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mHealth and Allergy / Immunology

mHealthThe importance of patient self-management for asthma and allergic conditions
The widespread availability of technology-based interventions for the clinical setting has important implications for allergy/immunology providers. Education and self-management interventions for asthma and allergic conditions enable patients to play an active role in their medical care.1,2 Patient-facing mobile health (mHealth) technologies (e.g. smartphone and tablet-based applications or ‘apps’) have a variety of features that include medication reminders, educational content, games, symptom diaries, electronic sensors, and/or patient self-tracking dashboards.1,3 Other emerging features include voice recognition, wearable technology, pollen (and pollutant) sensors, and virtual reality.3 Many of the successful apps are multifunctional and evidence-based.3 Along these lines, mHealth interventions have been shown to favorably impact clinical, economic and process outcomes.4,5 Specifically, these interventions have been linked to: improvements in patient knowledge and medication adherence; improvements in asthma control and quality of life; and fewer unscheduled office visits.6,7 mHealth technologies continue to rapidly evolve and have great potential to improve patient-centered outcomes and provider workflows in real-time.8

The growing mHealth market and available modalities of apps
The mHealth market has been exponentially growing with increasing numbers of smartphone (and tablet) users, and large numbers of currently available apps.9 A wide variety of apps are publicly available through online marketplaces, such as Apple’s ‘App Store’ for iOS devices (iPhone, iPad) and the Google Play store for Android devices.9 Since apps are easily accessible, patients and healthcare providers are quickly adopting these tools.10 mHealth apps have been shown to positively impact patient-centered outcomes, and providers commonly recommend apps to their patients. Apps have varied features (diaries, action plans, reminders, games, educational content, etc.), and therefore serve patients of all ages and educational levels.10-15 Apps help to collect and organize vital information in an easily accessible format and are especially useful for remote and underserved communities with little access to healthcare resources. In addition, mHealth apps are commonly available in English, Spanish and other languages, and can be used on many devices with an Internet connection.

The versatility of mHealth apps allow for their use in a variety of settings. These apps are available for smartphones, tablets, wearable devices, computers and personal assistants, and offer many advantages for patients who find it difficult to access health information; such modalities can deliver tailored content.16 mHealth tools also help providers to access information and deliver education in the setting of time constraints. Apps exist through distinct formats on Internet-connected devices such as smartphones, tablets and wearable technologies.16 Sensor devices are commonly Bluetooth capable, and can transmit data to mobile devices for the real-time display by apps.17-20 Such functionality enables the rapid capture, transmission and storage of information to facilitate patient monitoring and patient-provider communication.

The need for evidence-based and user-centered mHealth apps
Despite the growing number of mHealth apps, many lack comprehensive and/or evidence-based information. The validation of apps through clinical studies helps to ensure the usability, generalizability and high-quality nature of mHealth apps. Possible outcomes to consider include process, clinical and health economic endpoints. To promote app uptake and usability by patients and/or providers, app developers often consider a user-centered design process, which includes feedback sessions (focus groups, interviews) and iterative refinement based on user feedback. An app’s user interface (UI) and user experience (UX) design can be optimized by evaluating app analytics usage data. App users must be able to access high-quality and up to date information, and report any errors or glitches that exist. An app’s overall safety, usability and potential to positively impact patient-centered outcomes must be considered by providers before an intervention is recommended to patients.

Smartphone and tablet-based mobile apps for asthma and allergic conditions
Distinct types of mHealth interventions encourage patient self-management and have been shown to positively impact clinical outcomes.2,3 We describe the following types of tools: app-based medication and symptom diaries and action plans; medication reminders; remote patient monitoring; wearables; educational interventions; game-based self-management strategies; and mobile telehealth visits. mHealth interventions can help with adherence support and trigger identification and avoidance. Apps may deliver guideline-based education, increase patient engagement and optimize patient-provider communication.

