%% apa:: Chindalo, P., Karim, A., Brahmbhatt, R., Saha, N., & Keshavjee, K. (2016). Health Apps by Design: A Reference Architecture for Mobile Engagement. _International Journal of Handheld Computing Research_, _7_(2), 34–43. [https://doi.org/10.4018/IJHCR.2016040103](https://doi.org/10.4018/IJHCR.2016040103) %% # Health Apps by Design: A Reference Architecture for Mobile Engagement --- Chindalo, P., Karim, A., Brahmbhatt, R., Saha, N., & Keshavjee, K. (2016). Health Apps by Design: A Reference Architecture for Mobile Engagement. _International Journal of Handheld Computing Research_, _7_(2), 34–43. [https://doi.org/10.4018/IJHCR.2016040103](https://doi.org/10.4018/IJHCR.2016040103) ^apa --- ## Metadata title: Health Apps by Design: A Reference Architecture for Mobile Engagement author:: Pannel Chindalo, Arsalan Karim, Ronak Brahmbhatt, Nishita Saha, Karim Keshavjee cite-key:: chindalo2016HealthAppsDesign date_published:: 04/2016 url:: [http://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/IJHCR.2016040103](http://services.igi-global.com/resolvedoi/resolve.aspx?doi=10.4018/IJHCR.2016040103) doi:: [10.4018/IJHCR.2016040103](https://doi.org/10.4018/IJHCR.2016040103) keywords:: ## Abstract The mobile health (mhealth) app market continues to grow rapidly. However, with the exception of fitness apps and a few isolated cases, most mhealth apps have not gained traction. The barriers preventing patients and care providers from using these apps include: for patients, information that contradicts health care provider advice, manual data entry procedures and poor fit with their treatment plan; for providers, distrust in unknown apps, lack of congruence with workflow, inability to integrate app data into their medical record system and challenges to analyze and visualize information effectively. In this article, the authors build upon previous work to define design requirements for quality mhealth apps and a framework for patient engagement to propose a new reference architecture for the next generation of healthcare mobile apps that increase the likelihood of being useful for and used by patients and health care providers alike. ^abstract --- ## Notes > "Mobile health (mhealth) care applications are seeing a similar boom. Of the millions of apps in circulation, about 45,000 are mhealth apps (Research2guidance, 2015). More than half of these mhealth apps are new on the market. Thirteen percent of these apps were introduced in the first quarter of 2015. However, most mhealth apps are not used in healthcare despite their growing popularity (in terms of downloads) and potential medical purposes (Research2guidance, 2015)." ([Chindalo et al 2016:34](zotero://open-pdf/library/items/KAR74P5I?page=1)) While downloading mhealth apps is on the rise in popularity, it doesn't mean that users are actually using them. ([note on p.34](zotero://open-pdf/library/items/KAR74P5I?page=1)) > "Several studies have identified hurdles that challenge wide usage, including poor user interface designs, differing user literacy levels, implementation issues and organizational structures (Bailey, 2014, Boudreaux 2014; Brown 2013; Caburnay, 2015; McMillan, 2015; McCurdie," ([Chindalo et al 2016:34](zotero://open-pdf/library/items/KAR74P5I?page=1)) App adoption problems include bad ux design, user literacy, implementation problems and information architecture. ([note on p.34](zotero://open-pdf/library/items/KAR74P5I?page=1)) > "we build upon Albrecht et al.'s "synopsis for apps" in health care (Albrecht, 2014) to propose a novel reference architecture for mhealth apps that can overcome current barriers. Albrecht et al provide a comprehensive framework for mhealth app publishers to describe their compliance with a variety of pragmatic and evidence-informed criteria that are worth considering when evaluating apps." ([Chindalo et al 2016:35](zotero://open-pdf/library/items/KAR74P5I?page=2)) Look up Albrecht (2014) as another study looking at health app implementation and design. ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "We also build upon the patient engagement framework developed by Balouchi et al. that describes an enabling environment for engagement and communication between patients and providers (Balouchi, 2014)." ([Chindalo et al 2016:35](zotero://open-pdf/library/items/KAR74P5I?page=2)) Lookup Balouchi as second paper about engagement and communication between patients and providers ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "we propose an architecture for mhealth apps that arranges the critical functions identified in order to accomplish the following: (a) capture, validate and communicate data about the processes and outcomes of a disease; and (b) enable ongoing communication during treatment to enhance the patient-care provider relationship and ensure patients get the support they need to implement the advice and interventions prescribed by their health care provider." ([Chindalo et al 2016:35](zotero://open-pdf/library/items/KAR74P5I?page=2)) The main proposal of the paper. ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "We used a gap analysis that drew on philosophy, data science, education, life science and business analyses methods to develop a concept that would overcome the constraints and meet the goals identified in the introduction." ([Chindalo et al 2016:35](zotero://open-pdf/library/items/KAR74P5I?page=2)) The method was a multidisciplinary review of the literature ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "Other than fitness tracker apps and some tethered apps provided by insurance companies and by integrated delivery systems, most mhealth apps in app stores have not gained much traction (Research2guidance, 2015)." ([Chindalo et al 2016:35](zotero://open-pdf/library/items/KAR74P5I?page=2)) Unless a fitness app or tied to health insurance, health apps are not gaining usage ground. ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "We hypothesize that this is due to multiple factors: a) apps may provide information that conflicts with information received from health care providers (Bierbrier, Lo & Wu, 2014); b) the language and terminology of the app may not be compatible with the patient's health literacy (Caburnay, 2015); c) the patient has to enter the data himself or herself (Gruman, 2013); d) the patient has no way to use the information in a meaningful way; e.g., they cannot order diagnostic testing for or prescribe medications to themselves; e) daily use of the app is not required for most diseases and therefore the patient does not get into the habit of using it; f) lack of incentives to use, such as cost savings or social approval; g) providers may not value or use the data collected by patients in apps downloaded from an app store whose provenance and pedigree is not known or established (Terry, 2015); h) there is no way for providers to consume (i.e., visualize, analyze, derive meaning from) the large amounts of data that are collected in apps (Terry, 2015) and i) there is no way for providers to integrate the app data into their own electronic medical record system (EMR) for analysis or follow-up or share the data in their EMR with their patient's apps (Abebe, 2013)." ([Chindalo et al 2016:36](zotero://open-pdf/library/items/KAR74P5I?page=3)) Reasons for low adoption (hypothesis): 1. conflicting information in app as compared to HCP. 2. Language barrier for patient as in not in an accessible layperson’s terms 3. Not automated. Data entry onus is on the patient. 4. Data is not actionable by the patient 5. No habit formation is app is not used frequently. 6. No incentivization 7. Data is not trusted or used by HCP. 8. Data is siloed and does not easily merge into EMR. ([note on p.35](zotero://open-pdf/library/items/KAR74P5I?page=2)) > "Patients and healthcare providers have for centuries operated in a relationship that demonstrates trust, skills, dependence and knowledge. Yet, most mhealth apps try to avoid getting entangled in this relationship. It would be helpful to introduce mhealth apps into the patient and health provider relationship (Edelman & Singer, 2015)." ([Chindalo et al 2016:36](zotero://open-pdf/library/items/KAR74P5I?page=3)) Health apps have ignored the fundamental relationship between patient and HCP. ([note on p.36](zotero://open-pdf/library/items/KAR74P5I?page=3)) > "A patient and health provider relationship is important for patients to understand the difference between a gadget for entertainment and a tool for improving health." ([Chindalo et al 2016:36](zotero://open-pdf/library/items/KAR74P5I?page=3)) Context matters. The patient and HCP relationship helps to separate the device from entertainment and something to improve one’s health. ([note on p.36](zotero://open-pdf/library/items/KAR74P5I?page=3)) > "In order to gain acceptance, mhealth apps need to be designed to enter, meet, and enhance the patient and the health provider relationship. A patient and a health provider relationship is based on trust and skills, as such apps should be designed in a way that they could become valuable resources that fill-in the gaps in knowledge and support in a patient-provider relationship." ([Chindalo et al 2016:37](zotero://open-pdf/library/items/KAR74P5I?page=4)) A critical point about the patient and healthcare provider relationship. It’s based on trust and skills, so apps should reflect that. ([note on p.37](zotero://open-pdf/library/items/KAR74P5I?page=4)) > "The task of advising patients to perceive apps as a form of "prescription" in order to enhance treatment and communicate a sense of accountability depends on the health providers' willingness to use apps. Patients are likely to associate an mhealth app as a treatment plan when health providers introduce to it to them in that way. Educating healthcare providers about how an app meets the scientific standards of measurements and demonstrating how user-friendly designs account for their diverse clientele's educational levels and age groups is crucial to their acceptance." ([Chindalo et al 2016:37](zotero://open-pdf/library/items/KAR74P5I?page=4)) For the patient to buy in to the app, the healthcare provider needs to buy into the app. Prove the trustworthiness of the app for the healthcare provider and educate them how to work with patients with it. ([note on p.37](zotero://open-pdf/library/items/KAR74P5I?page=4)) > "Licensed health providers have considerable moral and psychological influence within the patient-provider relationship to rebrand and introduce mhealth apps as critical communication devices during monitoring or treatment phases." ([Chindalo et al 2016:38](zotero://open-pdf/library/items/KAR74P5I?page=5)) In the relationship, the healthcare provider has influence in terms of the app use and acceptance. ([note on p.38](zotero://open-pdf/library/items/KAR74P5I?page=5)) > "Inherent within the patient-provider relationship, there is a power and information asymmetry. Physicians have access to and control access to information generated by the health system, such as laboratory results, specialist reports, imaging reports and other health care data. Introducing mhealth apps in this relationship could empower patients and health providers in ways that could improve health care systems." ([Chindalo et al 2016:38](zotero://open-pdf/library/items/KAR74P5I?page=5)) Health apps have the possibility to change the power imbalance in the healthcare provider and patient relationship. An app can empower the patient. ([note on p.38](zotero://open-pdf/library/items/KAR74P5I?page=5)) > "In contrast, most healthcare providers are likely to be persuaded if apps were to embrace age-old cultural norms and values of the patient-provider relationship, core scientific methods of using validated measures in order to have confidence in the measurements that apps generate and interoperability that ensures two way communications." ([Chindalo et al 2016:41](zotero://open-pdf/library/items/KAR74P5I?page=8)) An interesting note that healthcare providers would embrace apps if they intern embraced age old cultural norms and values of the patient provider relationship. ([note on p.41](zotero://open-pdf/library/items/KAR74P5I?page=8))