, with most saying they have previously promoted an app or would promote one if it were applicable to their patient. Potential implications for GPs of patient use of mobile health apps GPs stated that mobile health apps were the way of the future for health care, with one GP saying, ‘It’s going to be more and more incorporated in our [GP] practice. Personally, it’s more so being ahead, as well as being able to provide the best care that is contemporary’ (GP #5). However, it was noted that mobile health technologies were yet to be integrated into their workflow. More regular promotion of health apps to patients was suggested as an area that GPs could expand. One GP elaborated, ‘You’re going to have patients bringing in their information [on apps] and discussing results with you – it’s just what’s going to happen, so we [GPs] need to be aware of that rather than fighting it’ (GP #3). Additionally, most GPs commented that they would be amenable to more regularly reviewing data entered by patients into a mobile health app during medical consultations. A GP explained, ‘If they were achieving their goals and they were reaching their targets… a summary could be made so that they can give it to their GP when they attend for review’ (GP #8). However, GPs stated that helping a patient to set up an app during consultations would be too time-consuming. When asked about whether they would like independent access to patient information stored on health apps, GP responses were divided. Some noted that it would be beneficial to track multiple patients through a single remote portal. However, others cited limited time and additional responsibilities outside of work hours as barriers to accessing health app data independently. Using an app to improve communication between GPs and patients was raised, with GPs being in favour of information from apps being fed back to them through non-urgent communication channels, such as email. A GP explained, ‘That is definitely going to become more useful and more important in the future – patients having those records themselves… And maybe some way to link in so that you could give them some information and they could give you some information… You could somehow email the patients their results to put in their [app]… Some sort of way of linking’ (GP #4). Other GPs elaborated, ‘If it’s something that we introduce – they use it, they really liked it, then it becomes a connection or a link that if they have any questions there’s an opportunity for them to ask… It can potentially facilitate that working together thing through a virtual thing’ (GP #5), and, ‘I wouldn’t have much time to see them, track the patient. This is a big medical centre. Patients can see a lot of different doctors… You can send [patient information from apps] to the medical centre. Then at least it will be in the patient’s file’ (GP #1). To engage GPs further in the use of mobile health technologies in their routine care, GPs were asked about their preferences for receiving information and training in this area. Most GPs said that online tutorials were preferable, as they could access and complete these in their own time. A GP explained, ‘Just a link to how to use it properly, and I’ll just do it on my own phone and see what happens. I’m sure it’s pretty simple, a simple app’. (GP #10). However, some GPs preferred face-to-face training in their practice. Discussion Obtaining the perspectives of GPs on patient use of mobile health apps is vital in understanding the long-term feasibility of these electronic tools for patients’ self-management. GPs were receptive to the idea of patients using mobile apps to keep records of their health, viewing apps as complementary to their role in patient management. However, apps are yet to become a common component of routine health care delivery in primary care. This study showed that promotion of health apps to patients, such as informing patients of the availability of potentially useful apps, is currently the primary role for GPs in engaging with mobile health. However, this finding is not reflected in a recent study that showed <10% of general practice patients reported their health app use was due to promotion by their GP (8), with another survey revealing that no patients had received an app recommendation from their GP (10). GPs in this study reported that patients with a vested interest in actively monitoring their health, such as women who were trying to conceive, utilized apps. Therefore, GPs are likely to only promote apps to patients presenting with a particular need, such as a chronic condition, that could be assisted by the ‘prescription’ of a health app. In addition, app credibility and inclusion of evidence-based information increased the confidence of GPs in promoting apps to their patients, with apps viewed as a method to educate patients, as seen in other studies (7). This may be due to the potential for information recorded in health apps to prompt changes to treatment regimens (11). Health apps should therefore be rigorously evaluated before dissemination, and GPs should be made aware of, and trained in the use and benefits of, credible apps. This could enhance the role of GPs in app promotion. In addition to app promotion, GPs postulated that regular review of ‘patient-entered’ app data during medical consultations and tracking patients through a remote portal outside clinic visits were potential avenues for future growth in health app interactions. However, GPs explained that they were time poor; therefore, incorporating additional app-related tasks into their workflow would be challenging. Potential involvement of allied health practitioners such as practice nurses, especially those trained in chronic disease management, and/or community pharmacists, in app promotion and helping patients set up apps, needs to be investigated. In addition