mHealth in Neurology - An Introduction

Primary Category

Digital Neurology

P-Category

Secondary Category

S-Category

Authors:

Filzah Faheem MD,
Junaid Kalia MD

Youtube Video:

Defining mHealth

💡

World Health Organization stated mHealth as:

“The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe.”[1]

Also defined as “The use of mobile computing and communication technologies in health care and public health” [6]

About 5 billion wireless subscribers worldwide and 70% of them belong to low-middle income countries. [1]

As of 2021, Google Play App Store and Apple App Store are the two largest app stores depending upon the availability of mobile apps to their users

3.48 million apps on Google Play Store
2.22 million apps on Apple App Store [3]

Medical Apps available on app stores

Google medical apps increased from 23,000 in 2015 to 53,000 in 2021 [4]
Apple medical apps increased from about 28,000 in 2015 to 54,000 in 2021 [5]

The utilization of Information and communications technologies (ICT) in the healthcare system termed eHealth has been increasing over the years and the provision of mHealth via applications is the new norm of the twenty-first century. [2]

From Home-visits to Hospital-based care to the advent of mobile technology, the healthcare system has revolutionized over time.

Need of the hour to incorporate mHealth as a part of the current healthcare system as it will

Refine quality and continuity of care
Make better the health information system
Improve the life quality of patients by preventing and early detection of acute as well as chronic diseases [7]

The implication of mobile health is not an easy task as the systems being used to build mobile apps should be intelligent enough to make decisions with the use of evidence-based algorithms

Clinical Decision-Support System (CDSS) is a software that integrates patient-related factors such as age, gender, ethnicity, health status with the computerized clinical knowledge basis that can be effectively used to operate Health related apps

Will minimize the medical and clinical errors
Will timely provide patient data to the healthcare physician
Will interlink patient-centered data

In order to effectively implement CDSS, first, we need data about physician decision making processes during the patient-clinician encounters that will refine the system and will make it error free[8] [9]

mHealth and all related applications should address both physician preferences and patient needs but we need systems and tools that should be more patient-centered.

Benefits of mHealth applications

Research done by Hussein et. al. depicts the adoption of a mHealth application by patients that will benefit their

Need to increase awareness about how any mHealth application will benefit them.
How to use it in the most effective way[14]

According to Health Belief Model, the perceived benefits factor has played a major role in the adoption of mHealth applications as these applications were perceived as

Easy to use
Time-saving
Cost-effective as most of them are free
Accessible
Enable two-way audio/video communication[14]

Will allow continuous monitoring of the patient's health, blood pressure, heart rate (stroke patients)

This regular self-monitoring by patients will result in fewer out-patient visits
Necessitating a visit by the patient only when needed [13]

An International survey done in 2012 highlighted the impact mHealth can have on patient behavior such as daily exercise, medication intake.

Three-quarters of patients considered mHealth as a tool that will help reach their disease control targets
60% enlisted mHealth as a means to let them take care of themselves independently[15]

With the increase in ownership of mobile phones by population and access to the internet, mHealth interventions are improving the already existing digital divide.

Upgrading healthcare in vulnerable populations
Providing access to health interventions worldwide
Still, the digital divide exists globally due to the illiterate, low-income population in LMICs.

Localization of the mobile manufacturers will decrease the cost thus improving technology access and affordability.[21]

💡

The headline findings of the Whole System Demonstrator program revealed that effective delivery of mHealth (telehealth) services will decrease

Accident & Emergency admissions by 15%

Emergency admissions by 20%

Elective admissions by 14%

Mortality rates by 40%

Bed days by 14%

Thus necessitating the enforcement of mHealth to have better healthcare outcomes [16]

With the innovation of cloud computing, mobile devices can now offload large amounts of data to other devices and data can be backed up on mobile phones whenever required via synchronization.

This will allow long-term storage of patient data, thus enabling its retrieval whenever needed [11]
Recently, NIH and ONC approved an initiative “Precision Medicine Initiative” which has been commenced to test the technology that allows patient-data sharing using Genomic Data Commons, Cancer Genomics Cloud Pilots, and Genomics Application Programming Interface.
This will allow the computing and sharing of patient data. [30]

Verification/Assessment of Mobile health applications

The Food and Drug Administration Agency

Policy for Device Software Functions and Mobile Medical Applications was first issued by FDA in 2013 then it was revised in 2015 and 2019.

