mHealth App Essentials: Patient Engagement, Considerations, and Implementation

Source: mHealth
by Mark R. Groshek, MD, Medical Director, Internet Services Group at Kaiser Permanente, HIMSS Physician Community , Jan Oldenburg, Senior Manager, Healthcare and Consumer Advisory Service at EY, HIMSS Connected Patient Committee , Jane Sarasohn-Kahn, Health Economist/Advisor, THINK-Health; Blogs at HealthPopuli and HealthcareDIY, HIMSS mHealth Committee , and Brad Sitler, SAS, Patient Engagement Population Health Strategist, HIMSS Connected Patient Committee
February 20, 2015

Executive Summary

As more apps focus on helping patients manage their condition(s), a challenge for app developers will be to develop holistic mHealth apps rather than focusing that focus on a single condition. While patients may find an app useful to manage a specific condition, it’s difficult integrate multiple apps, although new tools like Apple’s HealthKit hold the promise that data from multiple health apps can be integrated and consolidated.   

The value of apps in health and healthcare

“We don’t adopt cellphones. We marry them,” B.J. Fogg quipped in the book, Texting for Health, published in 2009.  Six years later, mobile platforms go beyond phones, and consumers and health providers have begun to embrace the use of mobile apps and digital health tools for health and healthcare.

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Figure 1: How consumers use mobile phones for health

Consumers favor app prescriptions over medications: in 2014, nine in 10 patients said they would use an app “prescribed” by a physician. In contrast, only 66% of patients would be willing to fill a prescription medicine from their doctor.[i] In fact, consumers would increase their use of health apps if physicians recommended them.[ii] While 70 percent of respondents used apps on a daily basis to track calorie intake and monitor physical activities, just 40 percent actually shared their data and insights with their doctors. What's more, 34 percent of mHealth and fitness app users in the survey indicated that they would increase their use of apps if their physicians actively recommended them. 

People who use mHealth tools are more engaged in health, and mHealth users are more likely to follow physicians’ advice and be more proactive about health treatment, according to Digitas Health.[iii]

Some clinicians are not convinced that consumers can change health behavior or improve disease management through apps. One provoking question is whether some consumers are opting out of shared-decision making with their providers in their pursuit of their own health improvement due to physicians' reluctance to embrace mHealth.[iv]

This report addresses the following:

  • Section 1: Value of mHealth for provider-patient engagement;
  • Section 2: Opportunities and barriers in adoption; and
  • Section 3: Key issues for organizations (and providers) implementing mHealth in practice.

Value of mHealth Apps to Patient-Provider Engagement

mHealth image 1a

Figure 2: Patient’s readiness to make behavioral changes

The Affordable Care Act (ACA) has extended health insurance to millions of previously uninsured patients with a goal to prevention and of helping patients proactively manage their health before they develop a disease, or to mitigate existing diseases.

However, the United States already has millions of patients who have had health insurance, yet continue to succumb to chronic disease and/or experience exacerbations. Furthermore, the Massachusetts Health Care Reform and Chronic Disease Outcomes Study concluded that providing health insurance to those not previously covered did not improve the patients’ health and outcomes.

Additional changes to the healthcare ecosystem to enable improved patient outcomes are also required. One necessary change is to improve patient-provider engagement for the purposes of:

  • Taking a patient’s needs, wants, and goals into consideration when designing treatment plans.
  • Facilitating shared decision-making on a patient’s goals and treatment plans.
  • Increasing a patient’s willingness to follow through on jointly developed treatment plans.
  • Supporting patient empowerment such that patients become proactive in the management of their overall health.

Provider-patient engagement already occurs in the clinical setting during visits between patients and providers. Providers can enhance this engagement when they:

  • Create a setting for an open dialogue.
  • Provide the pros and cons of various course of care/health management.
  • Actively listen to the patients’ needs, wants and desires.
  • Use shared decision making to align with the patient to form a treatment strategy and a plan for managing the patient’s health and healthcare.

mHealth apps can be a powerful tool to further enhance patient-provider engagement.

The degree to which mHealth apps will add value to the patient-provider relationship will vary with each patient’s readiness to make behavioral changes. For any given acute or chronic condition, there will be a spectrum of patients in different states of behavior change, ranging from being unaware of the need for change to maintaining changes that have already been made.  There will be patients that are:

  • Unaware of the need for change.
  • Aware but not ready.
  • Ready and preparing for change.
  • Actively changing behavior.
  • Maintaining change.

