Perspectives on the Evolution of Mobile (mHealth) Technologies and Application to Rehabilitation

Abstract

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often require complex habilitative and rehabilitative services to prevent and treat these complications. This perspective article reviews the evolution of mHealth technologies and presents insights as to how this evolution informed our development of a novel mHealth system, iMHere (interactive mobile health and rehabilitation), and other technologies, including those used by the Veterans Administration. This article will explain the novel applications of mHealth for rehabilitation and specifically physical therapy. Perspectives on the roles of rehabilitation professionals in the delivery of health care using mHealth systems are included. Challenges to mHealth, including regulatory and funding issues, are discussed. This article also describes how mHealth can be used to improve patient satisfaction and delivery of care and to promote health and wellness.

The term “mHealth” refers to the concept of using mobile devices, such as mobile phones, tablets, and smartphones, in medicine and public health. mHealth can be considered a subcategory of “eHealth,” which is a broader term for the use of all electronic technologies such as computers in medicine and public health. More than 80% of Americans have mobile phones, and more than 40% own smartphones, with the latter percentage projected to grow to more than 80% within 10 years.¹ Nearly half of American adults also have at least one chronic medical condition, and this number is also growing.² Chronic conditions result in poor medical outcomes as well as increased cost and utilization of health care services, not only for older adults but for all age groups.³ Because of the ubiquitous nature of mobile devices, and the fact that many Americans cannot leave home without them, their potential role in medicine and rehabilitation continues to become more evident. Recent statistics show that 83% of smartphones are always turned on and always with the user.⁴

Perhaps the “simplest” forms of mHealth are voice communication and text messaging. An advantage of these methods is that they can occur via low-cost mobile phones. Voice communication, either via person to person or using interactive voice response, is a simple example of mHealth.⁵ Text- and video-based messages have been used in cardiac rehabilitation programs^6,7 and to support consumer and clinician communication in disease management.^8,9 One meta-analysis reviewed several trials and reported overall modest evidence that text messaging has a positive impact on self-management and outcomes in conditions such as diabetes, asthma, and hypertension.¹⁰ A pilot study using text messages demonstrated increased healthy behaviors and improved diabetes self-efficacy and medication adherence in a population of low income and bilingual individuals with diabetes.¹¹ However, meta-analyses^10,12 reveal that small sample size, dearth of studies that compare various modalities with each other (eg, text messaging, calls) or study long-term interventions, and bias of publication of studies showing only positive results are barriers to evaluating efficacy of these basic technologies.

An exponential growth in the use of smartphones, however, has saturated the market with applications (“apps”) and web-based systems specifically geared for health and wellness purposes. As of 2010, there were 5,820 apps within health and wellness categories for smartphones.¹³ As of 2013, analysts estimated that more than 17,000 mobile medical apps existed, with the vast majority being free to the consumer.¹⁴ Thirty-one percent of cellular phone owners and 52% of smartphone owners have used their phone to look up health or medical information, and 19% of smartphone owners have downloaded an app specifically to track or manage health.¹⁵ The Food and Drug Administration (FDA) predicts that over the next 2 years, more than 500 million smartphone users will use mobile medical applications.¹⁴

The range of functionality of health and wellness apps and systems varies widely, and they can be categorized generally into 6 groups.

Lifestyle-oriented apps are those that aim to help individuals lead a healthier lifestyle by tracking their progress in activities such as diet, weight loss, or exercise programs.¹⁶ Examples include “Nexercise,”¹⁷ “Weight Watchers Mobile,”¹⁸ and “Lose It.”¹⁹ Individuals use these “stand-alone” apps on their own smartphones, usually without oversight by a clinician. Individuals both with and without chronic conditions may use these apps.