Defined the mobile application and mobile platforms
Set the regulatory approach for software functions
Advised regulatory requirements. [27]

FDA has been authorized to provide guidelines about the advent of mobile apps but it only provides data regarding patient safety using that application along with functionality.

FDA has categorized the mHealth apps as

Class I - least risk devices that just need general control
Class II - pose risks to patients, needs general control along with premarket FDA approval
Class III - applications with greater risk thus necessitating approval by FDA [19]

Xcertia mHealth App Guidelines

This guideline panel was first formed in 2012, then updated in 2017, 2018, and 2019 with the availability of public comment. This panel included the following founding members

American Medical Association (AMA)
American Heart Association (AHA)
Healthcare Information and Management Systems Society (HIMSS)
U.S. Food and Drug Administration (FDA)
Mobile Marketing Association
DHX Group [22]

In order to ensure mHealth delivery to the population along with goals to improve its adoption and utilization Xcertia guidelines are categorized into 5 sections;

Privacy
Security
Usability
Operability
Content [22]

A NIST Cybersecurity Practice Guide titled "Securing Electronic Health Records on Mobile Devices," was released by the NCCoE. The rationale to release this guideline for the healthcare system includes

The popularity of mobile devices use to access and transmit electronic health records
Risk of patient data-stealing if no proper system came into account
To make sure healthcare providers can share data using tools fulfilling cybersecurity standards [23]

mHealth Task Force Recommendations

In 2012, the Task Force created the community to set goals in order to provide care using wireless technology.

Identified barriers in the adoption and advancement of mHealth

It put forth five goals to be in consideration while making the recommendations

“Goal 1: FCC should continue to play a leadership role in advancing mobile health adoption.
Goal 2: Federal agencies should increase collaboration to promote innovation, protect patient safety, and avoid regulatory duplication.
Goal 3: The FCC should build on existing programs and link programs when possible in order to expand broadband access for healthcare.
Goal 4: The FCC should continue efforts to increase capacity, reliability, interoperability, and RF safety of mHealth technologies.
Goal 5: Industry should support continued investment, innovation, and job creation in the growing mobile health sector. “[35]

Health Insurance Portability and Accountability Act

Protected Health Information is essential to HIPAA

💡

Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual” that is:

Transmitted by electronic media;

Maintained in electronic media; or

Transmitted or maintained in any other form or medium. [41]

Apps that gather, store, and transmit patient data are required to comply with HIPAA as it

protects the secured patient information from threats and cyber-criminals.
prevents non-permissible sharing of patient data
maintains the integrity of the data [42]

Importance of mHealth in Neurological Patients

Since the invention of the first smartphone in the 1990s, [10] not only the communication perspectives have changed over time but it has also revolutionized the healthcare system.

From effective physician-patient communication to patient daily health monitoring. Mobile phones have become commonplace in the healthcare system, especially in neurology.

In the healthcare system, mobile phones have made it easy for patients to

Make appointments
Reminders about scheduled appointments, medication intake, healthy dietary intake, and any lab tests needed
Receive their medical reports via the use of 4G services[12]

But the use of mobile health goes far beyond this in the field of neurology

Blood pressure monitoring apps allow post-stroke patients to self monitor their blood pressure

Increased BP awareness
Reduced stress among the patients
Increased adherence to medication [17]
6-month survey observing the impact of mHeath revealed 87.5% emergency department visits in mHealth care group as compared to just a 20% decrease in the group receiving standard care (SC).

