Mobile health applications for asthma

Abstract

Clinical Implications•Many mobile health apps are available for asthma and have great potential to improve care for asthma. Nevertheless, measurements of quality and effectiveness and explanations of privacy risks are needed to help individuals choose the most appropriate apps.Asthma affects 300 million people in the world,1FastStats: Asthma. Centers for Disease Control and Prevention/National Center for Health Statistics; 2014. Available from http://www.cdc.gov/nchs/fastats/asthma.htm. Accessed April 25, 2014.Google Scholar and individuals with asthma are increasingly turning to mobile health to help with asthma management. Mobile health, or mHealth, refers to mobile computing, medical sensor, and communications technologies that can enhance chronic disease care.2mHealth—Mobile Health Technologies. National Institutes of Health, Ofice of Behavioral and Social Sciences Research; 2014. Available from http://obssr.od.nih.gov/scientific_areas/methodology/mhealth. Accessed April 23, 2014.Google ScholarThe number of medical apps has greatly increased over the past decade. As of 2012, there were more than 13,000 health care-related apps available to Apple iPhone users and more than 6,000 available in the Android store.3Dolan B. Just launched: Our 2012 Consumer Health Apps Report. MobiHealthNews; 2012. Available from http://mobihealthnews.com/17925/just-launched-our-2012-consumer-health-apps-report/. Accessed April 23, 2014.Google Scholar It is becoming common for patients to ask their physicians to help them choose apps, but many physicians do not feel confident in recommending apps to patients.4Eng D.S. Lee J.M. The promise and peril of mobile health applications for diabetes and endocrinology.Pediatr Diabetes. 2013; 14: 231-238Crossref PubMed Scopus (162) Google Scholar In this letter, we provide an overview of the types of apps that are currently available to aid patients with asthma. The apps reviewed are not endorsements of app quality.We focused our review on the 2 most popular smartphone brands, the Apple iPhone and Google Android, which, as of February 2014, comprised more than 90% of the U.S. smartphone market.5Jones C. Apple's U.S. smartphone market share holding steady against every competitor. Forbes; 2014. Available from http://www.forbes.com/sites/chuckjones/2014/04/07/apples-u-s-smartphone-market-share-holding-steady-against-every-competitor/. Accessed December 10, 2014.Google Scholar To identify asthma-related mobile apps, we used the general search bar in the iTunes store (for the iPhone) and Google Play (for the Android). We conducted our searches in April 2014 and separately entered the following search terms to identify apps that were related to asthma: “asthma,” “pulmonary,” and “inhaler.” We used the descriptions provided by app creators to confirm app relevance to asthma management and categorize apps. If an app served multiple functions, we grouped the app according to its primary category. In Table I, we present the number of apps in each category and subcategory. We did not include non-English apps and apps that were not specific to asthma in our results. In Table II, we provide examples of asthma-related apps and their functions, available devices, and prices. A complete, categorized list of all apps can be found in the Online Repository of this article at www.jaci-inpractice.org. Of 209 total distinct asthma-related apps, 50% (n = 105) were available for Android, 34% (n = 71) for iPhone, and 16% (n = 33) for both devices. The apps available for iPhone are also available for iPad. We did not include an assessment of the Galaxy app store as there is currently only one available app for asthma. Over half (58%, n = 122) of apps were free and 39% (n = 81) were paid. The paid apps ranged in cost from $0.99 to $29.99, and some (3%, n = 7) had free but less comprehensive versions available. The remaining 2% of apps (n = 6) were free to download, but required a paid subscription to access all features, required the purchase of an external device, or were demo versions of paid apps or software applications.Table ICategories of asthma-related apps, grouped according to specific functions (N = 209)CategoriesNo. of appsPercent of totalTeaching/training10952% Alternative treatments42 General information24 Treatment information18 Child-directed9 Food additives9 Parent-directed7Tracking and visualization of health information4722% Symptom tracking22 Medication use18 Tools/calculators7Medical provider-directed apps3718% Reference18 Trainee-directed10 Tools/calculators6 Journals3Air quality information126% General8 Location-specific4Social forums42% Emergency3 Community support1 Open table in a new tab Table IIExamples of apps in each category. A full list is provided in the Online Repository at www.jaci-inpractice.orgNameCostDevice (iPhone/Android)DescriptionApps for teaching and training Asthma Control Tips$10.10AndroidProvides information about