App-based medication and symptom diaries and action plans
App-based diaries can help to track patient adherence to treatment plans and may enhance symptom monitoring.11 Patients are encouraged to self-input data regarding their medication regimens and usage for providers to review and intervene, if necessary. Asthma patients may use electronic symptom diaries to report exacerbations of symptoms, such as dyspnea, chest tightness and cough.12 Such interventions may assist with trigger identification and help to identify the impact of treatment regimens. Mobile-based action plans provide specific steps to take when patients experience asthma symptoms.11 These tools have been linked to a high level of patient satisfaction and improvements in asthma control.11,13 Electronic diaries and action plans promote patient self-management and help providers evaluate medication usage and patient-reported outcomes.13

App-based medication reminders
Short message service (SMS)-based medication reminders and push notifications provide adherence support for patients suffering from asthma and allergic conditions.14 SMS-based reminders are well accepted by patients and have been linked to improvements in medication adherence, self-efficacy and quality of life.15 mHealth apps may send automated scheduled notifications once daily or multiple times per day to remind patients to take their medications. Studies have shown that SMS medication reminders have significantly improved treatment adherence rates among all age groups for distinct chronic conditions such as asthma.14,15 The access to mobile devices has enabled patients to improve their self-management skills by utilizing app-based medication reminders.

Remote patient monitoring
Remote patient monitoring enhances patient-provider communication, while promoting medication adherence.16 For example, smartphone-paired electronic sensor devices (physically connected to asthma inhalers) provide medication reminders and determine when patients take (and miss) medication doses; through a smartphone app that links to an Internet-based dashboard for patients and providers, medication adherence can be tracked in real-time.16 Remote patient monitoring most commonly occurs through smartphones and wearable technologies that collect data regarding a patient’s health status. Remote monitoring interventions have been associated with improved asthma control, an increased number of symptom-free days and decreased rescue medication use.17 It remains to be seen how this technology can be optimally integrated within the outpatient clinical workflow in a cost-effective manner.

Wearable technologies help to sense environmental triggers and/or provide information regarding symptoms.18 Wearables often connect to the Internet or pair with mobile devices. Many wearables have sensors that detect signals from the patient’s body, and assist with treatment modification.19 These devices silently collect clinical data through non-invasive techniques and have been evaluated among adolescents and older adults to track patient outcomes.18 Studies have shown moderate to low correlation in utilizing wearable technology to improve sleep patterns and physical activity among patients suffering from asthma.19 This intervention has also been effective in collecting data for clinical trials.20 Wearable technology has introduced a new method of health data collection and requires further modifications before being implemented into clinical care. Errors in collecting data may adversely affect patient outcomes in the clinical setting. However, there is major potential to utilize accurate and precise wearable technology in remote patient monitoring and improving self-management skills.18,19

Educational interventions
Educational mHealth interventions provide vital health information (e.g. regarding treatments and symptoms) that may not be conveyed in traditional healthcare settings due to the lack of access or resources.21 Through interactive multimedia platforms, healthcare providers can refer patients to learn about their condition at their own convenience.21,22 Through a variety of modalities such as mobile apps and websites, patients have several ways to learn about their conditions. Several types of engaging educational interventions include telephonic sessions (interactive voice response or delivered by a care coordinator), using mobile apps to educate patients and Internet-delivered modules.21,22 Patient-facing asthma mobile interventions that deliver educational content have been linked to a high level of patient satisfaction and improved asthma knowledge.23 Educational mHealth interventions are invaluable in addressing barriers to adherence through personalized strategies.

Game-based self-management
App-based games and quizzes are used to educate and better engage patients. Among children and adults, asthma games and quizzes have been linked to high patient satisfaction, as well as improved asthma knowledge, quality of life and symptom-free days.7 Current games have engaging features that effectively communicate health information to patients and promote self-management skills.24 Games may assess patient-specific knowledge and behaviors, and enable patients to access tailored information based on their symptoms and current treatment regimens.3,24 Virtual reality, augmented reality and algorithm-based games may offer exciting possibilities to deliver gamified content. Further research is necessary regarding the optimal strategies to develop and implement game-based apps for asthma and allergic conditions and determine how these tools can be designed to improve clinical outcomes.24

