Automated Sharing With Their Physician
The ability to share the data that patients are collecting with their physicians seems pretty intuitive. Going a step further, we identified automated sharing as a component likely to improve the utility of self-monitoring of blood pressure.
In a pilot study by Earle et al in which systolic blood pressure was reduced by 2.9 mm Hg utilizing an mHealth intervention, self-measured blood pressure data was transmitted on a weekly basis (8). Similarly, McGillicuddy et al utilized a system that sent weekly reports to clinicians caring for renal transplant patients with poorly controlled hypertension (2). While this study had many limitations, it was noted that more medication changes were made in the mobile health group based on these reports than in the usual care group though other studies suggest benefits in blood pressure control independent of medication changes (4).
Lending some, albeit weak, additional support to this recommendation is the general conclusion of a recent AHRQ comparative effectiveness review of self-monitored blood pressure. While poor data quality and heterogeneity limited their assessment, the panel noted that the evidence suggest synergistic benefits of additional support to self-monitoring alone (9).
Incorporating Usability Testing During Design
Feedback from the end-user is a critical part of good development practice. Work done by Lin et al suggest that such testing can have a dramatic impact on how effectively older adults interact with touch-based software.
In developing education software intended for tablets, Lin et al found a 200% reduction in interface errors and 30% reduction in time required when a single round of small group usability testing was incorporated into app development (10). They also provide an excellent review of the utility of usability testing in their manuscript.
While this is a single small study, the notion of usability testing is well established in software development – a space of which mHealth development is a small part. As such, it is likely that usability testing is likely to be an important contributor to an effective self-management app.
Recommend Validation Against In-Clinic Measurement
In a 2008 Scientific Statement, the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association gave a strong endorsement of home blood pressure monitoring (11). In their statement, one clear recommendation was confirming that a patient’s chosen BP cuff is accurate. They additionally provide a suggested protocol to do that. Given that this may not be the first thing that comes to mind for a patient, apps for hypertension self-management should include this recommendation as well.
Provide Instruction on Proper Technique
An important aspect of blood pressure assessment, both in clinic and at home, is use of proper technique. That is, not measuring blood pressure just after your patient ran up three flights of stairs to get to their appointment on time but rather after 5 minutes of rest. As most blood pressure cuffs are available over the counter, it is important that apps for self-management provide instruction in appropriate technique for measuring blood pressure. The AHA/ASH/PCNA 2008 statement is a useful reference for details on proper technique (11).
iMedicalApps has been doing clinically oriented reviews of medical apps for nearly five years. Here, we set out to examine the evidence for the use of apps for hypertension self-management and, in particular, identify features that should be included in the very best apps.
For many of these features, there are a number of different ways to actually implement them. For example, reminder functions can be based on time of day, location, missed logging of an event, and so on. We have intentionally not gone so far as to detail the implementation of these features. Thanks to relatively low development costs and the versatility of the devices themselves, we can expect a number of quality apps to become available that offer these features in very different ways letting clinicians and patients pick whatever best suits their specific situation.
Mobile health as an area of research is, in many ways, still in its infancy. This is something that became quite apparent in our review. There were very few studies that included the use of an app for hypertension self-management. Those that we did find were small and were of limited generalizability.
Reviewing these studies, we aimed to identify useful features that should be included in any app for self-management of hypertension. Given the quality of available data and the reality of studying these types of tools, we did our best to identify features that had some degree of support based on available evidence, our own clinical experience, and our experience in reviewing thousands of medical apps over the past few years.
Our hope is that this review provides some useful insight for clinicians, patients, and developers alike and helps motivate the creation of better apps for patient self-management and more effective implementation of these tools.
We welcome your comments and thoughts below. We are well aware that we have presented information that has a variety of strengths and weaknesses. Our aim is for this to be regularly updated and we plan on incorporating what we learn from our readers into future iterations.
- Patel, S., Jacobus-Kantor, L., Marshall, L., Ritchie, C., Kaplinski, M., Khurana, P. S., & Katz, R. J. (2013). Mobilizing Your Medications: An Automated Medication Reminder Application for Mobile Phones and Hypertension Medication Adherence in a High-Risk Urban Population. Journal of Diabetes Science and Technology, 7(3), 630–639.
- McGillicuddy, J. W., Gregoski, M. J., Weiland, A. K., Rock, R. a, Brunner-Jackson, B. M., Patel, S. K., … Treiber, F. a. (2013). Mobile Health Medication Adherence and Blood Pressure Control in Renal Transplant Recipients: A Proof-of-Concept Randomized Controlled Trial. JMIR Research Protocols, 2(2), e32.
- Vervloet, M., Linn, A. J., van Weert, J. C. M., de Bakker, D. H., Bouvy, M. L., & van Dijk, L. (2012). The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature. Journal of the American Medical Informatics Association : JAMIA, 19(5), 696–704.
- Logan, A. G., Irvine, M. J., McIsaac, W. J., Tisler, A., Rossos, P. G., Easty, A., … Cafazzo, J. a. (2012). Effect of home blood pressure telemonitoring with self-care support on uncontrolled systolic hypertension in diabetics. Hypertension, 60(1), 51–7.
- Park, M.-J., & Kim, H.-S. (2012). Evaluation of mobile phone and Internet intervention on wais circumference and blood pressure in post-menopausal women with abdominal obesity. International Journal of Medical Informatics, 81(6), 388–94.
- Park, M.-J., Kim, H.-S., & Kim, K.-S. (2009). Cellular phone and Internet-based individual intervention on blood pressure and obesity in obese patients with hypertension. International Journal of Medical Informatics, 78(10), 704–10.
- Yoo, H. J., Park, M. S., Kim, T. N., Yang, S. J., Cho, G. J., Hwang, T. G., … Choi, K. M. (2009). A Ubiquitous Chronic Disease Care system using cellular phones and the internet. Diabetic Medicine : A Journal of the British Diabetic Association, 26(6), 628–35.
- Earle, K. a, Istepanian, R. S. H., Zitouni, K., Sungoor, A., & Tang, B. (2010). Mobile telemonitoring for achieving tighter targets of blood pressure control in patients with complicated diabetes: a pilot study. Diabetes Technology & Therapeutics, 12(7), 575–9.
- Uhlig, K., Balk, E., Patel, K., Ip, S., Kitsios, G et al. (2012). Self-Measured Blood Pressure Monitoring: Comparative Effectiveness. AHRQ Publication 12-EHC002-EF. Retrieved from http://www.healthyworks.org/sites/default/files/Million Hearts self measured blood pressure monitoring.pdf
- Lin, C. a, Neafsey, P. J., & Strickler, Z. (2009). Usability testing by older adults of a computer-mediated health communication program. Journal of Health Communication, 14(2), 102–18.
- Pickering, T. G., Miller, N. H., Ogedegbe, G., Krakoff, L. R., Artinian, N. T., & Goff, D. (2008). Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension, 52(1), 10–29.
Additional Studies Identified But Not Included
Agboola, S., Havasy, R., Myint-U, K., Kvedar, J., & Jethwani, K. (2013). The Impact of Using Mobile-Enabled Devices on Patient Engagement in Remote Monitoring Programs. Journal of Diabetes Science and Technology, 7(3), 623–629.
Chudyk, A., Shapiro, S., Russell-Minda, E., & Petrella, R. (2011). Self-monitoring technologies for type 2 diabetes and the prevention of cardiovascular complications: perspectives from end users. Journal of Diabetes Science and Technology, 5(2), 394–401.