yoga and breathing exercises for controlling asthma. Homeopathy for AsthmaFreeAndroidProvides information about homeopathic asthma treatments. iAsthma in Control$0.99iPhoneDesigned to teach children to take their medication and learn the symptoms that may precede an asthma attack. Option to create a personalized asthma “rescue plan” and enter emergency contacts. Allows parents to record peak flow and email forms for school or sports to the child's doctor.Apps for tracking and visualizing health information AsthmaMDFreeiPhoneAllows users to log asthma symptoms, visualize asthma in graphical format, track medications, map peak flow to severity zones, and track asthma triggers. Can share asthma diary and graph with health care professionals. Inhaler Tracker$0.99iPhoneTracks and records inhaler use. Patients enter data. Displays remaining medication in each inhaler to notify patients of when the inhaler needs replacing. Asthma Tracker & Log Multiuser$1.49AndroidTracks peak flow, and asthma attack frequency, length, location, trigger, and treatment for multiple users.Medical provider-directed apps Miniatlas Asthma$1.99 (iPhone)/$2.99 (Android)BothAssists health practitioners in communicating with patients to help them understand their asthma. Provides images and explanations of the disease. iGuidelinesFreeiPhoneProvides medical professionals with point-of-care access to interactive guidance for select pediatric conditions, including asthma. ERres$3.99AndroidContains calculators, medication lists, algorithms, decision rules, clinical polices, and core content for emergency care providers. Includes information about asthma treatment and predicted peak flow rates.Apps providing air quality information Air Quality Pro$0.99iPhoneProvides Air Quality Index for U.S. locations. State of the AirFreeAndroidProvides air quality information for users' location. Includes ozone and particulate pollution counts as well as air quality alerts. iSmogFreeiPhoneDisplays air quality information for the San Francisco Bay area. Optional push notification alerts indicating when the air contains unhealthy levels of certain contaminants.Social forums OneHealthFreeAndroidAllows users with asthma and other chronic diseases to join health communities and connect with peers. HelpAroundFreeAndroidAllows users to locate nearby users with similar symptoms. Designed for use during emergencies, or to receive help or advice. Open table in a new tab The largest proportion of asthma-related apps (52%, n = 109) focus on teaching and training in techniques related to managing asthma. Most of these apps (39%, n = 42) teach users alternative methods for treating asthma, such as yoga postures, acupressure, and breathing exercises. Many apps (22%, n = 24) provide general information about asthma through text, video, and/or audio formats. Other apps (17%, n = 18) provide treatment information; for example, some demonstrate an inhaler technique. We identified 8% (n = 9) of apps with child-friendly interfaces designed to improve medication adherence and teach children how to manage their asthma through games or quizzes.Approximately 22% (n = 47) of asthma apps allow users to track and display health information. Most apps (47%, n = 22) in this category are designed to help users monitor symptoms by logging peak flow and recording details about asthma attacks. Many apps (38%, n = 18) focus on medication use, which allows users to track inhaler use, set medication reminders, and monitor adherence.Approximately 18% (n = 37) of apps are directed at health care providers rather than patients. Most apps in this category (49%, n = 18) provide medical reference information, whereas some (27%, n = 10) teach medical trainees lung sounds and general information about asthma and allergies. Approximately 6% (n = 12) of apps provide users with air quality information. Most of these apps (67%, n = 8) allow users to enter their location, whereas the rest (33%, n = 4) are directed at residents of a specific city. The remaining 2% (n = 4) of apps serve as social forums, which connect users with other asthma patients (25%, n = 1) and provide advice and emergency assistance (75%, n = 3).The large number of available apps most likely mimic the interest in apps for asthma. Because self-management in assessing symptoms and adhering to medication regimens is especially important, individuals with asthma may be particularly interested in apps that offer help with symptom monitoring or adherence to medical regimens. Nevertheless, there is no accepted measure of app quality, and most apps are not regulated or approved by the Federal Drug Administration (FDA). Mobile medical apps that the FDA would regulate include apps that transform a mobile platform into a regulated medical device; connect to an existing device for purposes of controlling its operation, function, or energy source; and display, transfer, store, or convert patient-specific medical device data from a connected