What’s Next in MHealth Apps in Rehabilitation: Re-Directing Our Attention to Evaluating Quality

Technological innovations and advancements are readily integrated into our lives, providing quick, convenient, and accessible information. The digital transformation of health services and resources could optimize patient outcomes and system costs,^1–3 but we need to continue to re-assess digital health interventions (DHI) as they evolve.

The World Health Organization (WHO) defines DHI as any electronic, digital, or mobile technology that can facilitate and support health care delivery.⁴ This term would include multiple tools to support communication and information sharing, such as wearables, monitoring sensors, telemedicine (telehealth), mobile health (mHealth), artificial intelligence, and information systems.^1,5 DHI are categorized by how they are used to address care (e.g., monitoring and communication) and their intended target users: (1) patients (clients); (2) clinicians; (3) health system; or (4) data services. For this editorial, we will focus on mHealth and patients (clients) as the primary users.

MHealth uses smartphones, or any wireless and mobile technology, for disease prevention, monitoring, or treatment.^6,7 In 2018, Statistics Canada reported 88% of the Canadian population owned a smartphone, with ownership rising in all age groups.^8,9 Smartphones can operate specialized software, called applications (apps), that have features for various purposes and can collect data using adjunct devices (e.g., wearables, biosensors).^1,2,10 From a rehabilitation perspective, mHealth apps can offer features such as medication logs, symptoms tracking, journaling or education, similar to individualized self-management plans.^11,12

MHealth Apps in Rehabilitation

Chronic diseases affect millions of people worldwide,¹³ emphasizing the urgency and need to reduce their burden on individuals and on health care systems.^13,14 Many of these individuals would benefit from rehabilitation to maintain adequate knowledge and skills to support their self-management while living with chronic diseases.^15,16

One potential solution to support rehabilitation is to use mHealth apps.^10,16 MHealth apps could help with the delivery of rehabilitation programmes, offering coaching, behaviour change education, self-management advice, and social support.^14,16,17 MHealth apps could also be used for self-monitoring of symptoms, medications, mood, and education for informative decision making.^18,19 There are numerous clinical trials that have reported positive outcomes of using mHealth apps to help patients monitor and manage their diabetes,^20,21 respiratory,^22,23 and cardiovascular^24,25 diseases. However, systematic reviews and meta-analyses have reported mixed results of apps’ efficacy and feasibility, creating hesitation among clinicians and patients on their use.^11,14,17,26 Thus, further research is needed to understand which components of mHealth apps can support patients and to identify the best approaches to integrate them into clinical care and self-management.²⁷

Consideration of MHealth App Quality and Design

Uncertainties about mHealth apps in rehabilitation are likely related to the inconsistency in their quality, design, implementation, and outcome measurements across trials and within each population.^7,10,26,27 This is exacerbated by the lack of clear standards in reporting the quality and design of interventional mHealth apps.⁷

While there is no consensus on the standard checklists or evaluation tools, reinforcing the use of existing ones is necessary. For reporting, the EQUATOR network endorses the mHealth evidence reporting and assessment (mERA) checklist for reporting studies and app characteristics.⁷ For mHealth app assessments, the most comprehensive tool to date may be the mHealth Index and Navigation Database (MIND) framework, with over a hundred objective questions across five domains (https://mindapps.org/).²⁸ This website houses evaluations for public mental health apps; however, the MIND framework can be broadly applied to evaluate any mHealth app and can be an outline for directing app development, improvement, and reporting.^28,29

State of MHealth Apps in the Public Marketplace

Many mHealth apps reported in the literature were methodically designed and trialed, but most do not become publicly available in the marketplace. Most mHealth apps in the public marketplace are low quality,^12,28,30,31 but they are usually free and accessible to the public. People who may be interested in using mHealth apps to support their rehabilitative needs may consider these resources. Therefore, it is critical to apply evidence-based criteria to app evaluations before they can be used in patients’ self-management.^28,32

Proposed Future Direction

It is frequently reiterated in the literature that more research on mHealth apps is needed.^10,14,16,17 But where exactly is the knowledge gap on this topic? Future direction of mHealth app research should include three focuses: (1) standardizing the reporting method of mHealth apps for future trials; (2) utilizing and evaluating public mHealth apps in studies; and (3) identifying ways to enforce long-term use.

Standardizing the reporting method of mHealth apps for future trials

The mERA checklist should be consistently used across interventional studies.⁷ However, additional details such as app privacy and security infrastructure, accessibility, reading level, engagement styles, and interoperability for data sharing should also be outlined in these reports.^6,10,28

Utilizing and evaluating public mHealth apps in studies

With the growth of smartphones and mHealth apps, we must consider their potential and quality, possibly by leveraging the MIND framework and website to assess and include apps intended for other populations.^30,31 Consolidation of these public mHealth app evaluations would inform clinicians and patients of their quality before use, and open doors to new studies on their effectiveness.

Identifying ways to enforce long-term use

We need to focus on the best approaches to encourage consistent and sustained use of mHealth apps. Most research studies to date only follow patients up to 1 year post intervention, with poor retention.^11,14,26 Integrating mHealth apps into patients’ daily-lives for self-management likely requires elaborate knowledge translation and implementation efforts, as motivation to sustain mHealth app behaviours will likely differ across populations.^33–35

This is a call for action as public mHealth apps can be a threat to public safety as they carry the risk for misinformation.³⁶ Unlike prescribing medications, mHealth apps cannot be simply prescribed as there are many structural and contextual factors to consider, including patients’ technology literacy, accessibility, and facilitators and barriers for use.^10,33–35 The current state of mHealth apps, especially those in the public marketplace, need much more research to fill the knowledge gaps that prevent us from drawing conclusions on their effectiveness.