Nancy Roget, MS
Project Director, Princial Investigator
National Frontier and Rural ATTC
Joyce Hartje, PhD
Evaluator
National Frontier and Rural ATTC
Our digitally connected, mobile society expects immediate access to goods and services. Order a pizza with the touch of a button. Start watching a movie on a smartphone and finish on a computer or tablet. And find or receive medical advice when you need it.
One recent forecast predicts that the mobile health market will grow from $10 billion in 2015 to $31 billion by 2020. This forecast may be partially explained by the data point that 90 percent of the world’s population over the age of 6 will own a smart phone by 2020. The Pew Research Center noted that in 2015 nearly two-thirds of American adults had a smartphone, and 62 percent of them had used it to look up information about a health condition in the past year (Pew Research Center, 2015). Two other recent reports highlight the US interests in texting and apps. Informate Mobile Intelligence (2015) conducted a study and found that Americans preferred texting rather than making phone calls (e.g., making six calls per day while sending/receiving over 32 texts per day). Moreover, in 2014 the average number of apps individuals in the US downloaded on their smartphone was 41. We are fully engaged in technology in all aspects of our lives.
Smartphones and other mobile technologies offer unprecedented opportunities to help patients who suffer from substance use disorders (SUDs). Apps and text messages can reach patients at any time so that routine information can be reviewed at the patient's convenience. Critical intervention can occur when risky situations arise and help is needed most.
The use of smartphones and cell phones is ubiquitous. As such, there no longer is a question about whether smartphones and other technologies will change the way people interact with health care professionals, only how best to use these technologies to improve and manage patients’ health.
Technological innovation has long driven better health outcomes, and medical providers are among the first to adopt new technology. As far back as the 1990s, providers had found uses for smartphone precursors like the Apple Newton. Today, Athena Health Service claims more than 1 million users of its Epocrates app (Epocrates, 2016).
Patients also are interested in their providers' using technology. A recent study (Connected Care and the Patients’ Experience, 2015) found that many patients would prefer that a physician be digitally connected so they could schedule and receive reminders for appointments, refill prescriptions, secure test results, ask questions of the practitioner, and not feel so rushed when at appointments. In addition, patients are more interested in managing their diseases and turn to mobile technology for better outcomes and convenience related to a variety of health problems. For example, evidence suggests that patients using mobile health technologies can positively impact conditions such as diabetes (Cafazzo, Casselman, Hamming, Katzman, & Palmert, 2012), HIV adherence (Ingersoll et al., 2014) and weight loss (Turner-McGrievy, 2013).
Mobile technologies also have benefits for behavioral health conditions (Dennis et al., 2016; Marsch, Carroll, & Kiluk 2014; Cohn, Hunter‐Reel, Hagman, & Mitchell, 2011). Smartphones and other mobile technologies offer unprecedented opportunities to help patients who suffer from substance use disorders (SUDs). Apps and text messages can reach patients at any time so that routine information can be reviewed at the patient’s convenience. Critical intervention can occur when risky situations arise and help is needed most.
Access to behavioral health services expanded significantly under the Affordable Care Act, but historic challenges to deployment remain a sticking point. Too few providers are trained in evidence-based behavioral health treatment, many service sites suffer an institutional bias against change, and there is a lack of resources to meet demand (Williams, Perillo, & Brown, 2014). Mobile technologies can overcome many of these barriers (Marsch et al., 2014a). For example, deploying an app requires less training than personally implementing an evidence-based treatment, and apps are very cost effective compared to individual provider contact with patients.
One web-based behavioral intervention was found to serve as a partial replacement for standard methadone maintenance treatment (Marsch et al., 2014b). The increased monitoring possible through interactive mobile phone use was found to increase mental health outcomes by providing frequent reminders and clinical resources (Reid et al., 2011). Additionally, a digital “dialectical behavior therapy” coaching system led to decreased emotion intensity and urges to use substances (Rizvi, Dimeff, Skutch, Carroll, & Linehan, 2011). Finally, A-CHESS, a multifaceted smart phone app used with individuals with alcohol use disorders, demonstrated positive results by significantly decreasing drinking days for patients post treatment (Gustafson et al., 2014).
Users of some specific health apps find improved treatment accessibility, participate at greater rates, receive real-time health monitoring and tracking of treatment progress, and seek personalized feedback and motivational support (Donker et al., 2013).
Despite these successes, technology-based health care remains a young field. It is telling that seemingly every paper on mobile apps concludes with a statement that more research is needed.
“More studies are needed to examine the efficacy of mobile technology in alcohol intervention studies. The large gap between availability of mobile apps and their use in alcohol treatment programs indicate several important future directions for research,” one team (Cohn et al., 2011) writes.
Another (Donker et al. 2013) concludes, “The public needs to be educated on how to identify the few evidence-based mental health apps available in the public domain to date. Further rigorous research is required to develop and test evidence-based programs.”
More research alone is not enough, though. Health researchers and providers who embrace mobile technology must also adjust how they think about it. A different paradigm is necessary.
For all of new technology's promise, health providers must come to terms with the fact that, at least for the foreseeable future, new technologies will not be as thoroughly validated as we might like. The rapidly evolving technological landscape all but ensures that by the time research on efficacy is complete, the tested mechanism will likely have changed or even been abandoned. Careful research requires a year or more, while apps can change monthly.