Prochaska’s Stages of Change provide a comprehensive framework for understanding patients’ readiness for behavior change.  As depicted in figure 3, depending on the individual patient’s stage of change, every mobile app prescribed or recommended may have a different potential to enhance patient-provider engagement. We also expect to see more apps that support people in moving through the stages of change.

mHealth Apps- Impact on Behavior Change

Patients that are actively changing their behavior may benefit from an app that:

  • Supports them in pursuit of their daily goals.
  • Enables them to have follow-up discussions based upon a rich history of mHealth app information with their provider. 

A patient that is aware of the need for change but still deciding about taking any action may benefit from an app that:

  • Provides disease-specific information.
  • Facilitates a communication with their provider outside the office setting.
  • Addresses questions as they evaluate their decision to make a change.
  • Enables them to obtain an answer quickly from their provider.

 

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Figure 3: Prochaska’s Stages of Change Model[v]

Patients in each of these stages of change will experience different value from mHealth apps when engaging with their provider. Consequently, either mobile apps will need to address the needs and wants of a diverse patient population to support on-going and effective provider-patient engagement, or providers will need to recommend mHealth apps for patients based on their present stage of behavior change.  When a patient transitions from one stage of behavior change to another it might be necessary to choose a different mHealth app to address their evolving needs.  Developers will not only need to be clear about a given app’s purpose, but also which stage or stages of change the apps support.

 mHealth Apps Can Have a Significant Role in Enhanced Dialogue

Enhancing the ability to share information between patients and providers affords both parties an opportunity for on-going, informative, and supportive dialogue. mHealth apps can facilitate increased provider-patient engagement and self-care support both inside and outside the clinical setting:

 

      I.        Within Clinical Office Setting

  1. Serve as a tool to capture and document defined goals (i.e., regularly checking a specific biometric; establishing and tracking exercise goals; or tracking dietary habits, etc.) These goals can be translated into an action plan for outside the office setting
  2. Provide previously recorded patient data for an objective assessment of how a patient is progressing toward jointly defined goals in managing their health.
  3. Enable a patient to share his/her data from other provider or healthcare system interactions.

 

    II.        Outside Clinical Office Setting

  1. Serve as a daily support mechanism for a patient in the management of their health and pursuit of specific goals.
  2. Facilitate timely and accurate capture of patient’s data for patient and/or provider review and assessment.
  3. Enable two-way exchange of information and communication between the provider and patient outside the clinical setting.
  4. Enable a patient to track their activity to goal to support the proactive management of their health.
  5. Facilitate sharing health goals with friends and family to engage a patient’s extended support network in overall management of their health. Social sharing in health can bolster ongoing self-care and health outcomes.[vi]

An mHealth app incorporated into a patient’s daily living has the potential to enhance patient-provider engagement and data-sharing. For example, a patient and their provider could more easily identify challenging aspects of a treatment plan and either revise it or develop strategies to successfully overcome difficulties. mHealth apps also can extend a provider’s on-going support and guidance outside the office setting for better overall patient outcomes and experiences inside and outside the office.  In addition, mHealth apps can provide patients with the tools and information they need to more proactively manage their own health and healthcare.

 

 

mHealth: Considerations and Barriers

Bullish market forecasts for digital and mobile health should be tempered by issues that can prevent consumers’ and providers’ adoption. This section of the report calls out these issues.

mHealth delivery is blending into healthcare workflow. As health providers adopt mHealth tools, a growing base of evidence supports adoption for specific applications and targeted patient populations. Evidence is growing that mHealth platforms are cost- and clinically-effective in addressing health challenges in challenging communities.[vii] “mHealth is revolutionizing the way patients are receiving their care. The differentiation between a conventional healthcare strategy and mobile healthcare strategy will be softened,” asserted Mary Alice Annecharico, CIO of Henry Ford Health System.[viii]  At the same time, physicians can access mobile apps to inform evidence-based decision making, ten of which are documented in this mHealth News article "10 Mobile apps for Evidence-Based Medicine".

Consumers are generally keen to adopt mHealth tools. Eight in 10 U.S. adults would consider a virtual appointment with a healthcare professional virtually for a range of medical issues.[ix] Virtual visits are defined in the Harris Poll as interactions with health providers through computers, smartphone and tablet apps, and other digital means. People managing chronic conditions are more likely to be interested in virtual visits than the overall population across all of these services, Harris found.

