How to Tell Good Health Technology From Bad

Health technology
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Long gone are the days when mobile apps were primarily for entertainment, and the smartphone is quickly becoming ubiquitous with health and self-management. According to the IMS Institute for Healthcare Informatics, the number of health apps already exceeds 165,000. However, the buzz surrounding wearable devices and health-care applications is also raising some questions about their usefulness, reliability, and safety.

While health technology used by clinicians usually gets properly evaluated in a peer-reviewed process, devices that are marketed directly to consumers rarely undergo such a rigorous vetting process. Hence, the health tech market is becoming littered with non-scientific claims and unverified promises. Consumers often make their choices according to an app’s popularity and not necessarily its accuracy or functionality. As users, however, we need to be increasingly alert to dodge potential risks and learn how to use new devices and digital health apps in a way that will likely benefit our health and well-being.

Although the Food and Drug Administration (FDA) has been monitoring smartphone applications that pair with medical devices since 2011, the field has proven difficult to regulate. Medical apps that are not considered to be medical devices and do not pose a significant risk if not working as intended are not required to be vetted by the FDA.

Becoming your own health advocate might, therefore, often be your best bet—especially when it comes to health technology.

Health-related Claims With No Evidence

Various researchers and health experts have warned that some digital health devices and apps do not have sound scientific backing. Also, data interpretation and limited integration into the existing health-care system are ongoing issues.

Often, data that gets collected does not inform the user’s life in a meaningful way. Most of the time, a one-fits-all approach is applied, so individual characteristics can sometimes get ignored. For instance, it has been pointed out that although the Fitbit goal of doing 10,000 steps a day might be healthy for most people, it is not necessarily appropriate for everyone. People with chronic conditions, the elderly and frail individuals might not benefit from pushing themselves without considering their exercise tolerance and fitness levels.

Some developers are also making unsubstantiated claims about what their products can do. In 2011, the Federal Trade Commission fined two companies that advertised their apps could cure acne by using colored light emitted from a smartphone. Both apps were removed from the market. The cases brought to attention the explosion of health applications that offer “treatments” for common conditions and target the average consumer who might be vulnerable to false medical claims.

With the proliferation of affordable health tech and different apps for unique issues, certain groups began to rely on them. Yet, research shows that technology-enhanced therapeutic interventions do not always bring the desired effect.

A study by Dr. John Jakicic and his colleagues from the University of Pittsburgh demonstrated that when people who were trying to lose weight used a wearable device, they lost less weight compared to those who only received a standard behavioral intervention. This could imply that health tech might be less effective for long-term behavior changes than what we have hoped. Others argue, however, that there is a place for health technology. Often the best-case scenario is when digital health is combined with other evidence-based approaches and/or with professional medical guidance.

Health Apps That Can Endanger Health

While some of the inaccuracies or false claims made by digital health developers are benign, others can cause serious damage.

Some studies have highlighted the dangers of applications that provide medical advice and are freely available to non-clinicians. For example, a study from the University of Pittsburgh Medical Centre evaluated four applications that used a digital image to decide if a skin lesion was potentially cancerous. The research team uploaded 188 images of lesions, of which 60 were melanoma, and 128 were benign. The results showed that the apps had different levels of sensitivity and varied in their assessments of risk. The most accurate app sent images to a board-certified dermatologist, therefore, involving a physician in the process of evaluation. The other three apps, which relied on algorithms for analysis, incorrectly classified at least 30 percent of lesions that were a melanoma. Even the most accurate of the three missed 18 cases of a malignant melanoma and assessed them as benign. Since early detection is crucial for treatment of melanoma, a false diagnosis can mean the difference between life and death—as such, these results are worrying. The authors point out that although the apps for melanoma detection were marketed as educational tools, they were released to the public without a proper supervision process. The advertisements suggested that they were able to perform a risk assessment on the lesion and tell whether it was malignant or not. If patients substituted a medical examination by a dermatologist for these readouts, they could find themselves at a serious risk of harm.

Another study, led by Dr. Kit Huckvale from the Imperial College London, evaluated apps that calculate insulin doses for patients with diabetes. Out of 46 insulin calculators, only one was issue-free according to the criteria set by the research team. Some flaws were not easily detected and only became apparent after careful testing. In their article published in the BMC Medicine, Huckvale and colleagues concluded that current insulin dose calculator apps could cause a patient to either overdose or receive a suboptimal dose. This could potentially lead to catastrophic events.