Patient-oriented apps aid individuals with medical problems in managing chronic medical conditions through early self-identification of symptoms as well as management and adherence to treatment. For example, “iTriage”²⁰ allows users to “self-diagnose” conditions and find appropriate medical providers. These apps do not have the capability of interacting directly with a clinician and, therefore, must be used with caution in the absence of advice of a professional.

Clinician-oriented apps aid the clinician in patient management by providing: (1) reference or educational information or (2) medical decision making or measurement tools or calculators. These apps are geared for clinicians to use on their own or to examine patients but not for “patient-only” use. Examples of reference or educational information include rehabilitation exercise guides,^21,22 medical encyclopedias, and drug reference books.²³ Examples of tools include mobile accelerometers, inclinometers, and goniometers.^24,25 The accuracy of some of these systems in gathering data is constantly improving. In one study, it was possible to quantify gait parameters with an iPhone with a degree of accuracy and reliability comparable to that of the tri-axial accelerometer.²⁶ However, native apps on the iPhone, the inclinometer and compass, may not be as reliable when used to measure range of motion.²⁷

Disease management systems are portals (often web-based) that help clinicians monitor patients with chronic conditions. These systems may be integrated into electronic medical records, practice management systems, and pharmacies and may include decision support tools. These systems utilize traditional computers but do not offer applications for monitoring of patients with external, remote devices as part of their core features. The drawback of these systems are that they require an active Internet connection.²⁸

Traditional telehealth systems use electronic communications to provide and deliver information and services over any distance.²⁹ Typically, they have interfaces for both the consumer and clinician and include a dedicated external device, such as a home-based blood pressure or heart rate monitor, and support communication via a desktop or laptop computer but not a mobile device such as a smartphone. Similar to disease management systems, they require clinician supervision, and some require an active Internet connection.

mHealth systems operate similarly to traditional telehealth applications but include a mobile phone or tablet application rather than a computer. For example, teledermatology applications have been described in which patients can report the condition and photos of a surgical wound or other skin problems to a dermatology specialist through a smartphone.³⁰ Individuals can use these systems in their natural environments and even when cellular or wireless connectivity may be unreliable because, in some systems, data can be stored and forwarded once connectivity resumes. Such mHealth applications, therefore, are useful in situations in which sustained adherence to schedules and interventions are the aims. Research has demonstrated improved health outcomes using mHealth applications in conditions such as hypertension.²⁸ Applications for diabetes management have also utilized 2-way mobile communications, but this functionality is scarce in applications used in rehabilitation³¹; therefore, literature in this area is still sparse for rehabilitation.

Why Smartphones?

Smartphones are becoming integral to mHealth for several reasons. First, as mobile phones and smartphones become more prevalent, individuals are becoming accustomed to carrying their devices unremittingly and using them for many different purposes. Thus, devices such as personal digital assistants (PDAs) are now scarce, despite the fact that they have shown promise in some prior studies. For example, PDAs were found to have a modest beneficial effect on weight loss.³²

Second, as people carry smartphones throughout the day, the phones can collect ecological momentary assessment (EMA) data, which are data obtained in real time when a person is in his or her natural environment. Such data are less subject to recall bias and can be used to maximize ecological validity in studies.³³ Often, EMAs are used to dispense ecological momentary interventions (EMIs)—timely, point-of-care treatments delivered when a symptom or need is identified.

Third, smartphones can connect to external devices either directly or wirelessly. These external devices can be placed on or within the body to sense, sample, process, or transmit physiological signals. Examples of signals include temperature, heart rate, blood pressure, oxygen saturation, electrocardiography, electromyography, energy expenditure, glucose level, and environmental conditions.^34,35 Various forms of wireless sensors, such as accelerometers, gyroscopes, and force sensors, can be used to record physical activity, movement, or gait patterns. This information can allow a clinician to monitor the quality of or adherence to exercise programs, and information can be fed back to the user for motivation. This information may be useful clinically to reduce cost and time associated with travel and from a research perspective because it provides objective data on adherence.³⁶