 

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Figure 4: Virtual Services

Health vs. health “care.”  Most apps and tools consumers use are currently for health maintenance and not for health “care.” The most well-used mHealth apps consumers use focus on calorie intake, weight and physical activity, and adoption of such tools are expected to grow[x]: most consumers plan to use some sort of wearable device to track health and fitness in the next few years.[xi] As more apps focus on helping patients manage conditions, a challenge for app developers will be to develop products that are patient-centric, and can be used to help manage a patient's health concerns holistically, rather than focusing on a single issue. While patients may find it helpful to use an app to manage a specific, time-limited issue, it is not likely they will find it easy to integrate multiple mHealth apps, each of which addresses only part of their overall health.  The potential of new tools like Apple Healthkit to integrate data from multiple apps may make it easier to create a patient-centered, holistic mHealth tool, but more work needs to be done to enable patients with multiple health issues to manage all their care under one platform.

Payment – changing incentives for providers and patients. Long the key limiting factor in slowing adoption of mHealth among providers (along with privacy concerns), the barrier of direct payment for mHealth is lowering for providers as they take on more value-based forms of reimbursement, including pay-for-performance, bundled payments, and assuming the role of the medical home. Remote health monitoring reduced hospital readmission among patients with chronic heart failure in a two-year study conducted at the University Of California Department of Medicine.[xii]  The researchers recommended that home blood-pressure monitors be reimbursed and widely adopted across the United States and integrated into current clinical practice of diagnosis and treatment of hypertension.[xiii] As of October 31, 2014 included within the CMS Physician Fee Schedule Final Rule are inaugural CPT codes for Remote Patient Monitoring for Chronic Care Management (CCM) reimbursement, effective January 1, 2015. 

When it comes to using wearable technology for patients, however, people like the idea of “cheaper” prices, “free” even better, or free plus being paid to use a device (e.g., by employer or health plan sponsor) being the most attractive financial models for adopting a device.[xiv]

 

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Figure 5: PwC, Health wearables: Early days, October 2014

Workflow for providers.  Two-thirds of physicians own a tablet, smartphone, and a desktop or laptop. When adopting mHealth tools, clinicians highly rank extending patients preventive support, continuity of care and telehealth as areas where mHealth can positively impact care.[xiv] Smartphone adoption among physicians in the United States is ubiquitous, and according to Manhattan Research has plateaued in the 80 percent range of physicians using it for professional purposes. Their survey found that physicians are increasingly using both smartphones and tablets in daily practice. The smartphone is most useful for quick reference checks (the “short burst” or “two-click” description), such as drug reference checks and a brief dip into Medscape or a medical journal. Tablets were more useful for more detailed information gathering – and for EHR access and recording.[xvi] Manhattan Research also found that in 2014, physicians tended to use a limited number of apps for professional purposes. Deloitte found that among physicians that do not use their mobile devices for clinical purposes, 44 percent said that their work doesn’t provide mobile devices and they’re unwilling to use their own; 29 percent were concerned about patient privacy; and 26 percent said the apps and programs available weren’t suited to their needs. However, 22 percent of non-users indicated a plan to use mHealth technology in the future.[xvii]  For providers who use an EHR, there may be a need to integrate the information coming from a patient’s mHealth app into the EHR – if this does not integrate seamlessly into the EHR workflows, it may be a barrier to provider adoption of these tools.

Enhancing consumers’ mHealth literacy. With research evidence supporting the use of mHealth programs for population health, the role of health literacy, and the focus on digital and mobile competency, cannot be overlooked. University of Michigan researchers found that Americans aged 65 and older, are not as comfortable accessing digital health technology as people aged 64 and younger, which may culminate in lower digital health literacy.[xviii] Among Americans 65 years and older, the most-used modes of communication are cellphones, landline phones and e-mail, albeit at lower rates than people under 65.[xix]

Privacy and security.  Along with cost, privacy is a key barrier physicians cite in their adoption of mHealth technologies. At the same time, 81 percent of U.S. adults are at least somewhat sensitive about health information privacy on the Internet.[xx] "The sheer number of people and devices with access to health information expands, making it much more complex for organizations to create mobile policies, manage data leakage controls, and conduct regulatory analysis," said Mike Raggo, security evangelist at MobileIron.[xxi] As wearable health device adoption grows among consumers, regulators are focusing in on health data security. Within months of HealthKit’s launch, the FTC approached Apple about the company’s approach to health data privacy. The preliminary plan was for data to be stored in Apple’s server, which could then be accessed by the patient’s health provider.[xxii] 

