Navigating the Digital Health Landscape

In February 2019, the Topol Review (Topol, 2019) reported that, of the “technological advances impacting healthcare” (p. 27), the top three are all in the field of digital medicine:

1. telemedicine
2. smartphone apps
3. sensors and wearables for diagnostics and remote monitoring

As a UX agency with a focus on digital health, we at Sigma are encouraged by this and would like to share some thoughts about mobile health (mHealth) smartphone apps and wearables, as well as online health support and advice services.

The number and variety of mHealth technologies available to the public is burgeoning, and people are increasingly using them to support their health and well-being.

• Search for “health” returns approximately 6 million apps on the iTunes App Store and almost 5 million on Google Play, as of 2 April 2019
• The firm Research 2 Guidance found 325K total health apps in 2017, on both platforms, up 78K from 2016

This prompts us to ask: What is the quality of these apps? How do people choose which ones to use? What impact do they have?

To explore possible answers to these questions, we turned to the research literature. A Google Scholar search for “usability health apps uk” on 20 February 2019 returned a list of almost 5800 research studies published since the beginning of 2017. We skimmed the abstracts of more than 50 of these papers and downloaded about a dozen to inform this article.

It turns out that research on mHealth apps and devices varies widely, and for the most part it appears to give usability less attention than other factors*. A 2018 analysis (Chib & Lin, 2018) of 85 empirical studies of mHealth apps found that the overwhelming majority (87%) focused on aspects of the apps themselves (including data quality and “usability”) rather than on the apps’ effectiveness in producing behaviour change or health improvements.

In stark contrast to this finding, another 2018 analysis (McCallum, Rooksby, & Cindy, 2018) found that almost all (96%) of 111 studies of apps and wearables for physical activity assessed the effectiveness of the technologies in promoting behaviour change, while only 32% also studied engagement and acceptability and fewer than 15% addressed usability.

Among the studies we read that considered what they called usability, almost all addressed only user satisfaction, which is more appropriately called perceived usability. (The International Organization for Standardization (ISO) defines usability in three parts: not only satisfaction but also the objective measures of effectiveness and efficiency (ISO, 2018), which must be observed empirically and cannot be assessed via comments or surveys.)

We did find a very small number of studies that involved user research methods such as interviews (Anderson, Burford, & Emmertson, 2016) or usability testing (Wildenbos et al., 2019), but we wouldn’t expect to see those approaches very often in academic research because of the time they require.

Although we do not propose to conduct academic research aimed at contributing to knowledge about mHealth technologies, we would like to offer some insights from our experience in studying and designing digital products for use by people.

Most interesting from our perspective are the studies that find that, in choosing and sticking with mHealth technologies, people place far more weight on user-centric features such as ease of use and their own experience of trying out apps than they do on provider-oriented aspects such as evidence basis and scientific validity. According to Schueller et al. (2018),

…many people do not simply pick one app and then use it. Instead, it was common for participants to report identifying multiple apps, downloading several, and then trying out those apps to be able to do direct head-to-head comparisons… (p. 6)

Similarly, Nicholas et al. (2017) found that the public value “content that is helpful, supportive, and easy to use” and that people are choosing healthcare apps “without necessarily considering the evidence-base or clinical effectiveness of the tool” (p. 2).

Some of the research, including the Topol Review, urges designers of mHealth apps to involve patients and carers in a user-centred design and development process. Other researchers (Torous et al., 2019) are promoting the development of standards for evaluating mHealth technologies. We wholeheartedly support both of these goals.

The UK’s National Health Service have developed such a set of standards, which they are using to evaluate candidates for their new NHS Apps Library of “digital tools to help you manage and improve your health”.

This library provides apps in categories such as medical condition (cancer, dementia, diabetes), type of service (dental, GP), and support (healthy living, online community). Before an app can be included in the library, it must pass an assessment by subject-matter experts to ensure that it conforms to clinical and technical standards and follows best practice, as defined by NICE, the UK’s National Institute for Health and Care Excellence.

We at Sigma recently designed and built HealthTech Connect, a new online service for NICE that allows technology developers to engage with CCGs, service commissioners and clinicians early in their development cycle, encouraging a much closer collaboration around the supply and demand of apps used in healthcare.

The NHS app assessment covers medical criteria — effectiveness (improved health outcomes) and clinical safety (avoidance of harm) — as well as patient privacy and security (including a great many points of data protection) and technical aspects such as interoperability and technical stability. It also includes more than 30 questions regarding usability and accessibility, such as whether the design/development process followed key principles of user-centred design and whether the app has adequate colour contrast between text and background.

If digital health is to become more widely adopted in a time when our health services are more stretched than ever, a minimum requirement is that patients be able to complete the tasks they need to — ideally quickly, without confidence and without undue hassle — and as it stands, they are, perhaps, currently being let down by apps that were rushed to the market to gain traction.

As we mentioned earlier, the ONS found that fewer than one-fourth as many Internet users in Great Britain made healthcare appointments online, as compared with the number who searched for health-related information online. We suspect that this discrepancy may be due at least in part to lower usability among online appointment booking services in comparison with health information websites.

In the UK, all patients already have a legal right to access their health records, and GPs are currently rolling out their Electronic Health Record systems and their appointment booking and messaging platforms, with products such as Patient Access, myGP, SystmOnline and Evergreen now available. Together, a combination of online public health services and targeted apps should provide patients with a greater opportunity to engage in and take control of their own health.

We are keen to understand how these services and apps are being designed and rolled out, how they are changing behaviours, and whether there is evidence they are having the desired impact for users, healthcare professionals and service commissioners. If these devices and digital services are to make a tangible difference to the public’s health, several conditions must be fulfilled.

Among the most important of these considerations is inclusive design based on solid user research and participatory design, making sure these tools are accessible to all who want to use them. We at Sigma are optimistic that the NHS Apps Library, and in particular the brand-new NHS app, will not only help to increase engagement but will also have a positive effect on public health in general.

*A Google Scholar search for “health apps uk” returned more than four times as many results as when we included “usability” in the search terms.