Finally, smartphones also contain numerous internal sensors (eg, global positioning system, gyroscope, oscillometer) that can be used with external devices to allow us to monitor a variety of contextual factors about a patient's activities. These sensor data can be combined with EMA data using machine learning systems to enable context-appropriate responses (eg, delivering timely feedback, providing guidance during therapy) without relying on the patient to initiate such therapeutic interactions.³⁷

Unique Features of mHealth Technologies

As mHealth technologies evolve, it is our expectation that they will provide an overarching infrastructure to support self-management, health monitoring, self-directed learning, and interactive patient-clinician communications. Recent advances in mHealth provide unprecedented opportunities for developing innovative health services and interventions that take advantage of the novel characteristics of mobile technologies.

Interventions delivered through mHealth can have several properties that give them the potential to be more effective.³⁸ Interactivity, the ability of the technology to exhibit a bidirectional mode of communication, can provide a “personal coach” type environment to delivering care. Personalization, the ability of the technology to provide an intervention that is customized to an individual's own unique needs, may open new opportunities for learning and skill development. Timeliness, the ability of the technology to assess and deliver an intervention at the right time, focusing on relevant, targeted, and timely information, may allow the intervention to occur when it is most likely to have the most beneficial effect. Context sensitivity is the ability of the technology to shape the intervention based on a unique circumstance or the individual's environment.³⁹ Ubiquity and accessibility refer to the availability and familiarity of the technology to all segments of populations and geographic areas, including underserved populations. Mobile phones are now available and popular even in some of the most remote and resource-poor environments.⁴⁰ They are also the most commonly carried devices for people with disabilities.⁴¹ These features allow “anytime and anywhere” assessments and interventions in those who may have the most limited access to care.^42–44

Roles of Rehabilitation Professionals and Patients in Using mHealth

It is first important to note that mHealth is not meant to take the place of in-person care but to enhance the service delivery process.⁴⁵ The enhanced services, however, may benefit the patient in several ways. First, the patient may be able to use the system to track and record data of interest, such as calories eaten and burned, vital signs, or time spent exercising. The patient may access educational materials such as exercise videos, diagrams, or instructions. In most outpatient clinical settings, patients with an active therapy plan of care may receive a very limited amount of therapy per week. mHealth may extend the clinical interface time by enabling 2-way communication at a time and place of convenience for the patient. This mobile on-demand access creates new opportunities for patients to strengthen their relationship with their therapist, reinforce their understanding of the plan of care, confirm home exercise techniques, receive education, and proactively address relevant concerns. Such higher patient-clinician information engagement, in some medical scenarios, can significantly improve the patient's ability to adhere to preventative medical plans.⁴⁶ Health systems offering the continuum of therapy care could use mHealth applications across a range of settings to improve the patient's experience during transition of care while maintaining patient engagement.

For rehabilitation professionals, mHealth technology provides tools to monitor the effects of home exercise programs, collect reliable outcome measures or vital signs, provide feedback on posture and body mechanics, supply educational material, and prompt patients with motivating messages. The improved access to clinical knowledge databases may provide therapists with supplementary ways to deliver evidenced-based interventions.

Because of the unique features of mHealth, rehabilitation professionals can utilize EMAs to provide EMIs to their patients in the environments in which they live and function.⁴⁷ For instance, a therapist could receive data on pain collected when a patient is actually experiencing the pain, combined with data on whether he or she is adhering to exercise regimens, rather than collecting this information through standard paper measurements after the event occurred, subjecting the data to more recall bias. Therapists also could choose to address these issues immediately when the patient is experiencing the pain, using an EMI, versus waiting until the next visit. In vivo care produces better health outcomes, and users of technology find it easier to apply learned skills when done in natural environments.⁴⁸

The Concept of Gamification in mHealth

Gamification⁴⁹ is a process by which the desirable features of games are used in non-game contexts to leverage a person's interest in competition to achieve results in another realm. Gamification is important to recognize as a trend in mHealth for 2 reasons.⁴⁹ First, mobile consumers continuously seek newer and better smartphone devices, which provides game designers with more opportunities to create interactive health interventions. Second, developers are generally eager to take what they learn about players' behaviors and incorporate the information back into the software they develop.