device.6Examples of MMAs the FDA RegulatesU.S. Food and Drug Administration.2014Google Scholar Thus, it is difficult for patients to know which apps offer legitimate clinical advice, have demonstrated utility to improve any health care measure, or are ideally suited to help them manage their or their children's asthma. Some independent organizations have noted this knowledge gap and are starting efforts to create formal reviews for medical apps.In order for providers to recommend apps to their patients, efficacy and effectiveness evaluations are necessary; however, few such evaluations are currently available. A Cochrane review of smartphone and tablet self-management apps for asthma in 2013 found only 2 trials of phone-based asthma self-management interventions that included randomized controlled trials to assess for efficacy.7Marcano Belisario J.S. Huckvale K. Greenfield G. Car J. Gunn L.H. Smartphone and tablet self management apps for asthma.Cochrane Database Syst Rev. 2013; 11: CD010013PubMed Google Scholar The authors deemed the utility of apps to be inconclusive and were unable to advise clinicians and the general public on the efficacy on apps for asthma self-management.7Marcano Belisario J.S. Huckvale K. Greenfield G. Car J. Gunn L.H. Smartphone and tablet self management apps for asthma.Cochrane Database Syst Rev. 2013; 11: CD010013PubMed Google Scholar Studies that include diverse asthma patients and providers, are designed to randomize interventions, and measure helpful patient-centered, as well as clinically relevant, outcomes are needed to determine which apps are truly helpful and should be recommended to patients.In addition to requiring demonstrated clinical efficacy and providing scientifically sound advice, apps must also ensure data privacy and security before health care providers feel comfortable recommending them. The health visualization and tracking group of apps, for which individuals can enter personal data to monitor symptoms, log peak flow, and more, is the category most vulnerable for loss of privacy or possible unwanted disclosure of personal health information. A previous study that systematically assessed availability of privacy statements for the most commonly used apps found that only 30% had privacy statements that addressed whether entered information could be shared with third parties.8Sunyaev A, Dehling T, Taylor PL, Mandl KD. Availability and quality of mobile health app privacy policies. J Am Med Inform Assoc [epub August 3, 2014] http://dx.doi.org/10.1136/amiajnl-2013-002605.Google ScholarIn conclusion, as the number of apps made available continues to increase and agencies such as the FDA become involved in their regulation, the mHealth landscape will continue to change. Although apps have great potential to improve care for asthma, most are currently limited by their inability to demonstrate quality, effectiveness, and protection of user data. Clinical Implications•Many mobile health apps are available for asthma and have great potential to improve care for asthma. Nevertheless, measurements of quality and effectiveness and explanations of privacy risks are needed to help individuals choose the most appropriate apps. •Many mobile health apps are available for asthma and have great potential to improve care for asthma. Nevertheless, measurements of quality and effectiveness and explanations of privacy risks are needed to help individuals choose the most appropriate apps. •Many mobile health apps are available for asthma and have great potential to improve care for asthma. Nevertheless, measurements of quality and effectiveness and explanations of privacy risks are needed to help individuals choose the most appropriate apps. Asthma affects 300 million people in the world,1FastStats: Asthma. Centers for Disease Control and Prevention/National Center for Health Statistics; 2014. Available from http://www.cdc.gov/nchs/fastats/asthma.htm. Accessed April 25, 2014.Google Scholar and individuals with asthma are increasingly turning to mobile health to help with asthma management. Mobile health, or mHealth, refers to mobile computing, medical sensor, and communications technologies that can enhance chronic disease care.2mHealth—Mobile Health Technologies. National Institutes of Health, Ofice of Behavioral and Social Sciences Research; 2014. Available from http://obssr.od.nih.gov/scientific_areas/methodology/mhealth. Accessed April 23, 2014.Google Scholar The number of medical apps has greatly increased over the past decade. As of 2012, there were more than 13,000 health care-related apps available to Apple iPhone users and more than 6,000 available in the Android store.3Dolan B. Just launched: Our 2012 Consumer Health Apps Report. MobiHealthNews; 2012. Available from http://mobihealthnews.com/17925/just-launched-our-2012-consumer-health-apps-report/. Accessed April 23, 2014.Google Scholar It is becoming common for patients to ask their physicians to help them choose apps, but many physicians do not feel confident in recommending apps to patients.4Eng D.S. Lee J.M. The promise and peril of mobile health applications for diabetes and endocrinology.Pediatr Diabetes. 