Continuing my series on Consumer Health Success, another group of apps getting good attention involves personal fitness and wellness. Wellness apps are great and I’ve seen some pretty cool ones recently for health challenges and diet tracking, but, for the purpose of this post, I want to focus on fitness apps specifically. They are already using social and gaming aspects tied to personal health that, in theory, create stickiness and can change behavior.
I realize that fitness apps really only appeal to the "Motivated Healthy", or the group that is probably in decent shape already and just wants to beat their last marathon time. Despite that, I really think there are some things that can be learned from them and potentially applied to more of a healthcare setting, or to more of a population that needs help getting healthier.
Specifically, I’m going to talk about RunKeeper. I’ll also talk about Nike+. I’m sure there are other similar offerings, but these two have the most uptake. I’ve only used RunKeeper myself.
(I was going to try Digifit, which I’ve heard a bit about, but the app store has a confusing number of Digifit apps. I decided it wasn’t worth the time to sort out which one I needed.)
It doesn’t really matter that I’m focusing on RunKeeper since I’m not comparing specific products or services, but rather exploring what is being offered to consumers to integrate personal data and encourage healthy behavior. If you were looking for a comparison of RunKeeper and Nike+, here is a good one.
What are RunKeeper, Nike+, and Digifit?
RunKeeper started in 2008 as an iPhone app that used the built-in GPS to track activity. It supports swimming, but I’ve only used it for running and biking. Nike was doing this first with its foot pod, but RunKeeper launched exclusively as an app to take advantage of the hardware and offer a very cheap alternative that worked with whatever shoe you were wearing.
Also, I didn’t know that the initial Nike foot pod was the inspiration for ANT, the wireless technology now used for most of the fitness monitors. RunKeeper has to use ANT with its integrated heart rate monitors on the iPhone because of the lack of control Apple gives to developers to access Bluetooth in iOS.
Over the last three years, RunKeeper has grown incredibly fast to over six million community members. It has gone beyond mobile fitness data collection to create an online fitness (I’m hesitant to call it health) community, with personal tracking and reporting tools.
Social+Fitness+Games
The other thing that RunKeeper did, and I think this is probably a result of starting as an mobile app company as opposed to an athletic gear company (Nike), was really take advantage of the smart phone functionality and connectivity.
The first thing RunKeeper enabled was sharing your activities via Twitter and Facebook, though I think initially it was Twitter alone. It is motivating to know that people are going to see your results. With RunKeeper Elite ($4.99/month), you can even share your performance in real time to increase the pressure to keep going.
It would be nice if you could motivate certain populations to post about things like meals to create incentive to eat better, although I guess people could just fudge meal entries if they wanted to cheat on a diet and not hear about it. That is the nice thing about GPS — it’s harder to fudge. It’s also why a sensor system, like GlowCaps, is nice for tracking adherence.
In addition to your own activities on RunKeeper, you can also share and find routes based on your geography. This comes in handy if you travel or move, as I recently did.
The other thing that RunKeeper has added is the ability to enroll in a "Fitness Class" (additional/hefty fees required per class). The idea is that you get to register for a marathon or 5K or run-to-lose-weight training program that creates a schedule for you and then uses the app to track your performance on the schedule. Your performance, and that of the other people in the "Fitness Class," are shared with the group. You get motivation and are encouraged to motivate others. Nike+ does this in a slightly different way with fitness challenges.
These challenges and classes are one of the key things I can see being of value as tools for healthcare. I’ve participated in in-person group sessions with diabetic patients where group members share about diet, activity, recipes, meds, etc, and get support from other members of the group. The problem is that they only meet a few times a month, making too late to fully encourage and affect healthy behavior.
It’s all about that timely feedback loop everybody keeps talking about. Doing it virtually and over mobile might be a way to improve that, but you need to get the group engaged and also using mobile. Both of those might be a challenge unless you’ve got full buy-in from a provider.
The next step – RunKeeper’s HealthGraph
As the user base has grown, RunKeeper has integrated additional products that connect to its platform. It has heart rate monitors, pedometers, body weight scales, and even the Zeo sleep monitor to track and report on your sleep. What is RunKeeper hoping to do with all of this personal data it is collecting from motivated users?