The FDA introduced final guidance to the industry on regulating health apps and medical software.  The FTC will monitor confidentiality ongoing and offers advice on building security protocols in the recent report “Careful Connections: Building Security in the Internet of Things”; the Agency’s appointment of Latanya Sweeney, formerly head of the Harvard Data Privacy Project, to lead privacy efforts at the FTC, signals the agency’s renewed focus on protecting consumer-generated data.  It is imperative to ensure privacy and security as recently demonstrated by the substantial Anthem data breach.

mHealth: Organizational delivery and implementation

For the most part, the secret of successfully implementing a consumer-focused mHealth program includes similar elements of a portal implementation and include actual users into the design process to ensure it is patient-centric.  They have more in common with the keys to launching a successful in-person behavioral change program than something radically new, despite the fact that this seems contrary to the mHealth buzz.

In fact, many mHealth programs have failed because lessons learned from other successful consumer-facing implementations were forgotten. Here are some tips about the things that matter when launching a program for consumers – along with a few tips about differences in mHealth.  As Section 3 is focused on organizations, additional resources for providers to consider include Selecting a Mobile App: Evaluating the Usability of Medical Applications5 FAQ's for App Development, and the HIMSS mHealth Roadmap.

Pre-launch

During the inception and design phases of a project, it is important to be absolutely clear about the program goals. Start planning to measure success. It is important to demonstrate to the program team and leadership that the goals are both clear and measurable.

It is also important to be sure the program solves a real problem for the target audience. Far too many apps and systems fail because the problems they’re solving aren’t fundamentally important enough to the target audience. As Judy Mottl said in a Fierce Mobile Healthcare article, “…while a doctor may prescribe a smartphone app for enhanced treatment or efforts such as weight loss, it comes down to the patient's perception of whether such a tool is worth his or her attention and time.”[xxiii]

To create and deploy a usable and useful app, bring actual users into the design process early – in this case, that probably means patients, caregivers and the medical personnel (nurses and doctors and staff) who will coordinate the program and use the data. Some tips for user-centered design in mHealth have been provided by Eirik Arsand, PhD, a research scientist at University Hospital of North Norway. He shared his experiences from designing apps for patients with diabetes over a period of more than 10 years. Specific tips from Dr Arsand include:

  • “Recruiting and involving users early;
  • Listening to users’ needs and suggestions;
  • Having open discussions around the possibilities and techniques available;
  • Using quick prototyping through iterations;
  • Testing in real settings without the fear of modifying the previous design due to test results; and
  • Building on the test results to further improve designs.”[xxiv]

The early design phase is also the time to determine whether to launch mobile health applications or a version of a website that is optimized for mobile devices. Early mHealth applications were primarily mobile versions of web applications, but that is changing as developers take into account the benefits of applications that use capabilities unique to mobile phones, including location sensing, context sensing and photos.

Think through the mHealth application distribution process. Will the program provide the devices used to run the apps as well as the apps themselves? While some programs have had success in packaging apps on tablets or smartphones, there are concerns to be overcome with this strategy. It ensures that everyone in the target population has a device on which to run the application(s), but it also raises the cost of the implementation significantly – and with it, the requirement to show sufficient return on investment to justify the additional cost. With a device-purchase strategy, there is also the question of what do as the devices age, as well as whether they truly become the users’ device or whether it is a device used in isolation for medical purposes. It is important to remember that one of the things that make smartphone applications useful is the way they are ubiquitous: always with the user on a device that they use for a wide variety of tasks. Providing a separate device strictly for mHealth use, reduces the likelihood that the target audience will consider it theirs and bring it into their lives.[xxv]

If the application is not being supplied to the target user then it is important to consider how to identify the app in each of the online stores. Is this the only app the organization will offer? If not, carefully consider how to identify individual apps within a family of applications, and what will happen when another app for the same or a slightly different population comes into play. This branding issue is somewhat different for mHealth applications than for other kinds of programs, which simply direct users to a central site where they can find their way to the capabilities that are attractive to them. With mobile apps, it is important to market individual applications in the online stores using some sort of brand identity that indicates they belong to a family of applications from the organization.

Decide on which operating system(s) the app will be coded early in development. The ideal approach is to will use a set of tools that allows the app to be coded once but deployed across multiple platforms simultaneously. This decision can have a significant impact on the lifetime cost of maintaining an application.

Pilot

It is always a good idea to pilot any consumer application with a small audience before expanding broadly. A pilot allows an organization to test its procedures and its assumptions. The pilot design should incorporate testing of documentation, support processes, scripts, distribution approach, and marketing and communications materials. Above all, however, the pilot permits testing the assumptions made about the behaviors of both the target audience and staff.