2013; 14: 231-238Crossref PubMed Scopus (162) Google Scholar In this letter, we provide an overview of the types of apps that are currently available to aid patients with asthma. The apps reviewed are not endorsements of app quality. We focused our review on the 2 most popular smartphone brands, the Apple iPhone and Google Android, which, as of February 2014, comprised more than 90% of the U.S. smartphone market.5Jones C. Apple's U.S. smartphone market share holding steady against every competitor. Forbes; 2014. Available from http://www.forbes.com/sites/chuckjones/2014/04/07/apples-u-s-smartphone-market-share-holding-steady-against-every-competitor/. Accessed December 10, 2014.Google Scholar To identify asthma-related mobile apps, we used the general search bar in the iTunes store (for the iPhone) and Google Play (for the Android). We conducted our searches in April 2014 and separately entered the following search terms to identify apps that were related to asthma: “asthma,” “pulmonary,” and “inhaler.” We used the descriptions provided by app creators to confirm app relevance to asthma management and categorize apps. If an app served multiple functions, we grouped the app according to its primary category. In Table I, we present the number of apps in each category and subcategory. We did not include non-English apps and apps that were not specific to asthma in our results. In Table II, we provide examples of asthma-related apps and their functions, available devices, and prices. A complete, categorized list of all apps can be found in the Online Repository of this article at www.jaci-inpractice.org. Of 209 total distinct asthma-related apps, 50% (n = 105) were available for Android, 34% (n = 71) for iPhone, and 16% (n = 33) for both devices. The apps available for iPhone are also available for iPad. We did not include an assessment of the Galaxy app store as there is currently only one available app for asthma. Over half (58%, n = 122) of apps were free and 39% (n = 81) were paid. The paid apps ranged in cost from $0.99 to $29.99, and some (3%, n = 7) had free but less comprehensive versions available. The remaining 2% of apps (n = 6) were free to download, but required a paid subscription to access all features, required the purchase of an external device, or were demo versions of paid apps or software applications. The largest proportion of asthma-related apps (52%, n = 109) focus on teaching and training in techniques related to managing asthma. Most of these apps (39%, n = 42) teach users alternative methods for treating asthma, such as yoga postures, acupressure, and breathing exercises. Many apps (22%, n = 24) provide general information about asthma through text, video, and/or audio formats. Other apps (17%, n = 18) provide treatment information; for example, some demonstrate an inhaler technique. We identified 8% (n = 9) of apps with child-friendly interfaces designed to improve medication adherence and teach children how to manage their asthma through games or quizzes. Approximately 22% (n = 47) of asthma apps allow users to track and display health information. Most apps (47%, n = 22) in this category are designed to help users monitor symptoms by logging peak flow and recording details about asthma attacks. Many apps (38%, n = 18) focus on medication use, which allows users to track inhaler use, set medication reminders, and monitor adherence. Approximately 18% (n = 37) of apps are directed at health care providers rather than patients. Most apps in this category (49%, n = 18) provide medical reference information, whereas some (27%, n = 10) teach medical trainees lung sounds and general information about asthma and allergies. Approximately 6% (n = 12) of apps provide users with air quality information. Most of these apps (67%, n = 8) allow users to enter their location, whereas the rest (33%, n = 4) are directed at residents of a specific city. The remaining 2% (n = 4) of apps serve as social forums, which connect users with other asthma patients (25%, n = 1) and provide advice and emergency assistance (75%, n = 3). The large number of available apps most likely mimic the interest in apps for asthma. Because self-management in assessing symptoms and adhering to medication regimens is especially important, individuals with asthma may be particularly interested in apps that offer help with symptom monitoring or adherence to medical regimens. Nevertheless, there is no accepted measure of app quality, and most apps are not regulated or approved by the Federal Drug Administration (FDA). Mobile medical apps that the FDA would regulate include apps that transform a mobile platform into a regulated medical device; connect to an existing device for purposes of controlling its operation, function, or