For example, Jacobs et al⁵⁰ pilot tested a competitive gaming system that provides feedback and adjusts the level of difficulty based on performance in people who have had strokes. They added rewards in the form of points that are viewable by the person playing the game during repetitive upper extremity tasks. A study specifically using mobile devices provided adolescents with diabetes with an app that allowed them to “team up” and monitor their blood glucose levels together.⁵¹ When rewards through iTunes music and apps were given, consistency of glucose monitoring and satisfaction with the program improved.⁵¹ Additional examples are provided in an article by Lin and Zhu.⁵²

Apps can provide supportive messaging or virtual rewards, such as coupons for products or restaurants.⁵³ A social component is available through many of these apps that may incentivize individuals to exercise or lose weight through peer support and a bit of healthy competition among friends and family as everyone reports their progress. A recent newspaper article⁵⁴ pointed out the latest apps that are geared to creating fun-filled unique challenges and reward systems for exercise.

The Role of mHealth in Patient-Centered Rehabilitation

mHealth technologies can be used as a patient-centered approach to health care to influence important patient outcomes.⁵⁵ High satisfaction with care has resulted from mHealth systems that improved diabetes self-efficacy and adherence.⁵⁶ The use of mHealth has improved the quality of health care by collecting blood pressure readings from patients through mobile phones and allowing medical doctors to make more informed choices and provide feedback to patients from the web services.⁵⁷ mHealth systems also have been found to have great potential for behavior modification in drug abuse treatment, human immunodeficiency virus therapies,⁵⁸ health behaviors, and physical and psychological symptoms.⁵⁹

Our Experiences in Using mHeath Within a Community Setting

Because of the potential to use mHealth to improve outcomes in the face of complex and chronic conditions, we developed our own system⁶⁰ and pilot tested it in individuals with spina bifida to assist them in managing skin integrity, neurogenic bowel and bladder, and general health issues such as medication management and mental health. We based our system on our own Wellness Pilot Program, in which wellness coordinators managed the care of individuals with spina bifida and which resulted in improved outcomes in terms of reducing the number of medical complications and reducing health care costs.⁶¹ Our mHealth system, iMHere,⁶⁰ is a web-based portal used by a wellness coordinator that is linked to a suite of smartphone apps used by patients. iMHere delivers reminders to patients to perform self-care activities such as catheterization, taking medications, or checking the skin for pressure ulcers that might have occurred from using orthoses or from inadequate weight shifting within a wheelchair. If a problem is encountered, the patient can report the problem and provide information such as a photo of the wound or information about symptoms. The wellness coordinator can provide instructions or educational materials to the patient and can use the dashboard on the portal to triage and manage a cohort of patients with the goal of identifying problems early and delivering EMIs. The system was evaluated by a focus group of individuals with spina bifida, clinicians, and caregivers who were overall receptive to adopting a system for personal and professional use.⁴⁵

The usability studies revealed several key issues of interest to rehabilitation professionals when using mHealth. Concerns of respondents about the time efficiency of using the system and frequency of alarms resulted in significant design changes to make the system more user-friendly. Some clinicians, individuals with spina bifida, and caregivers were more receptive to “new technology” than others. Thus, it is crucial with any mHealth system to carefully consider who the optimal users will be. Clinicians were most enthusiastic about having the ability to deliver EMIs in a new way. We have recently concluded a full randomized clinical trial evaluating the impact of the system on health and psychosocial outcomes as well as health care utilization, and the results are still being analyzed.