During the pilot phase, it is especially important to gather feedback and review needed changes. In a development cycle where everyone is eager for launch and where the pilot may seem like the ideal phase for “making up” time lost to development delays, it is critical to success to build in time to gain sufficient feedback from the pilot process – and have time to fix the most crucial issues before the launch.

The pilot is also the time to test a support plan. If there is no quick response plan when people encounter issues with the app, it can quickly lose credibility, and the resulting negative “buzz” can kill the launch.

Last, but surely not least, the pilot is a great time to make sure internal staff is comfortable with all of the components of the mHealth application, as their ease with the tool and its capabilities will have a significant impact on the comfort level of the target users.

Launch

The success of any mHealth launch hangs on the same issues as the success of a website and many other consumer-facing programs. Key elements to consider include:

Marketing and communications plan

It is crucial that the plan incorporate both communications to internal staff and marketing to the target audience. Take a page from successful web site launches and think through how the messages about the mobile application will be communicated at every appropriate touch point in the organization.

Is this an application that is aimed at everyone in a population or only a specific subgroup of people? If it is a subgroup, it is critical to think through how the staff will identify the people who should hear about the application. If, instead, the app is designed to provide mHealth services for everyone, it is important to have communicated and practiced scripts for every touch point, from appointments to rooming to the doctor’s visit. Each channel may need slightly different – but still coherent – messages.

Test the messages and channels in the pilot stage, as it is important to tweak anything that is unclear before the app is finalized. By tracking the doctors, nurses and clinics that are most successful in gathering users for your mHealth application, it becomes easier to broadly disseminate their effective practices within the organization.

Note that while marketing is a crucial aspect of a successful implementation, there is, as Joanne Rohde, CEO of Axial Exchange, says, “… clear delineation in our data in patient engagement between those institutions where clinicians are driving a program with measurable clinical results than those where marketing or IT is leading the program.”[xxvi]

Support

As noted in the pilot section, a plan is needed to address questions and problems that users report, and it is critical that to respond quickly and get the word out to other users and staff. Unaddressed problems – even if not considered critical – can snowball into a perception that the application is failing and subsequent loss of confidence, both with users and staff. Clear communication about any issues and the plan for fixing them can address those kinds of issues before they cause the launch to fail.

Measurement

It is important to plan a strategy for measuring success well in advance of the launch. Do not assume it will take a long time to understand the user experience. There are a number of ways to get indications of success early on in the process that will help the organization determine how well the roll-out is going:

  • What are the interaction levels?
  • How many complaints or questions are there?
  • How often is the app being downloaded and used?
  • Is the intended audience the audience actually using the app?
  • Is there any social media “chatter” about your application or its launch?

There are many potential long-term metrics of success for a mHealth initiative. It may be successful based on clinical outcomes, sustained use, costs saved or loyalty to the institution. Whatever the goals for the application, it is critical to create programs to track and measure indicators of success from the beginning.

 Remember to apply the many lessons of successfully launching consumer-facing programs in the context of mHealth, taking into account a few additional features and issues.

mHealth: Executive Summary

As mobile applications have become ubiquitous in society, consumer and health providers alike have begun to embrace the use of mobile and digital health tools for health and healthcare. Consumers are increasingly interested in using apps recommended or prescribed by their healthcare providers, and evidence suggests those that use these apps are more engaged in their health and healthcare. By enhancing the relationship and communication between patients and their providers, these apps have the potential to improve patient-provider engagement, lead to a more collaborative approach to healthcare, and ultimately improved patient outcomes.

The mHealth environment is rapidly changing. There is increasing evidence that these platforms are cost-effective and clinically-effective for specific applications and targeted patient populations. Barriers to adoption such as lack of direct payment through value-based reimbursement are being lowered. Most consumers appear to be open to adopting mHealth tools. And yet barriers remain. mHealth tools need to integrate seamlessly into patient lifestyles if they are to provide enough value for patients to continue to use them. Similarly, they have to integrate seamlessly into provider workflows to facilitate widespread adoption in healthcare beyond wellness and fitness. The plethora of apps existing for the same purpose makes it difficult for both patients and providers to know which apps have proven effectiveness, and which would be most useful and appropriate to a given individual and their life circumstances.  Furthermore, as recent large scale data breaches remind us, privacy and security remain significant concerns for patients, providers, regulators.

