2015 American Journal of Gastroenterology Lecture

How Digital Health Will Transform Gastroenterology

Brennan Spiegel, MD, MSHS


Am J Gastroenterol. 2016;111(5):624-630. 

In This Article

Digital Health Technology No. 1: mHealth Apps and EHR Portals

EHR portals and smartphone apps allow patients to transmit data to providers, track their own data, receive education, connect with other patients, schedule appointments, refill prescriptions, and access test results.[6] EHR portals, such as the Epic MyChart or Athenahealth Communicator, offer bidirectional access between patients and clinicians through the health record. Third-party mHealth apps, of which there are now >165,000 available,[7] may allow patients to connect with their doctor or may be a stand-alone program without connectivity to a health system. Because it is still technically challenging to connect third-party apps to many commercial EHR systems, most apps are not yet seamlessly integrated with the EHR. However, this should change soon as "meaningful use" legislation makes it easier for patients to access their own EHR data via apps. Also, most EHR vendors are developing technical solutions to connect with third-party offerings.

Treating the EHR like an "app store" has potential to transform it from a mere data repository to a dynamic, service-oriented platform. Yet, despite the promise of EHR portals and apps, there are relatively few digital solutions that assist clinicians in diagnosing, educating, managing, and ultimately enabling patients. As an example of a clinically useful app supported by published data, Bajaj and colleagues developed Encephalapp—a smartphone-based test for hepatic encephalopathy (Figure 3).[8,9] In a set of elegant studies, the investigators found that Encephalapp can diagnose encephalopathy with a high degree of accuracy when compared with the specialized Stroop test.[8,9] This is an example of an app that fills an unmet clinical need by efficiently and accurately diagnosing a critical condition at the point of care or even remotely.

Figure 3.

Example of mHealth apps in gastroenterology and hepatology that are supported by peer-reviewed research. On the top is Encephalapp, an accurate point-of-care test for diagnosing hepatic encephalopathy in cirrhosis. On the bottom is MyGiHealth, an app that measures NIH Patient Reported Outcomes Measurement Information System (PROMIS) scores in patients with gastrointestinal symptoms and automatically writes a history of presenting illness report for use in clinical practice.

As another example of an app supported by published data, our research team developed and tested an online system called MyGiHealth.[10,11] A patient connects to the system on their computer, tablet, or smartphone. Next, they report their symptom history from home, in the waiting room, or from any other connected location. The app collects information using a computer algorithm that guides patients through a library of questions measuring the timing, severity, frequency, location, quality, and character of their gastrointestinal (GI) symptoms, along with relevant comorbidities, family history, and alarm features. The app then "translates" the report into a narrative history of presenting illness (HPI) written in language familiar to clinicians and made available through a portal. In addition, the app measures symptom severity with validated scales from the NIH Patient Reported Outcomes Measurement Information System (Figure 3).[12]

We conducted a head-to-head study comparing the quality of HPIs composed by physicians during usual care vs. HPIs generated by the app.[10] Blinded clinical reviewers graded the HPIs using a standardized scale; they did not know that a computer had composed half the HPIs. The computerized HPIs were perceived to be of higher overall quality, better organized, and more succinct, comprehensible, complete, and useful compared with HPIs written by physicians. In addition, a blinded Medicare compliance officer judged that 100% of the computerized HPIs could be billed at the highest level of complexity, compared with 88% of the human histories. In a separate study, the app also identified more alarm features than the physicians, such as weight loss or rectal bleeding.[11] These results provide an example of how we might coax more functionality from the EHR by connecting it with an app designed to support the needs of patients and clinicians.

Although not yet published in peer-reviewed research, the SmartClinic app is another mobile solution designed to improve the patient experience and help the doctor. Developed by Paul Berggreen, a gastroenterologist in Arizona, SmartClinic can be used to remotely send colonoscopy prep protocols and instructions, appointment reminders, treatment instructions, and satisfaction surveys. The app also provides secure messaging between patients and their providers and allows for compliance tracking and measuring of quality indicators.

There are a wide variety of other apps of relevance to gastroenterologists, including symptom tracking apps (e.g., Poop Log, Bowel Mover, GI BodyGuard), bathroom finders for patients (e.g., Sit or Squat, Poop Map, ipee Address), and disease-targeted apps for inflammatory bowel disease (e.g., Gut Check, GI Buddy), irritable bowel syndrome (e.g., Sounds Like IBS, Bowelle), and constipation (e.g., Tummy Trends), among many others. Although many of these apps offer helpful information and positive user experiences, very few are supported by published evidence. This is important because the effectiveness of any biomedical intervention—whether digital or otherwise—should optimally be supported by peer-reviewed research.