From checking in with friends on Facebook to checking in at the airport departure gate, apps are becoming part of our daily lives. In 2014, there were 138 billion app downloads worldwide and most of them, 127 billion, were free, according to data from statistics website Statista Inc. Those numbers are expected to nearly double in the next three years as the app revolution continues, and they are figures which pharmacists would be unwise to ignore.
“Many pharmacists have embraced the technology — it’s just an extra tool in this information age to get information to patients,” says Geraldine Flavell, a pharmacy academic and West Midlands regional manager for the Centre for Pharmacy Postgraduate Education (CPPE) at the University of Manchester. “I can’t imagine life without apps, and I think pharmacists may be missing a trick if they don’t have a smartphone or an iPad these days.”
The CPPE has been helping guide the profession through the app revolution. For the past five years it has published an annual app directory, listing apps that it believes are useful for pharmacy. The latest edition was published in December 2014 and is divided into three categories. The first lists information apps for pharmacists and technicians that include, for example, the British National Formulary and the National Institute for Health and Care Excellence (NICE) guidance in app form. The second section is devoted to healthy lifestyle apps for the profession and for patients, such as an app offering a four-week course in stopping smoking produced by the NHS and another that helps patients decide if they are depressed. The guide also has a category devoted to self-care apps for patients. There is an app on how to prevent deep vein thrombosis and others designed to help patients track their blood sugar or blood pressure levels.
The CPPE makes it clear that it does not road test the apps in the directory or validate them in any way. Instead it has pulled together, and regularly updates, those its tutors and others in the profession have found useful. Flavell believes that it is up to pharmacists to use their own judgement to decide whether the apps are worthwhile. “Obviously there are apps from reputable organisations such as the NHS, the Royal Pharmaceutical Society (RPS) and NICE. But you must remember that an app is the window of the company — people with a reputation to maintain are not going to include something that doesn’t represent them properly,” she says.
Question of validity
Flavell’s comments illustrate one of the key issues confronting novice app users: how can you judge its validity? Looking at the clinical evidence that supports any app is crucial, according to Ash Pandya, chief executive officer of Essex local pharmaceutical committee (LPC). He would also like to see somebody taking a lead in providing guidance — possibly the RPS — about which apps can be trusted and are most valuable to the profession. He advises pharmacists to look at where the app has been reviewed and who has reviewed it. “Look at the data behind it — the process behind it being tested. What is the clinical background?” he says.
Sunil Kochhar is a pharmacist and a consultant at dearPHARMACIST.info — an online pharmacy advice website — and also runs a high street pharmacy in Kent. The dearPHARMACIST website invites users to register with the site and sign up to an individual health passport that works like an app and records their medical history, including regular blood pressure results or chronic obstructive pulmonary disease readings.
“Patients have to register with the site, which is secure and encrypted, and are given a username and password,” Kochhar explains. “They might say to us, for example, that their doctor said their blood pressure readings were high but, before the health passport was available, they couldn’t tell us what the readings were, so we are using it as an engagement tool. Online, we encourage apps to get the public to think about their health and for them to get an understanding of their risks.”
A mobile screen
Kochhar says in store the staff use iPads with preloaded apps as a tool to engage with patients and the public. For example, one app used in the pharmacy can calculate an individual’s chance of developing cardiovascular (CV) disease in the next ten years. The app records information including height, weight and smoking history, as well as family heart history, and calculates a percentage score of their risk of developing CV disease in the next decade. “We use it as a tool to engage people to tell them, for example, if they have a high BMI what the risk [reduction] would be if their BMI was lower. It’s a visual aid.”
Another screening tool he recommends is one produced by the charity Diabetes UK that calculates an individual’s risk of developing type 2 diabetes. He says the Diabetes UK risk score, available on its website, was particularly useful during the national diabetes awareness week, as was another designed to help patients stop smoking. The charity also has two apps on its website — one that allows patients with type 1 or type 2 diabetes to log their daily levels of blood glucose and other measurements, and another that includes the charity’s latest publications.
“A lot of the apps link to resources and give patients a lot of information,” Kochhar says. “There is still need for professional clinical engagement but it has made life easier as everything is embedded in the app so patients can use it as a resource in its own right. It’s a cost reduction for us because of the money that we save on paper and ink printing patient information leaflets.”
So what does Kochhar look for in an app in terms of accreditation or validity? He has confidence in any app on the NHS Choices website because it has the NHS brand behind it, and others produced by national patient charities such as the British Heart Foundation and Diabetes UK. “I would also go to other professional websites such as the British Medical Association to see what they offer,” he suggests.
Two pharmacies in Essex are using an app — which has a one-off cost of £75 — that provides a mobile electrocardiograph (ECG) reading within 30 seconds. A hand-sized mobile ECG is attached to a smartphone or android device that has the supporting app. The patient touches the mobile ECG, the reading is assessed remotely by a cardiologist and the result sent back to the mobile.
Pandya enthuses: “It’s absolutely fantastic and it’s really good for screening people for atrial fibrillation. It would be really useful if pharmacists were commissioned to screen for atrial fibrillation and we are talking to commissioners about that. The app is also useful as part of a medicines use review.”
He also endorses an app that is designed as a game to test a person’s memory function. “The results show whether the person has memory issues,” he says. “It’s about pharmacists being able to funnel patients — GPs can’t see everybody.”
Another popular app is capable of reminding patients when to take their medicine and prompts them if they forget — a useful tool in consultations for the new medicines service (NMS). “If you are looking at the app with the patient for an NMS you can check with them if they are taking their medicines. If they bring in their phone the patient can access their record and you can go through it with them,” Pandya explains.
Pharmacists who are promoting apps in their day-to-day practice dismiss the suggestion that it is only younger patients who are keen to use them. Kochhar notes: “There aren’t that many patients who have said ‘no’ they don’t want to use them. Some might need help the first time to use it but once you show them how to click and move forward we can leave them to it.”
Collette Johnson, a technologist who has worked for NHS Innovations, believes older people are just as interested in the potential of apps as younger people. “One app, for example, is designed to support people with Parkinson’s disease. Their carers can also use it and it prompts the patient if they haven’t taken their medicines. It also provides cognitive tests and tests reason,” she says.
“The pharmacist can look at the results and see what is going on and whether a patient needs to review their drugs. It helps patients see whether their condition has declined — maybe they were worried they had but in fact they hadn’t and that this new drug is really making a difference. This app is fantastic because it’s opening up conversations between the community pharmacist, the patient’s GP and the secondary care specialists.”
Johnson says most of the apps that community pharmacists could make use of in daily practice are free or low-cost and some GPs are even prescribing apps to patients with long-term conditions as part of their care. And she has this warning for those reluctant to break into the app world: “If community pharmacists aren’t engaging with this they are going to be behind the curve. It’s all starting to move fast now and it’s exciting. Apps are a big thing in terms of mobile health — how you can take something out of the clinic and put it into the community that informs patients and healthcare services. Apps are a game changer.”