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MobileAppsforPsychiatricNurses

ARTICLEinJOURNALOFPSYCHOSOCIALNURSINGANDMENTALHEALTHSERVICES·DECEMBER2013

ImpactFactor:0.72·DOI:10.3928/02793695-20131126-07·Source:PubMed

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BethElias

VirginiaCommonwealthUniversity

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SusanneAFogger

UniversityofAlabamaatBirmingham

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ABSTRACTMany health care professionals, including psychiatric nurs-es, are faced with increasing questions from patients about mobile applications (apps). The purpose of this article is to give psychiatric-mental health nurses (PMHNs) an overview of the world of mobile health and medical apps to answer their own questions as well as those of their patients. Mobile apps will continue to evolve; thus, this article will serve as a base for PMHNs to build knowledge and understanding to help their patients. [Journal of Psychosocial Nursing and Mental Health Services, 52(4), 42-47.]

Beth L. Elias, PhD, MS; Susanne A. Fogger, DNP, PMHNP-BC; Teena M. McGuinness, PhD, CRNP, FAAN; and Katherine R. D’Alessandro, MPH

Many health care professionals, including psychiatric-mental health nurses (PMHNs), are presented with increasing questions from pa-

tients about mobile applications (apps). This article pro-vides PMHNs an overview of the world of mobile health and medical apps to answer their own questions as well as those of their patients.

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MOBILE APPS DEFINEDMobile apps are programs or tools used with hand-held

information and communication technology (ICT) devices, such as smartphones or tablet computers, to perform specific functions. Due to their mobile nature, these apps can be used anywhere the owner is located; however, usage is limited by Internet accessibility. Apps can be used for a variety of purpos-es. As a focus of the current article, mobile health and medical apps are designed to help people track and document contribu-tors to their health (e.g., sleep, diet, exercise) or to track and document measures associated with a medical condition (e.g., hypertension or depression).

CURRENT APP DOMAINS AND META-DOMAINS Mobile health and medical apps (MA) can be sorted into

three broad and somewhat overlapping domains: (a) MAs used by consumers (i.e., patients), (b) MAs used by health care pro-fessionals, and (c) MAs intended to communicate with and/or control a device or interface with other ICT. Further, meta-domains are defined by various relationships between users/domains, depending on the app’s intended function.

For example, an app on a consumer (or patient) ICT device may communicate with an app on a health care provider’s ICT device. An example of this would be essentially a two-part app to allow for secure messaging between a provider and his or her patient. Timely communication has been shown to positively affect patients with mental health concerns (Cohn, Hunter-Reel, Hagman, & Mitchell, 2011), and such apps could pro-vide direct communication from a health care provider to a patient when negative trends are noted.

Several other meta-domains, or mobile health and MA scenarios, would also be of interest to psychiatric nurses—one being the relationship between a consumer and a larger infor-mation system or device. One example would connect data collected from a consumer’s MA to a partner app on a larger electronic medical record (EMR) system to transfer patient data for review by a provider, also perhaps transferring ap-pointment or medication reminders to the patient as part of the exchange. In the near future, apps such as this will connect consumer medical devices, such as insulin pumps, to an app that could control blood glucose levels.

Yet another meta-domain includes health care provider apps, which communicate with other apps such as EMR portals

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43Journal of Psychosocial nursing • Vol. 52, no. 4, 2014

Virtually any country that is

working to improve the health of their

population and that has smartphone

infrastructure, even sporadically, can

now access the best information literally

at their fingertips.

or appointment scheduling systems. A final meta-domain of interest to psy-chiatric nurse practitioners links the consumer, provider, and health care information technologies. Each of these domains participates in collect-ing, transmitting, and sharing patient data; provider documentation; and or-ganizational information. The impact of this meta-domain will change the nature of patient information, moving it from a single storage site and allow-ing for a more distributed and dynamic information system.