Well, pretty close to the time Google Health was announcing its retirement, RunKeeper announced Health Graph, which, as the Twitter post above implies, is designed to replace the PHR or evolve the PHR concept.
What is Health Graph exactly? I’m not entirely sure myself beyond concept, but my understanding is that it correlates health and wellness data (eating, exercise, sleep) with social interactions to help users gain insight — and more actionable guidance, I hope — related to what works and what doesn’t work for their health.
The Health Graph is not confined to fitness data. It has defined data types for blood pressure, cholesterol, CRP (really?), TSH (really again?), glucose, insulin, vitamin D, and a few others. All are relevant data points for certain conditions, provided users with those conditions find their way to RunKeeper. I have to assume RunKeeper plans to integrate this data automatically from labs and providers.
RunKeeper is opening up the API to hopefully encourage developers to create tools based on RunKeeper’s growing volumes of data. Maybe developers will be creative enough to stretch this beyond what RunKeeper is currently doing — providing motivated fitness enthusiasts with reports on their performance — and make it into a tool that could help a diabetic patient better control their disease.
I’m really not sure, though. When I look at the example of an app on RunKeeper’s site that could be powered by Health Graph, I have to wonder what is so magical about the correlation engine RunKeeper has developed. The example plots weight, average calories, average sleep, average activity, and social network motivation (# of comments) per week for several weeks. Not surprisingly, weight is down when you eat less, sleep more, are more active, and have more social comments.
Do people really not know this? I think for the most part they do, even the sick ones do. You need to do more than show them the correlation between eating poorly and being overweight. RunKeeper probably had it right with the social connections and fitness classes alone, before all the Health Graph stuff. But maybe Health Graph will encourage other app developers to give RunKeeper more data, and over time, that data will become actionable in a way that encourages unhealthy people to be healthier.
I think RunKeeper will have to create some institutional partnerships to accomplish anything meaningful outside of the group of motivated users it is already targeting. Maybe if you’re RunKeeper you’re thinking, why bother, I’ve got six million motivated users over three years, why do I want to fight an uphill battle to attract unmotivated users? It sort of makes sense, and to that end, maybe RunKeeper should not lose focus on its user base by extending to things like TSH and insulin.
Travis Good is an MD/MBA and is involved with health IT startups.
UpToDate (UTD), the clinical reference tool that is amazingly useful for finding summaries of evidence on medical topics, launched a native iPhone app today. Every academic center I’ve spent time in provides access to UTD on its network and clinicians use it frequently. It’s a pretty great tool as it has over 9,000 medical topics summarized and presented with links to countless studies. UTD is also used as the clinical content for ProVation Order Sets (both ProVation and UTD are owned by Wolters Kluwer Health).
UTD has over 450,000 subscribers. For a very good and timely article on why UTD is so popular with docs, check out this recent Forbes article. According to UTD user surveys (n=~14,000), 94% of users found that UTD improved care and 90% found it saved time.
The service is offered as a subscription at $495 per year for individual physicians (and I’m sure an arm and a leg for an institutional license.)
Mobile access is provided through mobile-optimized content accessible through the most popular mobile browsers. The new native app is available for free to current UTD subscribers.
I had a briefing with Vicki J. Brown, vice president of marketing for UTD about the new app. I was curious what percent of users access UTD over mobile browser and if she had any stats on the types of devices accessing the mobile site. She informed me that about 85,000 users access the site on iPhones, with iPads and Android devices a very distant second and third.
Though Internet connectivity is required in the initial release of the app, an offline mobile app loaded with UTD content (~1 gig) will be available later this year. UTD developed the current app in-house and tried to take advantage of the iOS functionality. They include common filter options (peds, adult) as buttons at the top of search result pages.
I was curious if UTD had any thoughts about consumer-facing mobile health apps. Vicki informed me that the UTD value and expertise is with providers. I definitely agree. Consumer value and usage for UTD is driven by providers linking them to the content.
If you have a UTD account, give the new app a try.
More News
A new service from non-profit FAIR Health allows users to look up the costs of medical procedures in there geographic area. The goal is to help users budget as well find cheaper providers. The organization was funded by a settlement between the State of New York and several large insurers.