Even physicians received weekly reports of patients in the mHealth group
Retrieval of the 6-month report was also possible
Daily alarm or email reminders made continuous monitoring of the patients in the mHealth group easy as compared to the SC group. [18]

Diagnosing epilepsy became easy per the availability of mobiles to record seizures right at the moment. [33]
Even the patient can send the video of his movement disorder to the neurologist from anywhere on the globe, [34]
Mobile applications such as ‘Speak it’ converting text into speech can help patients with stroke or aphasia. [43] [32] Similarly, another application that helps with anterograde amnesia will also benefit the patients.[31]

Utilization of m-health in Neurology

mHealth also known as the Internet of Things has advanced over the years and it is not only helping the patient to track record of their health but also easing the ways for the physicians especially neurologists, researchers, and clinicians.

Clinical Trials and Patient Assessment

Mobile apps and wearable technologies have made clinical trials easy and improved the strategies.

Patients with chronic diseases can continuously monitor themselves and thus this can be utilized in the clinical trials
Pharmaceutical companies are planning to use mHealth technology in clinical trials[25]

A meta-analysis done to observe the stroke risk factor control using mHealth revealed greater HbA1c reduction and abstinence from smoking among the stroke participants at the end of 6 months. [26]

Benefits of implementing mHealth in clinical trials include

Acquiring real-time data
More accurate continuous data collection
A better understanding of patient adherence
Telemonitoring reduces monitoring effort. [25]

Data Assortment and Medical Records

The Office of the National Coordinator for Health Information Technology (ONC) acknowledged research platforms that will boost the research strategies by providing new mHealth approaches. [28]

One example of such a platform is Apple ResearchKit. This will enable neurologists to

Gather more data related to their area of interest
Carry out surveys
Sharing of results with the community
Visual content creation[29]

Mobile Electronic Health records have become a norm with passing years and many guidelines have been commenced to decrease the vulnerability of patient records.

Many Hospitals have started mHealth as a part of their healthcare system to provide care to the patients.

M Health by the University of Minnesota is proving care to patients using mobile Electronic Health Records.

Patients are able to access their medical records using mobile applications and if their records are on the M Health they need not transfer as their physician can access them.[24]

Education and Training

Mobile apps help not only to educate patients but are also a tool to bring information to neurologists.

Many applications have been launched that help students, residents, and neurologists gather knowledge. These include

Similarly, there are many apps and websites for patients where they can access data and gain knowledge about their health conditions and neurological disorders These include

Thus, mHealth has made knowledge readily available, accessible, and updated.

Table 1: Examples of mHealth Applications in Neurology

1A. Neurovascular

mHealth Apps	Particulars
Language Therapy 4-in1	Speech therapy app that helps stroke patients with aphasia Improves reading, writing speaking, and listening
Dexteria	Helps patients to practice finger movements Improves learning pincer grip to full finger movement
Peak-Brain Training	Helps patients to improve their cognitive thinking
Stroke Patient	Provides stroke-related information to the patients in short segments
e-Stroke Mobile	Uses AI algorithms to support clinicians interpreting scans
mStroke	Mobile app with two NODE sensors Sensors on the chest, arm, or leg send motion data to the app
Stroke Code	Integrates NIH scale and scoring with AHA guidelines Assist in diagnosing, documenting, and transferring decisions
mHealth app	Uses AI technology to observe facial movements and speech Helps with early identification of stroke
Neuro Toolkit	Uses different neurology and neurosurgery scales to diagnose patients with stroke

1B. Epilepsy

mHealth Apps	Particulars
Nile.ai	AI-Powered Epilepsy Management - Endorsed by Epilepsy Foundation.
Epsy App	Tracks seizures, medication routine, and factors affecting the condition of the patient.
Seizure Tracker	Helps to keep a record of seizure length, intensity, triggers, and symptoms. Video can be captured and kept for the record.
Seizure First Aide	By Epilepsy Foundation. Helps anyone to manage seizures who encounters seizures happening around him.
SeizAlarm	Allows patients to set an alarm when the apple app observes any repetitive or abnormal movements.
Embrace2	FDA-approved app that records seizures. Sends data to the caregivers for better management of epilepsy.
Epilepsy Journal	Helps patients record their seizures just by using a simple button. Allows patients to share data with their doctors.
EEG Tutorial	Helps physicians and neurologists to learn EED and diagnose seizures.
Smartphone Brain Scanner-2 (SBS2)	Software and Hardware EEG mobile application. Records EEG of the patient and removes artifacts.