APP EXAMPLESOptimism App

Psychiatric assessment has long relied on retrospective self-reports, which are prone to distortion and in-accuracy. An alternative to retrospec-tive report is ecological momentary assessment (EMA), in which patients report reoccurring or moment-to-mo-ment phenomena, such as mood and anxiety symptoms (Hufford, Shields, Shiffman, Paty, & Balabanis, 2002). It is now possible to conduct EMA using MAs, which allow a patient to capture data describing his or her experience at the time it happens (or in the case of sleep, the next day). Because many people use smartphones on a daily ba-sis, the smartphone serves as a handy EMA tracking device. The proprietary Optimism app uses a daily mood diary that allows the individual to describe his or her mood and sleep quality and track multiple contributory factors such as negative triggers and coping strategies (Optimism Apps Pty Ltd., 2012). Although the app is free for in-dividual use, there is a subscription fee for the partner app to be used by pro-viders in working with their patients. This app is noteworthy because it in-troduces a business model that in part defines how the vendor makes money; many health apps can be expected to follow this model.

PTSD AppsApps are also being developed by

governmental agencies, such as the

National Center for Telehealth and Technology (T2) and the U.S. De-partment of Veterans Affairs (VA), to help returning veterans cope with conditions such as posttraumatic stress disorder (PTSD) (National Center for Telehealth and Technology, 2013b). Similar to the Optimism app, the T2 MoodTracker app (National Center for Telehealth and Technology, 2013c) allows the veteran to document and track his or her symptoms over time. T2 MoodTracker incorporates stress management techniques, educational material, and information on how to access support services.

The PE Coach app (short for pro-longed exposure therapy) allows the individual to review symptoms of PTSD in a normalizing way, facilitat-ing increased self-awareness and on-going individual assessment without labeling the symptoms. According to the website, PE Coach was developed by T2 in conjunction with the Veter-ans Administration’s National Cen-ter for PTSD (National Center for Telehealth and Technology, 2013a). The intended users are veterans, ac-tive duty personnel, and civilians who

are experiencing symptoms of PTSD. Although PE Coach is intended to be used as an adjunct to psychiatric treat-ment, it also serves as an educational tool by acquainting patients with the common symptoms of the diagnosis and assisting people to better under-stand the disorder.

Currently, none of these PTSD apps communicate directly with a partner provider app in the VA because of Internet security concerns; however, the tracking data could be reviewed, shared with the provider, and dis-cussed at the time of a clinic visit. The inability for the apps to “share” may encourage people with paranoia to use the apps and “choose to share” rather than have information sent directly to providers. In other words, the person with paranoia may feel safer by hav-ing the ability to control the sharing of information.

APP DOMAINS AND USESThe apps for health care provid-

ers can be grouped into four general categories. The first are apps designed by vendors to partner with consumer health apps. For example, the Op-timism app (used by an individual) partners with the Optimism Clini-cian Dashboard to allow the health care provider to monitor the self-re-ported Optimism data for a number of patients (Optimism Apps Pty Ltd., 2013). The individual patient data are uploaded to a database hosted by the vendor and then accessed by the provider through the Dashboard app. As previously noted, although the in-dividual app is free, a subscription fee is charged for the Clinician Dashboard based on the number of providers, pa-tients, or both.

Decision support and informational apps comprise a second category and can be considered MAs in that they provide data for direct patient care. Apps such as Epocrates (http://www.epocrates.com) began as applica-tions that ran on personal digital as-sistants and have now evolved to be smartphone apps. Epocrates provides a

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free app that is a basic drug reference, providing information on drug dosing, interactions, and pill identification. The basic app is free whereas a more comprehensive version of the app is available for a yearly fee. Other apps that calculate patient measures, such as body mass index, can also be used by providers at the time of a patient visit to give immediate feedback on weight trending.

Some agencies, such as the Centers for Disease Control and Prevention (CDC), are developing informational apps to deliver their content to mobile devices (http://www.cdc.gov/mobile/mobileapp.html). The available con-tent ranges from general health top-ics to more specific information on disease management and standards of care. The mobile apps provided by agencies such as the CDC allow the content to be viewed anywhere in the world where there is a mobile device or Internet connection. Such applica-tions have far-ranging implications; access to up-to-date medical data is no longer limited to the United States or even the developed world. Virtually any country that is working to im-prove the health of their population and that has smartphone infrastruc-ture, even sporadically, can now access the best information literally at their fingertips.

Health care organizations, such as insurers and health care networks, are also involved in app development so that providers can more actively examine patient data. This third cat-egory of apps allows providers to man-age patient data that are contained in larger organizational EMR systems. So-called patient portals and provider portals, initially developed for desk-top computers and web browsers, are quickly being adapted for mobile de-vices. These portals allow providers to view patient data and test results, as well as read documentation from oth-er providers, without being tied to a desktop computer. In addition to pro-vider access, patients are being given the ability to schedule appointments,

view test results, and document home measures.