A second type of mHealth system developed at the Human Engineering Research Laboratories (Pittsburgh, Pennsylvania) is a virtual coaching system. Virtual coaching is a form of persuasive technology that provides encouraging messages to elicit voluntary behavior change.⁵³ The Virtual Seating Coach is a programmable intelligent reminder system that was assimilated onto power wheelchairs to monitor the utilization patterns of power seat functions (eg, tilt, recline, and elevating leg rests) and provides reminders and cues for seat function use in accordance with clinical practice guidelines.^62,63 The Virtual Seating Coach can support in-person clinician training on seat function use with auditory and visual feedback and reminders through text appearing on a touch screen display. For example, the Virtual Seating Coach reminds, guides, and provides positive reinforcement to a user who has skin breakdown or lower extremity edema for adjusting the tilt to a degree (within a range established by the therapist) that has been found to relieve pressure or reduce edema. A new mobile phone application of the Virtual Seating Coach is being tested that provides feedback on seat function use plus affords users access to all of the features of their phones. The app is likely to improve availability of the Virtual Seating Coach technology to clinicians.⁶⁴

Initiatives of the Veterans Administration

mHealth policy has still not caught up to the technology, and more evidence from research is needed to influence policy regarding the efficacy of mHealth. However, the Veterans Administration (VA) has embraced all forms of telehealth and is currently providing clinical services, and VA clinicians are billing for it. The VA has aggressively deployed mHealth and telemedicine also, in part, to support its aim to provide patient-centered care.^65,66 Early studies evaluated in-home telehealth messaging systems that were linked to landline phones. Veterans indicated that this mode of communication was acceptable, easy to use, and helpful in the setting of drug and alcohol abuse.⁶⁵ The authors concluded that, because of the veterans' perceived benefits, these types of services could be especially beneficial for those who may otherwise lack access to traditional treatment services.⁶⁵ Another study evaluating the efficacy of a home exercise program for inactive older veterans revealed that those who received text message reminders had higher adherence to home exercise programs.⁶⁶

The VA's newer mobile health initiatives have targeted 3 groups: veterans, caregivers, and VA clinical teams.⁶⁷ Pilot projects have included a smartphone and tablet system that allows clinicians to access critical information from a patient's electronic health record; a tablet program with multiple apps connecting veterans, caregivers, and clinicians that provides coaching, access to medical records, and medication refills, among other functionality; and a system to make appointment requests through mobile browsers. The VA has already released several apps geared to supporting psychological health, treating symptoms of post-traumatic stress disorder, improving sleep, and assisting with smoking cessation.⁶⁷ The VA also will be releasing its own VA App Library once the pilot programs are complete.

Regulatory Issues and Funding Challenges

While mHealth is not yet a reimbursable service for rehabilitation providers in all states, the overarching method of service delivery termed “telehealth” is being reimbursed within an increasing number of states in the United States.

The American Physical Therapy Association (APTA) endorses the development and use of telehealth for the purpose of overcoming problems with access to in-person physical therapy services.^29,68 Delivery of telehealth, however, must follow the standards of practice, position statements, policies, and ethics of APTA,⁶⁹ including the Guide to Physical Therapist Practice,⁷⁰ Standards of Practice for Physical Therapy,⁷¹ and Code of Ethics,⁷² as well as state and federal laws for maintaining patient security and privacy^29,68 In addition, rehabilitation professionals licensed in the state where the telehealth services are provided must be accountable, follow standard documentation procedures, and have the experience and proficiency to provide top-quality telehealth services in a safe manner. The APTA stresses the importance of using reliable electronic systems to administer telehealth that deliver concise messages and receive accurate input from users and are able to be improved as technology progresses.²⁹

The American Occupational Therapy Association (AOTA) also has been a strong advocate for the integration of telehealth services into clinical practice. A 2010 position paper and a recently revised 2013 position paper on telehealth by AOTA provides an overview of the various technologies, terminology, policies, and ethical guidelines as well as several case studies that exemplify the use of telehealth practices in delivering occupational therapy services.^73,74