Mobile telehealth visits
Mobile telehealth visits connect patients and providers to optimize communication and further assist patients with their treatment.3,25 This method facilitates greater patient monitoring and treatment adherence support.26 Telehealth visits can be conducted over video conferencing apps and other secure bidirectional portals to facilitate communication between patients and providers.27 Current adaptations have been studied and demonstrate significant improvements in the quality of care delivered,27 although the technology may have limited diagnostic potential without a comprehensive patient assessment and advanced testing. Mobile telehealth visits have shown promise in educating patients on their asthma and allergy symptoms, and may be utilized as a supplement to regularly scheduled in-person visits. Telehealth interventions may also increase access to care in rural and other underserved areas.25,26
1. Farzandipour M, Nabovati E, Sharif R, Arani MH, Anvari S. Patient Self-Management of Asthma Using Mobile Health Applications: A Systematic Review of the Functionalities and Effects. Applied clinical informatics. 2017 Oct;8(04):1068-81.
2. Eakin MN, Rand CS. Improving patient adherence with asthma self-management practices: what works?. Annals of Allergy, Asthma & Immunology. 2012 Aug 1;109(2):90-2.
3. Tinschert P, Jakob R, Barata F, Kramer JN, Kowatsch T. The potential of mobile apps for improving asthma self-management: a review of publicly available and well-adopted asthma apps. JMIR mHealth and uHealth. 2017 Aug;5(8).
4. Anderson K, Burford O, Emmerton L. Mobile health apps to facilitate self-care: a qualitative study of user experiences. PLoS One. 2016 May 23;11(5):e0156164.
5. Ventola CL. Mobile devices and apps for health care professionals: uses and benefits. Pharmacy and Therapeutics. 2014 May;39(5):356.
6. Miller L, Schüz B, Walters J, Walters E. Mobile Technology Interventions for Asthma Self-Management: Systematic Review and Meta-Analysis. JMIR mHealth and uHealth. 2017;5(5):e57.
7. Morrison D, Wyke S, Agur K, Cameron E, Docking R, MacKenzie A et al. Digital Asthma Self-Management Interventions: A Systematic Review. Journal of Medical Internet Research. 2014;16(2):e51.
8. Kumar S, Nilsen WJ, Abernethy A, Atienza A, Patrick K, Pavel M, Riley WT, Shar A, Spring B, Spruijt-Metz D, Hedeker D. Mobile health technology evaluation: the mHealth evidence workshop. American journal of preventive medicine. 2013 Aug 1;45(2):228-36.
9. Huckvale K, Morrison C, Ouyang J, Ghaghda A, Car J. The evolution of mobile apps for asthma: an updated systematic assessment of content and tools. BMC medicine. 2015 Dec;13(1):58.
10. Ben-Zeev D, Schueller SM, Begale M, Duffecy J, Kane JM, Mohr DC. Strategies for mHealth research: lessons from 3 mobile intervention studies. Administration and Policy in Mental Health and Mental Health Services Research. 2015 Mar 1;42(2):157-67.
11. Perry TT, Marshall A, Berlinski A, Rettiganti M, Brown RH, Randle SM, Luo C, Bian J. Smartphone-based vs paper-based asthma action plans for adolescents. Annals of Allergy, Asthma & Immunology. 2017 Mar 1;118(3):298-303.
12. van Kruijssen V, van Staa A, Dwarswaard J, Mennema B, Adams SA. Use of Online Self-Management Diaries in Asthma and COPD: A Qualitative Study of Subjects' and Professionals' Perceptions and Behaviors. Respiratory Care. 2015 Apr 28:respcare-03795.
13. Anhøj J, Møldrup C. Feasibility of collecting diary data from asthma patients through mobile phones and SMS (short message service): response rate analysis and focus group evaluation from a pilot study. Journal of medical Internet research. 2004 Oct;6(4).
14. Sarabi RE, Sadoughi F, Orak RJ, Bahaadinbeigy K. The effectiveness of mobile phone text messaging in improving medication adherence for patients with chronic diseases: a systematic review. Iranian Red Crescent Medical Journal. 2016 May;18(5).