Dossia announces Dossia Health Manager. The new health platform is an extension of Dossia’s PHR platform and will includes customized tools, health gaming, and social connectivity. On the heels of Google Health’s demise, it seems like Dossia is trying to make its PHR something that consumers actually want.
The ONC and The National Cancer Institute launch an a challenge to develop new methods to inform the general public about cancer prevention, detection, and treatment. Winners get up to $10,000 in phase 1 and $20,000 in phase 2. Is that amount even a line item on ONC’s budget?
Along the same lines as UpToDate enabling mobile access for providers, The Sanford Guide is now available as a mobile app for $29.99 on Apple mobile devices. Sanford is the bible of infectious disease treatment. Pretty soon white coats won’t need so many pockets and drug reps will have to start passing out vouchers for mobile app downloads.
We posted last week about researchers at Hopkins correlating Twitter posts with actual flu and allergy rates in the US. Now researchers in Brazil will be doing something similar with dengue fever, but doing it for near real-time tracking.
A new survey finds that you are more likely to go online for health information if you are female, non-Hispanic white, employed, college educated, and privately insured. It’s not terribly surprising as more and more studies find women to be the main users of health apps and tools.
Sermo launches Sermo Mobile for iOS. The app gives Sermo’s 120,000 physician members access to posts, cases, and education on Sermo’s exclusive network. It seems like a timely response as Doximity is fighting hard to create its own exclusive network for providers.
iPad EMR vendor drchrono completes a round of financing, raising $675,000.
Mobile devices represent a threat to patient records because the physical device is easy to steal. The majority of med record breaches, over 60%, result from physical theft or loss. Adding to that, this article provides insights on mHealth security from health IT security experts.
Travis Good is an MD/MBA and is involved with health IT startups.
From Marc in response to rumors that RIM may discontinue the PlayBook: “Things are not going well for RIM, but they deny the PlayBook demise.“ I like that the official response from RIM was issued on Twitter.
Shifting gears a bit in the Consumer Health Success series after last week’s post on WebMD, I wanted to focus specifically on mobile health offerings as a component of a much larger business. For this I chose retail pharmacy and focused on Walgreens, though I tried the apps I found from other retail pharmacies as well to see how they stack up.
Why does mobile matter?
Intuitively we all know mobile is important because this is how people increasingly consume information and interact with the world around them. As such, it should definitely be one of the ways that health providers, payers, pharmacies and any other group in the health system interacts with patients and consumers.
That doesn’t necessarily mean mobile apps and mobile Web sites alone, as a more holistic mobile strategy is necessary. SMS, though without a real wow factor, is a valuable mobile tool we’ve seen used successfully in health for evidence-based and appointment reminders
What about how mobile affects consumers adoption of products and services? I’m fascinated by Facebook’s stats on mobile usage. One-third of facebook users, or 250 million people, access Facebook over mobile, and those mobile users are twice as active on Facebook than non-mobile users.
Understanding that Facebook’s user population is very different from the the population of big health care and Walgreens Pharmacy consumers though seniors are using Facebook more and more), this does show the power of mobile to increase user engagement and brand affinity.
Walgreens’ clear mobile superiority
Walgreens is doing a great job with mobile and is the clear frontrunner for retail pharmacies in terms of mobile strategy and offerings. Check out its mobile page. They have apps for iPhone, Android, and BlackBerry; a mobile Web site; and prescription text alerts. You can even text FLU to a shortcode and get a response with the closest location for flu shots.
In addition to the diversity of mobile offerings, the mobile app itself is far better than that of its closest retail rival CVS. The iPhone app does "Refill-by-Scan", which allows a user to take a photo of the barcode on the pill bottle and have the refill automatically sent to the Walgreens Pharmacy of choice. According to Walgreens, this is the most commonly used method of mobile refill. The app also helps you locate flu shot locations, see your prescription history, and even order photo prints.
The prescription text alert services, which sends a text when your refill is ready to pick up, surpassed one million subscribers in March 2011. It has been around since March 2010.
I tested the CVS iPhone app as well. It doesn’t seem to be optimized for the retina display on my iPhone, so it didn’t really look great. It does allow you to refill prescriptions and see prescription history. It also lets you find MinuteClinic locations, check acceptable insurances, and even find prices (pictured above) for medical services offered. I really liked the cost information, as well as patient education about the services.