Wading Through What Works and What Does Not

Since many health apps and mobile tech devices offer considerable benefits, it is important for users to be able to critically assess them. Angela Hardi of the Washington University School of Medicine in St. Louis identifies some of the questions we should be asking before deciding to use a health device or an app:

  • Who created the app? You should pay attention to the designers’ credentials and affiliations. You would expect a credible digital health device or app to involve work from doctors and health experts.
  • Are the sources that were used to create the app cited? There should be some understanding of what knowledge the app is based on.
  • Does the app seem like an advertisement for another product? Or, are there advertisements popping up? The app should feel like a source of information, not an entertainment/advertisement tool. 

Other factors you might want to consider when evaluating an app include:

  • Does it come with a clinical disclaimer? If so, read it carefully.
  • For apps that work as calculators, are the formulas that are used for calculations clearly displayed?
  • Is there evidence to support claims that are made by the designers? For example, have there been clinical studies about the device?
  • Is customer support available and/or is it easy to contact the maker?
  • When was the app last updated?
  • Does it come with a privacy policy? You should look at what data is being collected and what gets shared. Also, who owns the data?
  • Is it possible to download or export your data?
  • Does the app suggest it monitors a chronic health condition and/or provides answers to clinical questions? If so, consult your health-care professional before using it and default to the medical advice of your physician.

There are resources already available that can help you assess potential medical apps. For example, the American Psychiatric Association (APA) offers an app rating system for mental health apps. They developed an evaluation model that can help users make an informed decision. This model looks at the following criteria: background information, privacy and security, evidence, ease of use, and interoperability.

When evaluating an app, you should probably also consider its practicality and functionality. Is this something you are likely to use over a significant period of time?

All in all, there are many factors you might want to contemplate, so it is essential to take some time and carefully look at different aspects of any piece of health technology, as well as read reviews. However, popularity is not always a good sign an app is of particular quality. For instance, Dr. Iltifat Husain, who works as an assistant professor of emergency medicine at Wake Forest University School of Medicine, noted that an app for measuring blood pressure that for a while trended among the “top 10 paid apps” on the Apple App Store’s Health and Fitness category was not performing well and had no evidence to support its measuring methods. Husain suggested removing it from the online store. Since then, the company made it clearer that the device only offers an estimate of blood pressure and should not be used for medical advice or diagnosis.

It Is Also in the Way You Use It

Health technology and health apps can be a wonderful tool for self-monitoring and a great way to support a healthier lifestyle. It is important, however, to learn how to use them properly and conscientiously. It is not digital health per se that many experts warn us about, but our preoccupation with it.

The aspect of overuse can be particularly poignant when it comes to children. A team of psychologists from the University of South California conducted a study with sixth graders who were sent to a five-day outdoor camp without access to screens. In a short amount of time, their ability to understand non-verbal emotional cues improved significantly compared to a control group who had access to their digital media. These findings showed the importance of face-to-face interactions for the process of socialization. Although technology offers plenty of opportunities for interaction and development, it can also hinder some of our basic abilities, such as reading human emotion—a skill that cannot be learned by looking at a screen. Another study from the University of California, Los Angeles, that looked at how people bond also reported that in-person communication was superior to text, audio, and video chats. This is important to consider since close interpersonal attachments are a pervasive human need, and evidence supports that in many case these attachments lead to better health outcomes.

Perhaps one of the first things to keep in mind when evaluating any health technology is that we need to make technology work for us first and not vice versa. Do thorough due diligence, and you will likely be rewarded when it comes to finding the right digital health tools.

Sources:

Akilov O, Patton T, Moreau J, et al. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatology, 2013;149(4):422-426

Huckvale K, Adomaviciute S, Car J, Prieto J, Leow M, Car J. Smartphone apps for calculating insulin dose: A systematic assessment. BMC Medicine, 2015;13(1)

Jakicic J, Davis K, Wahed A, et al. Effect of wearable technology combined with a lifestyle intervention on long-term weight loss: The IDEA randomized clinical trial. JAMA, 2016;316(11):1161-1171

Sherman L, Greenfield P, Michikyan M. The effects of text, audio, video, and in-person communication on bonding between friends. Cyberpsychology, 2013;7(2): article 3.

Uhls Y, Michikyan M, Greenfield P, et al. Five days at outdoor education camp without screens improves preteen skills with nonverbal emotion cues. Computers In Human Behavior, 2014;39:387-392.

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