When physicians talk with me about apps, those conversations tend to fall into two categories. (No, not ‘glee’ and ‘horror.’) Maybe these apply to you:
- your patients are coming to you, talking/asking questions about various apps, or
- your organization uses a specific app, and you are talking to patients about that app.
So if you find yourself talking apps (or if you develop apps), and you’re concerned about what health literacy has to do with all of this, I’m here for you.
Quick glance at the field
Though consumer facing med tech can include patient portals, wearables, devices, and websites, it’s apps, delivered through smart phones, that have been getting the buzz lately. One industry insider, Cynthia Burghard, a research director with IDC Health Insights, points out that “Regardless of what one’s age is, no one goes anywhere without a mobile phone.”
Depending on what definition of mHealth you use, the numbers of apps vary. A recent statistic shows that in the Apple App Store alone, in the first quarter of 2018 there were nearly 48,000 mHealth apps. Other surveys show larger numbers.
And it’s more than apps. According to a recent Medical Group Management Association poll, 2/3 of healthcare organizations capitalize on people’s love of smart phones, and use text messages (mainly for appointment reminders).
Why people use health apps
It’s not news that most apps provide information. So patients often use health apps the same way they would use, say, a reference book. But according to another industry report, patients use health apps to:
- Share and receive info from doctors
- Comparison shop
- Tracking their own data
- For reminders or to journal
- To locate providers
Instagram, move over: 69% of mobile health users think that tracking their health and fitness on their smartphone is more important than using it for social networking or online shopping, according to the NASEM Health Literacy and Consumer-Facing Technology Workshop.
How providers and systems are responding
In my direct experience, I’m seeing a trend of patients being encouraged to do on their own time what has usually been done onsite, in the clinical encounter. For example, there’s some remote monitoring of weight or blood pressure, and some chemotherapy pumps being taken home.
I can see how different providers and patients could have different reactions to this. Overall, those who talk to me are generally happy. Patients like the convenience and control. Providers tell me they like how it opens up the workflow on the clinical side and increases patient access.
CMS is changing their tune when it comes to reimbursement, as well. Earlier this year they “unbundled” a remote patient care CPT code. According to one industry report, this is a sign of things to come. As you can imagine, with so much at stake, the lobbying has already begun.
Where health literacy comes into it
According to the 2010 version of Health.gov’s Health Literacy Online, “Roughly 1 in 3 adults has limited literacy skills; however, a far greater number of adults (as many as 9 in 10) struggle with complex health information.”
Adding to these challenges, twenty-four million Americans (8.7 percent) are not proficient in English (via HealthAffairs), the language used in most apps in the US.
A study published earlier this year indicates patient education materials continue to be written at grade levels beyond the average American’s literacy skills.
We’ve known this for at least ten years. A similar study from 2008 says Internet-based consumer health information on the top 5 medical-related causes of death in America (heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes) exceeds the USDHHS recommended reading level.
According to the IOM Designing Health Literate Mobile Apps “If mobile apps are poorly designed, they may contribute to the challenges most users face in trying to understand and act on health information—challenges that are exacerbated for users with low health literacy.” (p.1)
Steven Rush, director of the Health Literacy Innovations Program at UnitedHealth Group, told the NASEM workshop on Health Literacy and Consumer-Facing Technology in 2015:
“If we think about health literacy as something that is accessible, accurate, understandable, and easy to use, and we apply that to what we talked about today, which of the 40,000 to 50,000 [health] apps out there are good?”
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Med tech crosses social groups
Health literacy is an appropriate concern here, folks!
Sixty percent of seniors are somewhat or very likely to turn to online communities for health information, and are becoming more technically savvy on their smartphones. (NASEM workshop on Health Literacy and Consumer-Facing Technology).
And from the IOM Designing Health Literate Mobile Apps:
- Minorities are more likely to use their smartphone to access health information and track their health (Fox, 2012)
- Health-focused apps are more likely to be downloaded by African Americans and Hispanics than the white non-Hispanic population (Fox, 2011; Purcell, 2011)
What the government and professional organizations are saying
The National Institute of Health (NIH) and the American Medical Association (AMA) both recommend patient education materials be written at or below a sixth-grade reading level. The Joint Commission recommends materials be written at a fifth-grade level or lower (Grabeel et al, 2018)
Advice and guidance has been provided by the ODPHP including the Health literate care model. As I’ve already mentioned, in 2015 the NASEM convened a workshop on Health Literacy and Consumer-Facing Technology. This followed in the footsteps of the IOM Roundtable on Health Literacy’s Collaborative on New Technologies, which stated:
“We call on developers to build “health literate apps”—apps that apply both usability and health literacy strategies throughout the development process.”
The problem remains…
Though health systems, pharmaceutical companies, and health insurers are developing their own apps, app developers in general are not subject matter experts.
Catina O’Leary, president and chief executive officer of Health Literacy Missouri, points out that “One challenge lies in the fact that many of those developing apps have never heard the term ‘health literacy’ and have no idea of how to develop an app that has a foundation in health literacy.”
Here’s the good news
Tech is one powerful way to advance health literacy.
Read Holman, program director and senior advisor on internal entrepreneurship at the HHS Innovation, Design, Entrepreneurship and Action (IDEA) Lab states: “Well-designed technology can help when it conveys useful information in such a way that users do not even realize they are engaging in a learning experience. In such cases, the usage experience is so intuitive that it becomes routine and natural enough to then have an impact on behavior.”
The AHRQ makes compelling points to those who develop and purchase health IT: the increasing cultural & linguistic diversity of US population means developers who pay attention to health literacy will be broadening their potential audience.
They also argue that everyone benefits when health literacy concerns are included in development. “Higher literacy user groups also benefit from making health IT accessible to limited-literacy populations.” (p.1)
What you can do
Here are three things you can do when you next talk about an app with a patient:
1.Take small steps.
You’ve heard me say this before: start where your patient is. How well does this technology fit with what your patient is already doing? Think about this in terms of the tech in general, i.e. how do they use other apps, trackers, etc. And also consider it in terms of how your patient is already managing their condition. The key here is to take small steps, adding gradually on to what they are already doing.
2. Assume nothing.
As I’ve pointed out here, people use tech differently, and for different reasons. As tempting as it may be to jump to conclusions about what your patients knows and can do regarding tech, don’t. Just ask.
3. Stay curious!
Whatever you think of the app (as long as the info is medically accurate, of course), try to keep an open mind. From your patient’s perspective, is this app, device or website helping them live a better life? That’s as compelling reason as any to keep going.
If you’re responsible for an app or website in your organization, click here for more information.