The VA’s personal health care portal MyHealtheVet, one of the more successful patient por-tals, also has a mobile device app (http://www.northrupgrumman.com/capabilities/vamobile). The so-called Blue Button app developed by Northrup Grumman gives veterans the ability to access the portal when and from where they need. Pharmacies such as Walgreens are adding apps as well to allow individuals to easily make use of their prescription services (http://www.walgreens.com/topic/apps/learn_about_mobile_apps.jsp).

HOW THEY WORKThese mobile apps allow data to be

stored on the mobile device only or shared with other apps in some man-ner. Health apps and MAs often share data with provider or organizational apps by either pushing data directly to a provider app or a larger organi-zational information system. Others, such as the Optimism app, push data to a secure database hosted by the ven-dor that the provider can then access. For apps that do not connect directly to another app or system, reports can usually be generated and then shared

with others during a clinic visit or by facsimile.

For apps that share data, the mobile device will use either cell phone tech-nology or wireless Internet technology to communicate with the remote app or system. Many smart mobile devices are capable of both types of connec-tivity and will attempt to use wire-less Internet first, rolling over to cell phone technology if wireless Internet is not available. Some apps can also be configured to store data when there is no connectivity, transferring it when either cell or Internet becomes avail-able. The transfer of data and connec-tion time will contribute to the total cell phone plan minutes and/or Inter-net data limits, set by the vendor, of the smart device plan for which a pa-tient and/or provider is paying.

Users must beware of the costs asso-ciated with smart mobile device plans sold by vendors; the cell minutes and Internet data may accumulate past the allotted amount and increase the monthly charge. In the near term, the majority of vendor plans will include limits with any unlimited plans being phased out. Usage should therefore be monitored when using apps of any kind to avoid unknowingly exceeding these limits, which can result in sig-

KEYPOINTSElias, B.L., Fogger, S.A., McGuinness, T.M., & D’Alessandro, K.R. (2014). Mobile Apps for Psychiatric Nurses. Journal of Psychosocial Nursing and Mental Health Services, 52(4), 42-47.

1. Mobile health and medical applications (apps) can help individuals track and document factors that contribute to their health, such as exercise, or document measures associated with chronic conditions.

2. New risks to patient data privacy and security are arising from the explosion of apps that are populating the smart devices of nurses and their patients.

3. The U.S. Food and Drug Administration currently does not regulate these apps, but is moving to regulate mobile medical apps as medical devices.

4. Currently, no processes exist to ensure that mobile app vendors are complying with the Health Insurance Portability and Accountability Act.

Do you agree with this article? Disagree? Have a comment or questions?Send an e-mail to the Journal at jpn@healio.com.

45Journal of Psychosocial nursing • Vol. 52, no. 4, 2014

nificant additional cost. This is partic-ularly true for apps that automatically connect to other apps or services.

VENDORS AND DEVELOPERSWhere do mobile apps come from?

Mobile health and medical apps are being developed at every point in the health care delivery system, from chain pharmacies to health systems to start-up companies hoping to develop a revolutionary product.

Organizations such as the Cleve-land Clinic with its Go! To Sleep app (http://my.clevelandclinic.org/mobile-apps/go-to-sleep-app.aspx) and the government agencies’ PTSD apps are intended to reduce costs and ameliorate health outcomes through health improvement and reduction of health care utilization. Apps de-veloped by businesses such as Weight Watchers® can improve outcomes for their clients, boost their popularity, and indirectly impact profits. Gener-ally, data may be collected by the orga-nization or company for internal use, patient management, or both.

Many commercial vendors also provide apps for free, or as seen in the case of the Optimism app, free for an individual but with a monthly sub-scription fee for the provider’s match-ing app. In this business model, a regu-lar fee is charged for the professional side of the app pair and data are used for patient management. Other busi-ness models provide apps for free, or a nominal sum, and utilize data col-lected from the use of the app to target advertising to the individual.