energy source; and display, transfer, store, or convert patient-specific medical device data from a connected device.6Examples of MMAs the FDA RegulatesU.S. Food and Drug Administration.2014Google Scholar Thus, it is difficult for patients to know which apps offer legitimate clinical advice, have demonstrated utility to improve any health care measure, or are ideally suited to help them manage their or their children's asthma. Some independent organizations have noted this knowledge gap and are starting efforts to create formal reviews for medical apps. In order for providers to recommend apps to their patients, efficacy and effectiveness evaluations are necessary; however, few such evaluations are currently available. A Cochrane review of smartphone and tablet self-management apps for asthma in 2013 found only 2 trials of phone-based asthma self-management interventions that included randomized controlled trials to assess for efficacy.7Marcano Belisario J.S. Huckvale K. Greenfield G. Car J. Gunn L.H. Smartphone and tablet self management apps for asthma.Cochrane Database Syst Rev. 2013; 11: CD010013PubMed Google Scholar The authors deemed the utility of apps to be inconclusive and were unable to advise clinicians and the general public on the efficacy on apps for asthma self-management.7Marcano Belisario J.S. Huckvale K. Greenfield G. Car J. Gunn L.H. Smartphone and tablet self management apps for asthma.Cochrane Database Syst Rev. 2013; 11: CD010013PubMed Google Scholar Studies that include diverse asthma patients and providers, are designed to randomize interventions, and measure helpful patient-centered, as well as clinically relevant, outcomes are needed to determine which apps are truly helpful and should be recommended to patients. In addition to requiring demonstrated clinical efficacy and providing scientifically sound advice, apps must also ensure data privacy and security before health care providers feel comfortable recommending them. The health visualization and tracking group of apps, for which individuals can enter personal data to monitor symptoms, log peak flow, and more, is the category most vulnerable for loss of privacy or possible unwanted disclosure of personal health information. A previous study that systematically assessed availability of privacy statements for the most commonly used apps found that only 30% had privacy statements that addressed whether entered information could be shared with third parties.8Sunyaev A, Dehling T, Taylor PL, Mandl KD. Availability and quality of mobile health app privacy policies. J Am Med Inform Assoc [epub August 3, 2014] http://dx.doi.org/10.1136/amiajnl-2013-002605.Google Scholar In conclusion, as the number of apps made available continues to increase and agencies such as the FDA become involved in their regulation, the mHealth landscape will continue to change. Although apps have great potential to improve care for asthma, most are currently limited by their inability to demonstrate quality, effectiveness, and protection of user data. AppendixOnline RepositoryComprehensive list of asthma-related mobile apps on the Apple and Android marketplaces (as of April 2014)CostCategorySubcategoryiPhone/AndroidDescriptionAir Quality ForecastFreeAir Quality InformationGeneraliPhoneProvides Air Quality Index for U.S. locationsAir Quality Pro$0.99Air Quality InformationGeneraliPhoneProvides Air Quality Index for U.S. locationsAsthMasterFreeAir Quality InformationGeneraliPhoneProvides air quality for current locationBreatheFreeAir Quality InformationGeneraliPhoneShows users the current air quality in their areaMyAQIFreeAir Quality InformationGeneralBothProvides real-time air quality information based on the closest monitoring site. Allows for personalization of Air Quality Index reported to users' particular health concerns, including asthmaPollen.com's Allergy AlertFreeAir Quality InformationGeneralBothTracks pollen and allergy forecast, asthma index, and UV index for U.S. locationsSmog ReportFreeAir Quality InformationGeneraliPhoneProvides real-time air quality information from the Environmental Protection AgencyState of the AirFreeAir Quality InformationGeneralAndroidProvides air quality information for users' location. Includes ozone and particulate pollution counts as well as air quality alertsAlberta Air Quality Health IndexFreeAir Quality InformationLocation-SpecificiPhoneProvides air quality information for residents of AlbertaAQMDFreeAir Quality InformationLocation-SpecificBothProvides air quality data for residents of southern California. Lists air quality events and provides information on air quality newsGood Days San DiegoFreeAir Quality InformationLocation-SpecificAndroidDesigned for residents of San Diego, Calif, with allergies, asthma, and autoimmune diseases to track their symptoms and track air quality in San DiegoiSmogFreeAir Quality InformationLocation-SpecificiPhoneDisplays air quality information for the San Francisco Bay