Why is Walgreens pushing — and I’m sure paying — for mobile?
Obviously Walgreens is pushing mobile to help build its brand and differentiate itself from competitors in terms of convenience to consumers. It’s doing this, as I was told by a close buddy that worked for a national retail pharmacy for a while, because "the ROI for anything that gets people into the store more frequently to pick up meds is almost immeasurable. That’s because they are bound to walk out with a lawn chair and a candy bar in addition to the meds."
What’s the point of this post?
Despite Walgreens’ motivations around money, shareholder interests, and lawn chair sales volume, there is real potential to help consumers get timely refills (also a benefit to Walgreens) and maybe even curb some of the estimated $300 billion per year in medication non-compliance costs. I’m not sure if that last part about reducing the financial burden of non-compliance is very realistic, but hey, it’d be nice if the app and refill reminders helped that at all.
That said, there are definite lessons to be learned. Walgreens and its mobile offerings, which I’d classify as a success given the number of text subscribers and iPhone reviews (~19,000), have a much easier time finding willing users than a health system would for its mobile offerings. There are probably several reasons for this, but the most important is that Walgreens is much more a part of the daily life of all consumers (chronic disease health care consumers included) and people will use services that make their consumer experience more convenient.
Most people with chronic diseases — and I’m not talking about the ones that are home bound, immobile, or in assisted living facilities — go to get meds at least once a month. Many of them only go to see their PCP once every three, six, or 12 months (we hope). Because of that, pharmacies and pharmacists are seen as a place where healthcare can be delivered to the masses. We see in-pharmacy clinics popping up, and if not a full-fledged clinic, then at least you can get your flu vaccine while you pick up your insulin.
Maybe the same applies to consumer and mobile health tools. Maybe consumer health companies should look beyond providers, payers, and employers to retail pharmacies as partners. They’ve certainly got better reach, though I’d bet you’d be hard pressed to prevent the Walgreens and CVSs of the world from doing it themselves. Still, it still seems to me to be worth a shot.
Travis Good is an MD/MBA and is involved with health IT startups.
FDA Issues Guidance on Oversight of Mobile Medical Apps
As many predicted, the FDA finally issues proposed guidance on the regulation of mobile medical apps (press release and actual guidance.) The proposed oversight is open to comments from the public for the next 90 days.
According to the FDA, "The Food and Drug Administration (FDA) is now proposing guidelines that outline the small number of mobile apps the agency plans to oversee—medical apps that could present a risk to patients if the apps don’t work as intended". The subset of mobile apps that the FDA has identified to regulate include those that 1) are used as an accessory to medical device already regulated by the FDA and 2) transform a mobile communications device into a regulated medical device by using attachments, sensors, or other devices. If regulated, devices fall into Class I, II, or III, each with its own regulatory requirements.
My summary and interpretation of apps that will be regulated are:
Those that use sensors or connect to a device directly or wirelessly. For providers, these are all the attachments to EKGs and other monitors. AirStrip and Calgary Scientific come to mind and I think both already have FDA approval. For consumers, this would be apps that connect to devices or sensors to store and transmit data. MedApps and Withings come to mind and again, I think they both have FDA approval.
Those that use patient-specific data to come up with treatment decisions. WellDoc is the obvious one here and they have FDA approval, at least for diabetes.
Those that act as medical calculators. This group includes tools like Epocrates but also lots of cheaper (and in my opinion, easier to use) medical calculators. A lot of these have been built by and are used extensively by residents and medical students. I can’t really imagine most of those small developers filing for FDA approval for a simple app that calculates acid base status or Apgar score. Maybe that’s a good thing because, as much as I prefer those apps, in reality lots of decisions are based on them and they should be regulated.
The FDA excluded certain apps as well, including mobile EHRs and PHRs, copies of medical textbooks or other teaching aids, and apps that track, log and "similar decision tools that generally relate to a healthy lifestyle and wellness." I guess as long as the treatment is lifestyle-related, like losing weight if you’re pre-diabetic, an app can help with specific treatment goals and not be regulated.
More News
A new Bulletin Healthcare Briefings report finds that physician mobile use grew by 45% and that 76% of smart phone-using docs have iPhones.