Many apps require an agreement to Terms of Service before using them. Terms of Service can be many pages long and often written in le-gal language that the average person would find difficult to understand. With this business model, informa-tion is collected about the individual as he or she uses the app and its asso-ciated services. This information can then be used for targeted marketing either directly by the company or sold to others for marketing or product

development. It is important to be aware that with this business model the app and service provided are free to the individual, but privacy is not assured. How much the vendor can understand about an individual di-rectly drives its profit.

MOBILE APPS SPECIAL TOPICS The Regulatory Environment

In September 2012, the Feder-al Communications Commission’s (FCC) mHealth Task Force released the task force findings reporting that the FCC “should continue to play a leadership role in advancing mobile health adoption” (Goldman, Jar-rin, & Trauner, 2012, p. 5). Stating that people now expect technology and mHealth apps to be integrated into their health care, the task force put forward that mHealth will sig-nificantly change the U.S. economy. Although the task force did not di-rectly address privacy and security for mobile apps, other agencies are step-ping forward to speak to these issues; no federal or state agency is currently tasked with ensuring that vendors and other app developers take steps to protect privacy and security. Apps are currently operating in an unregulated environment (Federal Trade Commis-sion, 2012).

However, the U.S. Food and Drug Administration (FDA), which already has regulatory authority over medical devices, issued a guidance document in September 2013 for mobile medical applications. The guidance states that it is the intent of the FDA to extend its regulatory power to include certain mobile medical apps.

“The FDA is issuing this guidance document to inform manufacturers, distributors, and other entities about how the FDA intends to apply its reg-ulatory authorities to select software applications intended for use on mo-bile platforms (mobile applications or ‘mobile apps’)” (p. 4).

The guidance clarifies the types of mobile medical apps that are of par-ticular concern to the FDA, specifi-

cally these apps are ones that are “used as an accessory to a regulated medical device” or that “transform a mobile platform into a regulated medical de-vice” (p. 7).

Privacy language about the PTSD app and Health Insurance Portabil-ity and Accountability Act (HIPAA, 1996) has been added to the app web-site that indicates how regulations may work once in place (National Center for Telehealth and Technology, 2013a). The language states that while data are on an individual’s mobile de-vice those data are only as secure as the device and HIPAA does not apply. The statement goes on to clarify that HIPAA only applies to data trans-mitted or shared with a health care provider who must then comply with HIPAA.

APP PROLIFERATIONThe phrase “there’s an app for

that” is used jokingly today to refer to the explosive proliferation of apps of all kinds. Challenges now facing consumers include managing a com-plex mix of mobile devices, personal apps, and apps that they need to use for health care purposes. Each has its own learning curve, possible financial costs, and security and privacy con-cerns. As our population ages and health care becomes more patient centered, this burden on consumers could become overwhelming with each organization, provider, and as-sociated businesses requiring use of their own apps.

These challenges will also be faced by health care providers who, given the business models emerging, could incur significant financial costs from the need for a variety of subscrip-tion-based patient management and business apps. With the additional provider and organizational responsi-bility for patient care, apps will need to be verified as operating correctly and safely to mitigate legal and pa-tient risk. Managing regular updates to apps and mobile devices also has the potential to become a significant

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burden in both time and effort, par-ticularly for large organizations.

IMPLICATIONS FOR APP USE BY PSYCHIATRIC NURSING PRACTICE

Using apps in a psychiatric practice still falls in a gray area with little evi-dence to support the practice at this time. However, apps can be helpful for some patients. The use of the apps as tools can assist the patient attend to and have guided prescribed assistance with symptom management that is immediate in modifying thoughts through cognitive reappraisal. The app limitations include not being ef-fective if the patient is not as enthused about use of the app as the provider. Other limitations include the patient’s access to use the app. Some patients cannot afford smartphones or the re-quired high-speed Internet connec-tion. Those in rural areas may have limited or no signal and will be unable to benefit from use. Beyond access, the patient has to commit to daily use of the app. The selling point of app use is the instant assessment and ongo-ing monitoring. A few have reminders that prompt the user to stop and com-plete an assessment. Although the fre-quency of the prompt is set by the user, keeping up with the assessments can quickly lead to abandoning use due to a relatively static feedback. Novelty wears off quickly.

Those who use the apps may find a sense of accomplishment, as prompts provide instant responses and track progress. The current connection with providers has limited sharing of data. Some of the current psychiatric apps have options that require providers to purchase software to allow sharing so the provider may track progress as well. Apps can give providers insight into better understanding of their pa-tients’ triggers and successful coping. Yet, recent news of government access to phone records (Greenwald, 2013) may increase the concern over privacy and access to personal information.