In September 2013, the FDA released a statement on the guidance of regulations for mHealth apps.⁷⁵ The FDA concluded that the majority of medical apps do not pose a significant health risk to consumers and do not require oversight. However, systems that use either a smartphone or tablet connected to a peripheral device such as a heart monitor or blood pressure cuff, for example, should be regulated at the federal level. At the time of the released guidance document, FDA officials had approved 75 mobile medical applications.^14,75

A Global Perspective

Worldwide, 2 international organizations that are actively promoting mHealth are the World Health Organization (WHO) and the International Telecommunications Union (ITU). The ITU develops standards for interconnection of technologies and networks and aims to improve access to information and communication technologies all over the world. In addition, the International Society for Telemedicine and eHealth (ISfTeH) has official relationships with WHO and ITU, acts as a federation of telehealth organizations, and assists with starting new technology initiatives in developing countries.

Worldwide, mHealth is seen as an enabler of change because of its high reach and low-cost solutions, especially in the areas of chronic and communicable diseases.^10,76 Mobile phone penetration in developing countries is 89%, whereas computer penetration is only 5%.⁷⁷ Although mHealth is becoming useful in resource-constrained environments, particularly in developing countries where access to care may be limited, there are a few barriers that may limit its efficacy. A review article by Chib⁷⁸ states that, although most literature on global use of mHealth describes technology development for developing countries, there is a gap in the literature on health outcomes and adoption of mHealth in global populations. As mHealth is intended to augment but not completely replace medical care, outcomes from its use may not be as favorable in some populations if few individuals ultimately access in-person medical services, even if they are provided with and use the technology. Moreover, socioeconomic and cultural differences as well as extreme poverty and illiteracy can influence the adoption of mHealth. In countries where gender and social-cultural hierarchies exist, some women must rely on men to access information or technologies. Yet, in many resource-constrained environments, some countries such as Rwanda have made great strides in the implementation of mHealth technologies.^79,80

Looking Ahead to the Future

A significant barrier to using smartphones in rehabilitation is cost. In a previous study using a diabetes self-management program in which patients were given rebates to purchase phones and service, the dropout rate was high because patients still could not afford them.⁸¹ Although there are widely varying estimates of what smartphones will cost in the coming years, what is agreed upon is that costs will inevitably decrease. According to a report released by the International Data Corporation, average retail prices of smartphones are expected to drop to as low as $304 by 2017.⁸² A study by Informa Telecoms & Media predicts that 50% of smartphones sold in 2017 will cost $150 or less.⁸³

The lower cost of smartphones is certainly a factor that will allow them to continue to become more ubiquitously used. However, mHealth systems will eventually need to be able to share data with the electronic health record or personal health record.²⁸ Today, there are only a few systems that achieve such integration and that provide exchange of a very limited number of data points. Some diabetes applications, for example, synchronize with a personal health record or server, relaying information on diabetes management to the clinician, but few provide detailed or personalized patient education.³¹ The ability to exchange vast amounts of information on a patient's multiple, chronic conditions with health records is crucial to harness the full potential of mHealth systems. Furthermore, rehabilitation professionals will need to lend expertise to teams developing mHealth systems for these technologies to evolve to standards that meet the needs of the rehabilitation profession.

Conclusions

The evolution of mHealth technologies has changed the way we deliver and think about delivering care to patients with chronic conditions and how individuals in the community manage their own health and wellness. In general, these systems have shown promise from improving the quality of health care delivery, patient satisfaction, participation in self-care regimens, and behavior modification. However, there are significant information gaps regarding the long-term effects, acceptability, costs, and risks of such interventions, which warrant more research. As the role of mHealth within the field of rehabilitation grows, the emergence of studies on novel applications such as iMHere will begin to elucidate the impact they can have on important functional and patient-centered outcomes.