Health apps and how to evaluate them: Review of the PHE 2016 conference, part two

suchita_shahEmbedded in the NHS Five Year Forward View is a sleek, bullet pointed ministerial promise: “an expanding set of NHS accredited health apps that patients will be able to use to organise and manage their own health and care.” Whatever your views might be on ministerial promises, it’s definitely true that digital technology is making its way into mainstream public health. In my previous blog, a roundup of several sessions at the Public Health England (PHE) annual conference, I wrote about how digital technology is partnering with behavioural science to influence the health choices we make. Here, I’ll share what I learned about health apps.

Health apps to measure, record, nudge, and influence
PHE has articulated a need for digital health products (“apps”) to help people take personal responsibility for their health, improve efficiency in NHS care pathways, and meet demands on the NHS. Population level measures are expanding from primary prevention to self-care in long term conditions. Correspondingly, health apps have shifted from merely raising awareness of the need to change to supporting people to actually change.

They can do this in a number of ways. Apps can collect, share, and feed back  information, adapting as people exhibit different levels of sickness. An example discussed at the conference was StopAdvisor, an internet based, “automated adviser” that was subsequently developed into an app that helps low socioeconomic status (SES) smokers to quit. According to Professor Susan Michie from UCL, it was developed based on four elements: evidence on the efficacy of particular interventions, web design, person centredness, and behaviour change theory. This method, it seems, is not the norm because most app developers rarely draw on the science.

Sorting the wheat from the chaff: app accreditation
With around 200 000 apps, the digital health landscape is a complex one, in which we need some clarity about what is a good product. The PHE team, we were told, commissioned a systematic review of app accreditation methodologies currently in use, which concluded that there were, well, none. The same review, which evaluated 47 smoking cessation apps, also reported that the more popular apps (higher display ranking in the store) were of lower quality (conformed less well to relevant guidelines). It concluded that the health apps market is not working.

Cue an interesting initiative led by the National Information Board, which brings together PHE, NHS England, NHS Digital, and the National Institute for Health and Care Excellence (NICE), among others. It aims to accredit specific apps using recommended methodologies, so that health apps with a solid evidence base will be promoted and used. The endorsement model involves three stages: firstly, self-assessment against a range of criteria (for example, effectiveness, safety, equality, usability); secondly, community evaluation (for example, by health and IT practitioners, the third sector); and, finally, an expert evaluation by NICE, to include considerations such as cost effectiveness. This is all still in the development stages, but the idea is to have an NHS rubber stamped library of apps accessible to clinicians and the general public.

Future considerations
When it comes to technology, are you an early adopter or a laggard? Maybe you’re the innovator. Each group within the spectrum has its value, and the conference raised a number of questions and thoughts about the consequences of some of these digital interventions. For example: you have the data, but what will you do with it? How do you transform a bunch of apps into better health outcomes? What about information governance and regulation? Who do you trust more with your data—the commercial sector or the NHS? There are also logistical considerations, for example, about data storage and technology becoming obsolete. There’s the essential question of how to measure effectiveness; and then there’s the human element. How will technology truly capture the human experience? What about user boredom or unintended harms? What about unhealthy influences competing for the same digital space?

The process of developing and accrediting digital health products will be an iterative one, and you can’t think of every possible outcome at the start, but it’s reassuring that people are trying. In fact, to help us navigate the subject, there’s an A-Z of Digital Public Health, an online lexicon of often ordinary words that have marvellously taken on new, digitally oriented meanings: words such as “agile,” “waterfall,” “scrum,” and—my favourite—”retirement.”

Final thoughts
The developments discussed at the conference subvert the view that technology makes us inactive and unhealthy. But neither should it be regarded as a quick fix cure for the nation’s ills. It’s up to us to decide how we use technology, and if we can use it to influence behaviour that improves health, particularly where health practitioners can’t extend their reach, then that seems like a good thing. “Evidence into Action” was the theme of this year’s conference, and to make that work for digital health—to keep it real and joined-up—end users and health practitioners really need to be involved in this conversation.

Many thanks to Dr Mary E Black, head of strategy, digital, PHE; Mr. Simon Dixon, mobile strategy lead, PHE; and all the speakers. The interpretations and views expressed here are my own.

Suchita Shah (@SuchitaShahUK) is a portfolio GP in Oxford, UK. She also holds degrees in public health and international relations. Her professional interests include general practice, public health, global health, medical education, writing, editing, photography, and the arts.

Competing interests: Nothing further to declare.