Consider use of apps with caution especially when recommending to individuals who are suspicious of gov-ernment control. Apps may be coun-terproductive in this situation. The provider may also need to explain free apps and the current privacy concerns before the patient begins using them.

FUTURE DIRECTIONS Health care apps for mobile devices

are a new set of technologies and like any new technology offer many ben-efits and a number of risks. Perhaps the greatest benefit will be the new avenues of communication open to patients and providers. For now, the greatest risk related to mobile apps is the potential for breaches of confiden-tiality. Anyone who uses mobile apps in health care (consumers, providers and organizations) must understand that mobile medical apps should be approached with caution, the para-mount caution being that health care information is not yet fully protected. It is foreseeable that improved meth-ods of data protection will evolve and thus allow mobile medical apps to at-tain other full potential to improve patient outcomes.

REFERENCESCohn, A.M., Hunter-Reel, D., Hagman, B.T.,

& Mitchell, J. (2011). Promoting behavior change from alcohol use through mobile technology: The future of ecological mo-mentary assessment. Alcoholism: Clinical & Experimental Research, 35, 2209-2215. doi:10.1111/j.1530-0277.2011.01571.x

Federal Trade Commission. (2012). Mobile apps for kids: Disclosures still not making the grade. Retrieved from http://www.ftc.gov/os/2012/12/121210mobilekidsappreport.pdf

Goldman, J., Jarrin, R., & Trauner, D. (2012). mHealth task force findings and recommen-dations: Improving care delivery through en-hanced communications among providers, patients, and payers. Retrieved from Infor-mation Technology and Innovation Foun-dation website: http://www2.itif.org/2012-mhealth-taskforce-recommendations.pdf

Greenwald, G. (2013, June 5). NSA col-lecting phone records of millions of Ve-rizon customers daily. Retrieved

from http://www.theguardian.com/world/2013/jun/06/nsa-phone-records-verizon-court-order

Health Insurance Portability and Accountabil-ity Act, Pub.L. 104–191, 110 Stat. 1936. (1996).

Hufford, M.R., Shields, A.L., Shiffman, S., Paty, J., & Balabanis, M. (2002). Reactiv-ity to ecological momentary assessment: An example using undergraduate problem drinkers. Psychology of Addictive Behaviors, 16, 205-211.

National Center for Telehealth and Technolo-gy. (2013a). Mobile app: PE coach. Retrieved from http://www.ptsd.va.gov/public/pages/pecoach_mobileapp-public.asp

National Center for Telehealth and Technol-ogy. (2013b). PTSD coach. Retrieved from http://t2health.org/apps/ptsd-coach

National Center for TeleHealth and Tech-nology. (2013c). T2 mood tracker. Re-trieved from http://t2health.org/apps/t20mood-tracker

Optimism Clinician Dashboard [Mobile appli-cation software]. (2013). Penrith, Austra-lia: Optimism Apps Pty Ltd.

Optimism iPhone and iPad [Mobile applica-tion software]. (2012). Penrith, Australia: Optimism Apps Pty Ltd.

U.S. Food and Drug Administration. (2013). Mobile medical applications: Guidance for industry and Food and Drug Administration staff. Retrieved from http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationand G u i d a n c e / G u i d a n c e D o c u m e n t s /UCM263366.pdf

Dr. Elias is Assistant Professor, Dr. Fogger is Associate Professor, Dr. McGuinness is Professor and Interim Chair, and Ms. D’Alessandro is Pro-gram Manager I, Community Health, Outcomes and Systems, University of Alabama at Birming-ham School of Nursing, Birmingham, Alabama.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This manuscript was developed with grant funding from the Health Resources and Services Administration, U.S. Department of Health and Human Services.

Address correspondence to Beth L. Elias, PhD, MS, Assistant Professor, Community Health, Outcomes and Systems, University of Alabama at Birmingham School of Nursing, 1720 2nd Avenue South, Birmingham, AL 35294-1210; e-mail: blelias@uab.edu.

Received: June 25, 2013Accepted: September 19, 2013Posted: December 4, 2013doi:10.3928/02793695-20131126-07

47Journal of Psychosocial nursing • Vol. 52, no. 4, 2014

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