15. Johnson KB, Patterson BL, Ho YX, Chen Q, Nian H, Davison CL, Slagle J, Mulvaney SA. The feasibility of text reminders to improve medication adherence in adolescents with asthma. Journal of the American Medical Informatics Association. 2015 Dec 11;23(3):449-55.
16. Vegesna A, Tran M, Angelaccio M, Arcona S. Remote patient monitoring via non-invasive digital technologies: a systematic review. Telemedicine and e-Health. 2017 Jan 1;23(1):3-17.
17. Barrett MA, Humblet O, Marcus JE, Henderson K, Smith T, Eid N, Sublett JW, Renda A, Nesbitt L, Van Sickle D, Stempel D. Effect of a mobile health, sensor-driven asthma management platform on asthma control. Annals of Allergy, Asthma & Immunology. 2017 Nov 30;119(5):415-21.
18. Izmailova ES, Wagner JA, Perakslis ED. Wearable devices in clinical trials: hype and hypothesis. Clinical Pharmacology & Therapeutics. 2018 Jul;104(1):42-52.
19. Bian J, Guo Y, Xie M, Parish AE, Wardlaw I, Brown R, Modave F, Zheng D, Perry TT. Exploring the association between self-reported asthma impact and Fitbit-derived sleep quality and physical activity measures in adolescents. JMIR mHealth and uHealth. 2017 Jul;5(7).
20. Munos B, Baker PC, Bot BM, Crouthamel M, Vries G, Ferguson I, Hixson JD, Malek LA, Mastrototaro JJ, Misra V, Ozcan A. Mobile health: the power of wearables, sensors, and apps to transform clinical trials. Annals of the New York Academy of Sciences. 2016 Jul 1;1375(1):3-18.
21. Axelsson M, Lötvall J. Recent educational interventions for improvement of asthma medication adherence. Asia Pacific Allergy. 2012 Jan 1;2(1):67-75.
22. Clark NM, Griffiths C, Keteyian SR, Partridge MR. Educational and behavioral interventions for asthma: who achieves which outcomes? A systematic review. Journal of asthma and allergy. 2010;3:187.
23. Rush K, Hatt L, Janke R, Burton L, Ferrier M, Tetrault M. The efficacy of telehealth delivered educational approaches for patients with chronic diseases: A systematic review. Patient Education and Counseling. 2018;101(8):1310-1321.
24. AlMarshedi A, Wills G, Ranchhod A. Gamifying self-management of chronic illnesses: a mixed-methods study. JMIR serious games. 2016 Jul;4(2).
25. Hui CY, Walton R, McKinstry B, Jackson T, Parker R, Pinnock H. The use of mobile applications to support self-management for people with asthma: a systematic review of controlled studies to identify features associated with clinical effectiveness and adherence. Journal of the American Medical Informatics Association. 2017 May 1;24(3):619-32.
26. Elliott T, Shih J, Dinakar C, Portnoy J, Fineman S. American College of Allergy, Asthma & Immunology position paper on the use of telemedicine for allergists. Annals of Allergy, Asthma & Immunology. 2017 Dec 1;119(6):512-7.
27. Chan DS, Callahan CW, Hatch-Pigott VB, Lawless A, Proffitt HL, Manning NE, Schweikert M, Malone FJ. Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial. Pediatrics. 2007 Mar 1;119(3):569-78.


Additional Resources

Mobile technology in allergic rhinitis: evolution in management or revolution in health and care? »

What is the impact of innovative electronic health interventions in improving treatment adherence in asthma? The pediatric perspective »

Journal Article Summaries

The Impact of Patient Self-Monitoring Via Electronic Medication Monitor and Mobile App Plus Remote Clinician Feedback on Adherence to Inhaled Corticosteroids: A Randomized Controlled Trial »

Impact of Technology-Based Interventions on Patient-Reported Outcomes in Asthma: A Systematic Review »

A computerized decision support tool to implement asthma guidelines for children and adolescents »

A systematic evaluation of asthma management apps examining behavior change techniques »

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