Sheryl A. Bedno, MD, MPH, MS; Darrin M. Vicsik, MBA, MHA


December 18, 2012

In This Article

Public Health Smartphone Apps: Disadvantages

Non-evidence-based apps. Although the number of health-related apps has skyrocketed, it is not known how many of these are evidence-based or were developed by reliable or reputable health or medical organizations. Because almost anyone can write and post a smartphone app, most apps do not adhere to evidence-based literature. Recent articles on apps for exercise[9] and tobacco cessation[10] concluded that most of these apps do not follow any established guidelines. Abroms and colleagues[10] examined iPhone apps for smoking cessation and found that most of the apps were not evidence-based. Rabin and Bock[9] tested physical activity apps among a small group of sedentary adults to determine their most-used features. Most of their study participants wanted goal-setting and problem-solving features in their apps. However, app developers might not have involved patients or consumers sufficiently during app development.

Workplace distraction. Healthcare providers can become distracted by their smartphones. According to a recent study,[11] smartphone use during attending rounds was prevalent and had the potential to distract users during important information transfer. Attending physicians strongly favored the creation of formal policies governing appropriate smartphone use during inpatient rounds.[11] In one case, an attending physician told a resident to stop administering a patient's warfarin. While the resident was using her smartphone to enter the order into the hospital's computerized physician order entry system, she received a text message from a friend about an upcoming party. The resident texted her party RSVP but never completed the order to discontinue the warfarin, and the patient continued to receive 10 mg each day for the next 3 days.[12]

Acceptance and image. Smartphones may not be acceptable to all patients or even to all healthcare providers. In the NHS antibiotic project, the main reasons why providers were reluctant to use smartphone apps in front of patients were that smartphones were not allowed and that it would look unprofessional to use them.[7] Although many residents believe that smartphones increase their efficiency, smartphone use also was associated with more interruptions, unprofessional behavior, and weakened relationships.[13] An understanding of barriers and attitudes about smartphone use is critical. Putzer and Park[14] explored the decision by physicians to adopt smartphones in their daily clinical practices. They explored various factors, including physician compatibility with smartphones, personal demographics, relevance of the smartphone to the physician's job, and internal and external environments. Variables that showed a higher magnitude of significance were compatibility, job relevance, and hospital environment.

Security and confidentiality. Another concern, especially with personally owned vs corporate-owned smartphones, is security. Smartphones are embraced for their convenience, but security expert Prof. Mark Duke, of the National Defense University, stated, "Show me a convenience and I'll show you a vulnerability." (Information Assurance and Critical Infrastructure Protection [Course AII 6203]; March 22-26, 2010.) Malicious software ("malware") for cell phones could pose a greater risk for consumers' personal and financial well-being than computer viruses, say scientists from Rutgers University. In a laboratory environment, scientists have developed a particularly resilient malware, known as a rootkit, that can turn a cell phone's microphone, GPS, and battery against the phone's owner.[15,16]

Smartphone users can follow a security checklist to minimize vulnerabilities to the information on their devices. Smartphones, similar to wallets and other valuable property, should never be left unattended. This minimizes the chance of unauthorized use or the installation of malicious apps. Next, the smartphone's password protection should be enabled, a simple step that most smartphone users do not take. Users should install and update their smartphone's operating system whenever available. A 2011 report stated that 90% of Android users were susceptible as a result of using an outdated operating system.[17] Installing an anti-malware protection app (if available for the device) to thwart infection from malicious apps and Web sites is highly recommended; all major platforms have been hacked and are susceptible. Similar to online use of a home personal computer, smartphone users should be selective in visiting questionable Web sites or buying and installing apps from untrusted sources. Also, as with laptop or tablet usage, smartphone users should not use "open" (non-WEP/WPA enabled) Wi-Fi spots because data sniffing on these open networks is common. Finally, Bluetooth should be default disabled and enabled only when needed.[18]

Smartphone access. Many patients do not have smartphones or do not fully understand how to use their smartphones. They are unable to use an app even if one is recommended to them. Some do not understand why a healthcare provider is using a smartphone during the visit. In addition, patient-related or other sensitive information should not be recorded on any smartphone without consulting with the local facility's policy. Some institutions distribute devices that have encryption and security to support the recording of patient information. Hospital-specific policies could include the use of smartphones and other devices in cases where smartphones do not interfere with medical equipment[19,20] and regulations on confidentiality (to include taking photos and storage of sensitive medical information).

Medical application regulation. The US Food and Drug Administration recently outlined regulation of medical mobile applications[21]; as expected, this prompted much discussion and debate. Some have wondered whether this oversight will have an effect on innovation and certain mobile applications. The mobile apps that will be included in the regulations are those that use supplemental attachments to transform a mobile platform into a medical device and others that act as accessories to an already regulated medical device.[21]