- A recent program to have patients at a federally qualified health center use an mHealth app to manage their hypertension or diabetes failed miserably, with most of the patients abandoning the app within a couple weeks.
But while highlighting the challenges faced by healthcare providers in getting patients to use digital health tools to manage their care at home, the project offers some good lessons for future programs.
As detailed in the Journal of Medical Internet Research, the four-month project first identified 22 FQHC patients with hypertension, diabetes or both chronic conditions, then assigned them an mHealth app for managing their conditions at home. The plan was to have those patients collect their data through the app, then communicate with FQHC providers to improve care management.
But seven of the 22 patients didn’t download the app, saying they weren’t interested, didn’t have the time to learn about the app or didn’t have a mobile device. The remaining 15 who did use the app sent 139 messages to their care manager – although two patients accounted for just about half of all the messages. And most stopped sending messages after a couple weeks.
FQHC staff, meanwhile, sent 141 messages back to those patients before the program was shut down. But they, too, were dissatisfied with the process.
In interviewing both patients and staff after the program, the researchers – Kathleen Thies, RN, PhD, and Daren Anderson, MD, of the Connecticut-based Community Health Center and Weitzman Institute and Benjamin Cramer, MD, of Western Michigan University – discovered a laundry list of problems, including:
- Staff used only a 20-minute clinic visit to show the patient how to download and use the app – far too short a time period to help the patient become comfortable with the technology.
- The app didn’t fit the nurses’ workflow, forcing them and the primary care provider to move from the EHR on one screen to the app on another. Some said during the interview that the app was “one more thing to manage.”
- Patients didn’t understand what the app could do, and many tried to request medication refills through the app even though they’d been advised not to do that.
- Some patients used the app while still keeping paper logs, and told researchers the app “has become another step … one more thing.”
- Patients said they wanted the app to be “simple and easy,” but couldn’t elaborate on what that meant.
In looking back on the failed program, Thies, Anderson and Cramer said several steps should have been taken prior to launch that would have likely improved the outcomes. They include:
- Testing patients’ eHealth literacy or proficiency with technology – or even making sure they used a mobile device capable of supporting an mHealth app - before enrolling them in the program.
- Giving nurses and primary care providers more than 20 minutes to download the app, explain its functions and make sure the patient is comfortable with the technology and process.
- Either dedicating time in the nurses’ daily workflows to work with patients on the mHealth program or assigning specific staff to those patients.
- Making sure staff are comfortable with the app before assigning it to patients.
- Finding an app that integrates with the EHR.
“In general there was a poor fit between the app, the end-users, the recruitment, and the treatment approaches in our setting,” the researchers noted. “Additional usability testing might have revealed this fact prior to launch. For both patients and staff, the app became an add-on, just one more thing to attend to.”
“Lack of integration with the EHR required staff to toggle between internal and external platforms, which took time and multiple steps,” they added. “It also might have helped if staff had dedicated time to work specifically with the patients using the app; but as an unreimbursed activity, such work was not feasible. Consequently, the key feature of the app - collaboration between the healthcare team and patient - could not be achieved.”
And while the program was a failure, it does offer a valuable framework for future mHealth programs.
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“This brief trial underscores some of the pitfalls faced by providers hoping to utilize mHealth apps to improve chronic disease outcomes for some medically underserved patients,” the three researchers concluded. “Effective use of mHealth tools for clinical management requires a good fit between the app, the users’ eHealth literacy, recruitment efforts, the treatment approach, and resources, especially time and reimbursement for services.”