1C. Movement Disorder

mHealth Apps	Particulars
Loud & Clear	Detects changes in patients’ voices. Helps with muscle movements to make voice better.
Swallow Prompt	Helps to swallow saliva and improve muscle movements.
My Parkinson’s Disease Manager	Keeps record of patient’s symptoms and disease progression along with medication reminder. Recorded data helps physicians to know the progress of their patients.
Parkinson's Disease @Point of Care™	Uses AI to help decision-making. Provides clinicians with content that helps diagnosing and decision making.
HopkinsPD	Helps physicians to access the severity of Parkinson's symptoms and the progression of the disease.

1D. Headache

mHealth Apps	Particulars
Migraine Buddy	Records and identifies your migraine symptoms.
Manage My Pain Pro	Records migraine and show this to you in the form of charts or calendars.
N1 Headache	Identifies migraine, triggers and provides the best management for your headache.
Health Log	Record and shares ingo with your doctor not only of migraine but also your health record.
iHeadache	Helps record and share the data with your physicians.

1E. Neurorehabilitation

mHealth Apps	Particulars
Clock Yourself	Helps patients to maintain balance. Patients exercise by moving their feet around the clock face.
Flow Free	A game-based app to help patients. Improves speech, finger dexterity, and also the mood of the patient.
Seeing AI	Helps with speech and language. Reads texts aloud and helps patients with dyslexia.
NHS 24 MSK help	A physiotherapy app helps patients to do exercise along with reminders about their appointments.
Dysphagia	Videos depicting the normal swallowing process. Clinicians can use it to educate people.
Via-therapy	Stroke-specific app showing videos about limb rehabilitation. Heps clinicians refine reasoning and rehab techniques.
Hudl Technique	Helps pro athletes refine their technique. Clinicians can ask their patients to make videos to watch later on.

Challenges/gaps

Though mobile phones have gained popularity because of their smaller screen, do mobile phones really have access to the real web page?

As we all notice the difference in the appearance of websites on the laptop and mobile phones. So, if the answer is yes, after centralizing mHealth we need to advance the websites according to the mobile specifications to render the best form of technology. [36]

Issues like network access, internet speed, bandwidth, and signal strength should be addressed most importantly in rural communities so that better universal health should be delivered. [40]

Though there are many apps available to access and monitor patient health only a few are approved by FDA

Apps providing patient’s data to the physicians should abide by federal laws
Physicians should be aware of fraudulent apps as recommending those will affect their career
mHealth is growing so fast that it is now really difficult to approve and certify apps and then to regularly monitor them [19]

The next challenge that will arise will be interstate laws or practice

Will the physician be allowed to provide care via mHealth in another state or country where he is not licensed to practice?
Either that state has amended the medical laws to include mHealth as a part of care?
We need multistate licensure to be in effect to address this problem.[20]
The Interstate Medical Licensure Compact (IMLC) will help physicians address this issue thus allowing them to practice in multiple states as it has been adopted by many states

objectives of this are to strengthen access and promote healthcare
promoting the use of mHealth to provide patient care [19]

To promote the usability of mobile apps is another hurdle

complex designs requiring multiple links to reach the required information will decrease user engagement
we need simple designs and software to ease the application use
mHealth apps should have user-centered designs [37]

With the availability of EHR on mobile devices, it is a challenge that physicians and nurses connect their devices to a secure wireless network.

connecting devices to a nearby insecure network will increase the risk of criminal access to the health records
Any means resulting in an inability to back up the data from the cloud system can result in the loss of patient statistics.
cloud computing also poses data-stealing threats if it is stored in a non-secure location [38]

There is a need to store the patient data in secured rooms and access should be given to just authority figures.

Health and digital literacy needs to be promoted to enhance mHealth use among the patients as well as neurologist

A survey revealed digital health illiteracy among 16% of participants
27.5% of the low literacy patients utilized patient portal while
42% of digitally-literate patients utilized patient portal to access healthcare facilities[39]

Efforts should be made to increase awareness about how, when, and why we should use mHealth services to maximize patient-centered benefits. [39]

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