area. Optional push notification alerts indicating when the air contains unhealthy levels of certain contaminantsAmerican Thoracic Society Journals AppFree w/subscriptionPhysician-Directed AppsJournalsiPhoneContains abstracts and articles from the official journals of the American Thoracic Society. Includes hyperlinks to additional information and resourcesERS PublicationsFreePhysician-Directed AppsJournalsiPhoneContains articles from the European Respiratory JournalPulmCCM.orgFreePhysician-Directed AppsJournalsBothReviews and summarizes articles from more than 30 medical journals related to pulmonary and critical care medicine. Provides access to most recent guidelines from major medical societies and professional organizations. Provides regular practice updates for respiratory conditions and critical illnessesAsthmaFreePhysician-Directed AppsReferenceAndroidHelps clinicians, researchers, and patients stay informed about the latest news, publications, and research in the field of asthmaAsthma @Point of CareFreePhysician-Directed AppsReferenceiPhoneProvides medical professionals with information on the diagnosis, treatment, and management of asthma. Program chapters are supplemented by links to external multimedia resources such as illustrations, videos, journal articles, and other resourcesBreathefree (iPhone), Breathefree App (Android)FreePhysician-Directed AppsReferenceBothProvides medical professionals with information about peak expiratory flow rate, chronic obstructive pulmonary disease severity, inhalation device use and selection, as well as medical newsBreathefree App for DoctorsFreePhysician-Directed AppsReferenceBothProvides medical professionals with information about peak expiratory flow rate, chronic obstructive pulmonary disease, and inhalation devices through videos and interactive tools. Provides medical news and a product index of all Cipla drugsBronchiolitis$1.99Physician-Directed AppsReferenceiPhoneDetermines the severity of an asthma attack using the Downes rating, or bronchiolitis grade using the Wood-Downes ratingERres$3.99Physician-Directed AppsReferenceAndroidContains calculators, medication lists, algorithms, decision rules, clinical polices, and core content for emergency care providers. Includes information about asthma treatment and predicted peak flow ratesiGuidelinesFreePhysician-Directed AppsReferenceiPhoneProvides medical professionals with point-of-care access to interactive guidance for select pediatric conditions, including asthmaLungs & Breathing$2.99Physician-Directed AppsReferenceiPhoneProvides information about topics related to lungs and breathing, including asthmaMD Spiro-FlashFreePhysician-Directed AppsReferenceBothReviews elements of spirometry for health care professionalsMedGuide Emergency$6.40Physician-Directed AppsReferenceAndroidGuide to algorithms and drugs used in the case of emergency, including asthma attacksMERITFreePhysician-Directed AppsReferenceAndroidInteractive template for patients with asthma, chronic obstructive pulmonary disease, and allergic rhinitis that provides instant validated clinical feedbackMiniatlas Asthma$1.99 (iPhone)/$2.99 (Android)Physician-Directed AppsReferenceBothAssists health practitioners in communicating with patients to help them understand their asthma. Provides images and explanations of the diseasepalmEM: Emergency Medicine$15.99Physician-Directed AppsReferenceAndroidQuick reference for emergency medicine that provides information about conditions including asthmapalmPEDi: Pediatric Tape$2.99Physician-Directed AppsReferenceAndroidPediatric resuscitation reference that includes information about asthma and airway maintenance medicationsPFT a-pocketcards LITEFreePhysician-Directed AppsReferenceAndroidDisplays all parameters necessary for performing and interpreting pulmonary function tests. Contains tables, illustrations, and formulas. Describes different testsPFT evalFreePhysician-Directed AppsReferenceiPhoneWalks clinicians through stepwise approach to analyze pulmonary function tests (PFTs)Pulmonology pocket$9.99Physician-Directed AppsReferenceBothProvides information about assessment, monitoring, and treatment for all major pulmonary disorders. Includes latest guidelines from the Genetic Information Nondiscrimination Act, the Genomes OnLine Database, and the American Thoracic Society. Provides interactive calculators, index search, full text search, and treatment guidelinesRT: For Decision Makers in Respiratory CareFreePhysician-Directed AppsReferenceiPhoneProvides information for respiratory care practitioners about clinical information, trends, business tips, and news on the latest products and servicesNurse's Toolbox$29.99Physician-Directed AppsTools/CalculatorsAndroidAllows users to perform instant weight-based calculations for drug dosages, emergency drugs, and other calculations for pediatric and adult patients. Includes emergency medications and peak flow calculatorPediatric Support$4.88Physician-Dire