For example, one easily finds recent studies that have reviewed the implementation and efficacy of text messaging systems (Herbert, Collier, Stern, Monaghan, & Streisand, 2015; Hall, Cole-Lewis, Bernhardt, 2015; Ingersoll et al., 2014; Pop-Eleches, et al., 2011). Text messaging with adolescents with SUDs as part of continuing care services yielded positive results (Gonzales, et al., 2014), and text messaging with young adults treated at an emergency department assisted them in monitoring and reducing the number of risky drinking days (Suffoletto et al., 2014).Other apps such as Snapchat and WhatsApp are quickly gaining market share at the expense of SMS and MMS.
However, just as researchers are starting to examine the effectiveness of SMS text messaging to assist patients in managing their SUD conditions, technology trends demonstrate that traditional SMS text messaging may be in slow decline as users turn to other messaging platforms that include multimedia, such as images and videos called multimedia message system (MMS), especially with adolescents and young adults (Hall, Cole-Lewis, and Brenhardt, 2015 and National Public Radio, 2014).
When this happens with other mobile apps, as it certainly will, health providers should not jump to the conclusion that the research is not useful. Uncertainty need not undermine the implementation of evidence-based practices for behavioral health. Instead, researchers and health providers must think differently about how and what they study. A particular app might not have deep data validating its use, but the model and theoretical framework it embodies can be tested and validated.
That is not to say that any given application should go untested. Smart phone apps are vulnerable to possible dangers such as malfunctioning or faulty programming, poorly-designed knock-off apps developed without clinical input, and personal privacy violation (Buijink, Visser, & Marshall, 2013).
Among the thousands of apps that claim to provide medical help, few are legitimate. Providers play a crucial role not only in helping patients choose the best ones but also in ensuring that quality apps for specific needs are available. This can and should be achieved with better regulations and standards (van Velsen, Beaujean, & van Gemert-Pijnen, 2013; Luxton, McCann, Bush, Mishkind, & Reger, 2011). Providers versed in evidence based practices must be at the center of those conversations.
Boudreaux and colleagues (2014) recommended seven strategies for practitioners to follow when evaluating and selecting apps for their patients. These seven strategies include: (1) Review the scientific literature; (2) Search app clearinghouse websites; (3) Search app stores; (4) Review app descriptions, user ratings, and reviews; (5) Conduct a social media query within professional and, if available patient networks; (6) Pilot the apps; and (7) Elicit feedback from patients (p. 365). These strategies can provide guidance to practitioners as there are few validated reviews of apps. There are organizations that certify or classify apps regarding their usability, functionality, accuracy of content, and evidence base. Some examples of these websites include: mobihealthnews.com; zurinstitute.com; socialwellth.com; iMedicalapps.com; and imshealth.com. Recently, a well-established website for rating behavioral health apps, NHS Health Apps Library, took down its website as many of the apps it recommended were found to have privacy and security concerns related to collecting users’ personal information. Most apps and mhealth technologies do not fall under the Food and Drug Administration definition of mobile medical apps so are not regulated because they “pose minimal risk to consumers.” However, it is important to remind patients about safeguarding private information when using apps.
Health care providers who develop apps must work with validated models and evidence-based practices if they are to provide the best treatment to mobile patients. They must ensure that the programmers who write apps incorporate those systems properly. Then, though we might not have deep testing of how well a new app works, providers can at least know that it is grounded in a well-tested model of care that has been demonstrated to improve patient outcomes.
In the behavioral health field, especially for those individuals with SUDs, "…technology has enormous potential to provide a highly influential tool to assist individuals in overcoming their addictions that appropriately meets individuals’ expectations and needs" (Gainsbury & Blaszczynski, 2011). Recently, research studies found that intervention, treatment and recovery technologies provide effective tools for people struggling with addiction. This finding is significant and has important implications for the SUD field given that a large proportion of individuals with SUDs do not seek treatment and there are high attrition rates among those that do. Consequently, technologies can play a critical role in ensuring equity in and access to both treatment and recovery support services.
The Substance Abuse Mental Health Service Administration (SAMHSA) developed four free apps that are available to download at http://www.store.samhsa.gov/apps/:
In addition, SAMHSA has a new TIP on Technology Assisted Care called Tip 60: Using Technology-Based Therapeutic Tools in Behavioral Health Services.
The National Frontier and Rural Addiction Technology Transfer Center: (NFAR ATTC) has a variety of training curricula, workshops, and products available for behavioral health practitioners that help promote the use of technologies in intervening, treating, and providing recovery supports from SUDs. NFAR ATTC offers these training workshops:
These trainings can be added to conferences or offered as stand-alone trainings. Please visit the NFAR ATTC website at www.nfarattc.org to request a training as well as review and download different products.
Technology-Assisted Care for Substance Use Disorders: In collaboration with several regional ATTCs (Northwest ATTC, Northeast ATTC, and South Southwest ATTC), NIDA and NIDA researchers, NFAR supports the www.sudtech.org website, which includes training, videos, and a literature review on technology-assisted care.
Telehealth Tuesdays: In addition, NFAR ATTC sponsors a monthly media series called Telehealth Tuesdays on the second Tuesday of every month and highlights new trends in the delivery of technology-assisted care.
Annual Technology Summit: Finally, NFAR ATTC conducts an annual summit on technology and behavioral health. The 2016 summit will be held in Philadelphia August 3-5. There is no registration fee to attend the summit. Registraion is now open! Visit www.nfarsummit.org to check out the line-up of speakers and workshops.