to the clinical usefulness of health apps, they can also provide a communication platform between patients and health care providers. Some GPs in this study were amenable to an app feeding back patient data to them through email or directly to their practice. Increasingly, GPs work in medical practices that have multiple GPs on site (12). Consequently, patients may not see the same GP at each practice visit, which can reduce the capacity of GPs to be personally aware of patients’ complete histories. Patients have been reported to share information gathered in health apps with GPs via printouts or using smartphones (7). Providing a structured communication channel, such as linking data entered into a health app with electronic patient files, could provide a means of ensuring GPs have access to all relevant patient data, regardless of their direct interactions with the patient. In the case of patients with chronic diseases, health apps can record medical information, such as symptoms and pathology results, between GP visits. This additional source of information would provide a more complete picture of a patient’s health status for health care providers and could lead to more personalized decision making. This would be of particular benefit to patients who live in remote areas, where GPs are not readily accessible, with apps acting to prompt GPs to provide suitable care in real time. The potential for data linkage between patient apps and medical record systems was viewed positively by GPs in this study. However, it should be noted that security issues surrounding confidential patient data could arise (10). Encryption of linked data, appropriate GP training and legislation changes may be required before data linkage between apps and GP medical software becomes routine practice (13,14). Research has shown that apps developed with patient input are more clinically effective and have better patient satisfaction ratings (15–19). The main barriers to the usefulness of apps raised by GPs were associated with technical issues. There was a perception that younger, ‘tech-savvy’ patient populations would find health apps more useful. It is important that these issues are addressed, perhaps by increased education for patients and GPs, as well as co-development of future health apps to ensure that all target populations have their needs addressed within the app, and that technical issues are identified during development. Co-development can improve longer term app utilization and effectiveness, with user-centred design employed to develop mobile health apps that are effective in chronic self-management of diabetes, asthma and cardiovascular disease (16–20). As GPs take on a larger role in patient-focused mobile health, their input into the design of apps is important. For example, feedback from GPs regarding the ease of accessing patient data on apps for review during consultations would be useful in designing a health app. Limitations This study had several limitations. GPs were only recruited from Sydney, Australia. Therefore, the results might not be generalizable to other GP populations, especially those with different health care systems. Additionally, the participants were a self-selecting sample. GP responses to the advertisement likely reflect higher levels of interest in technology-assisted health behaviour change. Also, information on GPs’ attitudes towards mobile health or their personal use of any forms of apps was not collected. Conclusions GPs continue to be encouraged to adopt health technologies into their routine practice. GP involvement in frequent and targeted promotion of health apps to patients was viewed as a feasible method to facilitate the integration of health apps into routine GP workflows. Further studies examining how health apps can improve health care delivery and patient communication in general practice are required. Information recorded by patients in their health apps could be used to improve patient–doctor communication and provide an additional source of data for GPs to use during routine consultations. GP-specific training, as well as consulting GPs in app development, may help overcome barriers to GP use and promotion of health apps. Further, understanding of how apps could complement and improve the role of GPs in patient management will facilitate the development and implementation of patient-focused mobile health apps in routine care. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: This research was funded by a National Health and Medical Research Council (NHMRC) Program Grant #1054146 and the Lexy Davies Bequest at St Vincent’s Hospital, Sydney. The funding bodies were not involved in the design and data collection of the study, or review and approval of the manuscript for publication. Ethical approval: Ethical approval for the study was obtained from The University of New South Wales Human Research Ethics Advisory Panel (reference # HC16384). Conflicts of interest: Authors declare no conflict of interest. References 1. Quinn CC , Clough SS , Minor JM , et al. WellDoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction . Diabetes Technol Ther 2008 ; 10 : 160 – 8 . Google Scholar CrossRef Search ADS PubMed 2. Swendeman D , Farmer S , Mindry D , Lee SJ , Medich M . HIV care providers’ attitudes regarding mobile phone applications and web-based dashboards to support patient self-management and care coordination: results from a qualitative feasibility study . J HIV AIDS 2016 ; 2 ( 4 ). 3. Holtz B , Lauckner C . Diabetes management via mobile phones: a systematic review . Telemed J E Health 2012 ; 18 : 175 – 84 . Google Scholar CrossRef Search ADS PubMed 4. Jordan JE , Osborne RH . 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Family PracticeOxford University Press

Published: Jun 5, 2018

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