For an organization planning to implement a consumer-focused mHealth program, careful planning is essential to success. The team must be clear about the program goals, and must be sure the program solves a real problem for the target audience. An app should be developed with actual users as part of the design process. A new app should be piloted with enough time to correct defects, test the support plan, and ensure staff comfort with the application and its capabilities before it is launched broadly. An excellent marketing and communications plan should be in place prior to the launch of the app, and a strategy for defining and measuring success should be in place, as well. 

Whether apps are being developed for an organization, or by a developer for direct marketing to patients or providers, as mHealth apps are developed and used more widely, it will be important to continually evaluate which apps are effective, for which patients and situations. These findings should be disseminated widely and often in order to support both providers and patients to identify the app(s) that will best serve a given patient.

References

[i]Digitas. m.Book: Marketing Mobile Health, 2013 Edition
[ii] Mobiquity. Get Mobile, Get Healthy: The Appification of Health & Fitness Report, 2014
[iii] Digitas. m.Book: Marketing Mobile Health, 2013 Edition
[iv] Slabodkin G. Consumers Circumvent Physicians When Using Mobile Health Apps. Health Data Management, April 17, 2014
[v] Prochaska’s Stages of Change Model: http://www.ilru.net/html/training/webcasts/handouts/2011/10-06-NCO/html/images/slides/slide19full.jpg
[vi] Shaya FTChirikov VVHoward DFoster CCostas JSnitker SFrimpter JKucharski K. Effect of social networks intervention in type 2 diabetes: a partial randomized study. Journal of Epidemiology and Community Health. 2014 Apr;68(4):326-32
[vii] mHIMSS. Apps to Aid Healthcare Delivery in Disparate Communities: A Guide from mHIMSS. April 13, 2011
[viii] Annecharico MA. The Implementation of Mobile Computing in Health Care. CIO Review. Accessed at http://healthcare.cioreview.com/cxoinsight/The-Implementation-of-Mobile-Computing-in-Health-Care-nid-3803-cid-31.html
[ix] Johnsen M. Almost 80% of Americans would consider a virtual visit with their healthcare professional. The Harris Poll. November 19, 2014
[x] Witters D, Agrawal S. How Mobile Technology Can Improve Employees' Well-Being. Gallup, November 3, 2014
[xi] Mobiquity. Get Mobile, Get Healthy: The Appification of Health & Fitness Report, 2014
[xii] Black JT, Romano PS, Sadeghi B, Auerbach AD, Ganiats TG, Greenfield S, Kaplan SH, Ong MK. A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial. Trials. 2014;15:124, April 13, 2014
[xiii] Arrieta A, Woods JR, Qiao N, Jay SJ. Cost–Benefit Analysis of Home Blood Pressure Monitoring in Hypertension Diagnosis and Treatment. Hypertension. December 2014
[xiv] PwC, Health wearables: Early days, October 2014
[xv] HIMSS Analytics. 34rd Annual HIMSS Analytics Mobile Survey. February 26, 2014
[xvi] Manhattan Research, Decision Resources Group. Personal interview by JSK discussing the Digital MedTech Physician 2014 survey. November 7, 2014
[xvii] Deloitte. Annual Checkup on Physician Adoption of Health IT. September 2014. Accessed at: http://deloitte.wsj.com/cio/2014/10/08/annual-checkup-on-physician-adoption-of-health-it/
[xviii] Levy H, Janke A, Langa KM. Health Literacy and the Digital Divide Among Older Americans. Journal of General Internal Medicine, November 2014
[xix] Gallup. The New Era of Communication Among Americans. November 2014
[xx] Pew Research Center, November, 2014 “Public Perceptions of Privacy and Security in the Post-Snowden Era
[xxi] Diana A. Securing Mobile Healthcare Devices: Best Practices. Information Week, June 3, 2014
[xxii] Farr C, Bartz D. U.S. FTC asking Apple about health data protection. Reuters, November 13, 2014
[xxiii] http://www.fiercemobilehealthcare.com/story/why-doctor-prescribed-apps-arent-yet-showing-value/2014-11-17
[xxiv] http://www.mhealthnews.com/blog/three-examples-mhealth-success-%E2%80%93-european-style?page=1
[xxv] http://www.fiercemobilehealthcare.com/story/why-doctor-prescribed-apps-arent-yet-showing-value/2014-11-17
[xxvi] http://healthcare-executive-insight.advanceweb.com/Features/Articles/Launch-and-Expand-a-Successful-Patient-Engagement-Strategy.aspx