A study from Johns Hopkins finds that Twitter can be a useful tool in public health. My favorite tweet, which was discovered as the researchers were creating a model to read tweets, was "Got a case of Bieber Fever. Love his new song". The researchers analyzed about 1.5 million health-related tweets and found that the analysis correlated with actual data for things like flu rates and the start of allergy season. That’s very cool and a useful example of what can be done with Twitter’s data. Maybe the government should cough up the $8 billion to buy Twitter?
The British Medical Association issues clear guidance for providers on social networks – "politely refuse" friend requests and be wary of posting things to Twitter.
A design firm contracted by Seattle Children’s Hospital builds what I’d describe as a mobile patient viewer. The mobile app, which looks great, takes data from Cerner and other systems to create aggregated summary views of patients, care teams, and hospital floors. The key, now that the prototype is built, is fitting this into the workflow of the providers so that they can use it and benefit from the improved experience. If you can turn Cerner into this then there is still hope. I’m not sure the app does anything more than view, so you still have to use Cerner to enter all the data.
Here’s a story featuring several of the more interesting health technology startups from the Bay Area. Most are consumer facing, like HealthTap and Simplee. I can’t believe Practice Fusion is up to 100,000 docs.
A telehealth group in Tennessee, Community Health Network, lost or misspent $1.2 million over three years. It’s a pretty interesting story showing fraudulent misuse of public funds. It makes me wonder how much is being lost or misspent out of the HIT money.
According to this report, RIM might stop production of its BlackBerry PlayBook tablet. According to a friend of mine, "I knew it was bad for them when they sent me not one, but two PlayBooks to test."
EXTENSION releases its clinical alerts and notifications platform for Android.
Travis Good is an MD/MBA and is involved with health IT startups.
Happy Bastille Day everybody! For some reason it’s a date that sticks in my head from my high school European History class with Miss Murley. Anyway, if you like wine and cheese you should raise a glass tonight. If you like freedom fries and are offended, I’m sorry and in the spirit of transparency, I prefer wines from Australia and New Zealand, specifically Marlborough.
I got an email from my last post when I mentioned the story on “connected independence” telling me about Jitterbug, which I’m quite familiar with and I’ve posted about as GreatCall because that is the website name. “I enjoy reading your HISTalkMobile, and today’s post reminded me to let you in on a little secret called Jitterbug. It’s a mobile phone for older users – asks Yes/No questions only, so the confusion is eliminated. It even has a dial tone. The customer service is incredible, and the website allows care-facilitators (ie, family or others) to set up the phone book on the phone via a web site. But the real kicker is the added services that you can contract. They have services that will call to remind the user to take their meds, call to check in on them, use the phone as an emergency button (and not have to relay the signal through the user’s home land line), and others. Probably worth looking into and including in your posting about connected independence. I know for my 94 year old mother, it’s been wonderful.”Good point and they should at least be mentioned with Robert Bosch and Independa as currently in the “connected independence” space.
Continuing, or starting I guess as this is the first post that is actually about a consumer facing health offering, my series on Consumer Health Success, I thought I’d include what I think of and always hear about as the big success in consumer health, WebMD.
First, maybe everybody knew this but I had no idea that WebMD was much more than just the consumer facing, and ad-driven, website with health information. I was shocked to learn that they also operated several business other than the consumer site.
Medscape – an app I used in med school but decided I preferred Epocrates, as well as an email list and information source for info about providers and practices, including doc salaries. In fact, I still get med student emails from them a few times a week.
eMedicine – I’ve used this site for disease reference and have seen it used by lots of docs to quickly pull up information about symptoms, diseases, and treatments. It’s sort of like UpToDate without the trusted name but much cheaper.
Private Portals – these seem to be catering to employers and health plans.
Again, sorry if this is old news and I’m just uninformed. The company is public with a market cap of $2.7 billion on $558 million in revenue last year. I’m not sure what percent of that revenue or valuation is based on the consumer side of the business but, since that’s the title of the post, that is what I’m going to focus on.
According to WebMD: “WebMD has created an organization that we believe fulfills the promise of health information on the Internet. We provide credible information, supportive communities, and in-depth reference material about health subjects that matter to you. We are a source for original and timely health information as well as material from well known content providers.”
Timing over the last several years couldn’t be better for WebMD as more and more people turn to the Internet for health information. A recent Pew Internet survey found nearly 80% of Internet users, or 60% of all Americans, look for health information on the Internet. The same study found that the majority of those that looked for health information online used that information to make a decision about their health and to change the way they maintain their health or the health of someone they care for. Also, 39% said online information changed how they “cope” with a chronic condition or manage pain.
And where do people go for online health information? You guessed it, WebMD. WebMD gets almost 50% of all health related searches. Doing some math gives you about 30% of the US population that looks at WebMD for health information. That’s pretty staggering, especially considering the same survey found government sites to be the most credible. Maybe the governments needs to hire some search engine optimizers.
So who’s searching WebMD? According to Alexa, WebMD’s audience is disproportionately older (over 45 and all the way up), female, and without a graduate degree. That got me wondering if the graduate school group, underrepresented on WebMD, is bypassing WebMD and going direct to the more credible government sites. To test that theory, I checked Alexa for NIH.gov and found that graduate school users are disproportionately represented on NIH.gov while being underrepresented on WebMD. The NIH also has a higher proportion of over 65 year old users.
My excitement about my new discovery was short-lived as I discovered that the most popular search resulting in somebody visiting the NIH site is “pubmed”. It looks like the graduate users accessing NIH are likely researchers. Oh well.
So what are visitors that come to WebMD searching for to get there? According to Alexa, the most popular conditions people are searching for that direct them to WebMD are shingles, ticks, weight loss, symptom checker, ringworm, depression, and a few other common conditions. Most of these are acute and the most important one is probably weight loss, at least with the lens I’m using to look at the site, because obesity is a central problem and catalyst in most of the common health problems in the US – diabetes, high blood pressure, high fats and cholesterol, and eventually heart disease.
What do you get if you actually Google “weight loss”? You get directed to WebMD’s Healthy Eating and Diet page, it’s the top search result. It’s also the same place you get if you search WebMD for “weight loss”. The site provides all sorts of tips and guidance on dieting, cooking, calculators, shopping, exercising, and a list of forums.
It’s all great information and WebMD is the most popular place for most people looking online for health information but does it hold much hope of improving people’s health, especially the people in desperate need of help. As a passive source of information I can’t really imagine it changing individual behavior. But I guess that’s not what WebMD is all about. It’s just about access to information. My bet is that the first week of January and end of spring is when WebMD gets the highest amount of activity looking for diet and exercise info. Whatever lessons are learned are probably only transiently followed as people slip back to their previous behavior.
To WebMD’s credit, they’ve released several mobile apps that apparently have been downloaded over 5 million times, so they are at least trying to reach people where the are increasingly accessing information. But this is more about eye balls and revenue, not mobile tools to improve health. Realistically, without any incentive or motivation or social network integration or provider links, I don’t think you can meaningfully change behavior, especially with an unmotivated group of American consumers.
What are the big criticisms of WebMD? The WebMD ad-supported model is criticized and WebMD has been described as a “pill pushing” site that doesn’t do any good for consumers except play into their fears about their health. While I agree that sites created to provide evidence-based education and credible content ideally would be without advertisements, this is easier said than done. The NIH does it, but obviously has lost out to WebMD in terms of users and gaining back the upper hand on Google’s page rank is no easy task.
Mayo has just launched it’s online communities site and, as a deep-pocketed health system, it can provide it free without banner ads. But Mayo launched its site in 2011 and WebMD has been around for what seems like forever, having been founded as Healtheon by James Clark, the creator of Netscape. It was founded as a business, to make money, and has survived precisely because of this.
As the default source for health info in this country, all that web traffic creates good advertising revenue. At a $2.7 billion market cap, changing the business model to focus on individual outcomes doesn’t seem necessary or prudent. Besides, focusing on being the trusted source of health information is what brought WebMD out of the trough of the dot-com bubble. If there is anything to be learned from that story, it is that a business needs to prioritize and focus on the core value proposition of the business.
Consumers need to know, clearly and concisely and without searching, what you are offering and how it benefits them. Access to health information is enough for WebMD and it’s users, so why change?
Travis Good is an MD/MBA and is involved with health IT startups.
