Digital tools can help patients, but prescribing the right app is no simple feat

At HXD 2019, a team from Kaiser Permanente described their efforts to build and populate a mental health app ecosystem for their clinicians.
By Dave Muoio
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A staggering number of health apps are being released with each passing year, many of which could have a lasting impact on patients entering the health system with stress, anxiety or depression. That sheer volume of options comes at a cost, however, as many therapists and clinicians who are interested in recommending a digital tool or service to their patients simply don’t have the time to comb through the App Store for the perfect tool.

Tackling these issues is a core focus for Kaiser Permanente’s Project Chamai, an internal effort launched in 2016 that is looking to address the 25 percent of patients entering the system with subclinical behavioral health symptoms. Through interviews with 38 members and dozens of other clinicians and stakeholders, the Chamai team has spent the past couple of years developing an ecosystem of convenient mobile apps that a clinician can suggest to a patient as a supplement to their normal care.

“Our members really take it seriously: ‘My therapist prescribed me this app.’ It’s a different level than a free or a 99-cent app in the App Store, they know it’s very involved,” Trina Histon, a senior principal consultant for prevention, wellness and digital health at Kaiser Permanente, said during a session at HXD 2019 in Boston. “All of these solutions, no matter how beautiful they are, you have to figure out how to get them into workflow [or] they’re not ever going to be referred. … So we’ve gone very deep in our [EHR] and digital prescribing platform lately to make it really easy for a therapist to refer whichever tool they feel from their conversation would match the patient best.”

So far the team’s app prescription ecosystem is comprised of just six mental health apps, three of which focus on mindful meditation and three of which are based on CBT. Of note, Histon highlighted the diversity between each of the apps — for instance, some are video based, one has a coach and another one has a navigator. The team is also interested in beefing up its selection with apps built for non-English-speaking users, although Histon noted that those options are still few and far between.

Having this kind of range on hand is vital to ensure that the most appropriate tool is offered to each patient, Aubrey Kraft, a service designer at Kaiser Permanente Design Consultancy, said. Unfortunately, the glut of digital offerings and the needs of each individual has made app selection an ongoing project.

“If somebody comes in that kind of fits this type of person and is experiencing these symptoms, what do we suggest as the best option — or even more specifically, what piece of content they should do within that app or what article they should read?” Kraft said during the session. “That is something we’re still trying to figure out, but we are trying to make that as easy as possible for clinicians. We know that the best way for them to do that is to get in there and do it all themselves, but we also know that they don’t have even close to enough time to [do] that.”

Despite the challenge, the feedback of a practicing clinicians and patients is first and foremost in determining whether an app is appropriate for referral to a patient, Kraft and Histon said. As such, the team recruited a small handful of their members and “champion clinicians” to help test and review some of the apps being considered.

“[We said] 'We’re thinking about maybe using this one, could you guys try it out for a little bit and let us know what you think?’ because they’re going to come at it from a very different perspective — is this teaching members the things that we want to teach, is this going to be a tool that supports that?” Kraft said.

Along with providing a handle on user experience, incorporating clinicians and members into the review process has also provided the team with practical advice they could use to educate other providers who may be interested in the tools. These include guidance on which apps might be best for which patients, and on the type of language should be used within the content and by the prescribing clinician.

“I think the actual words of ‘I should prescribe this to you,” or “I really think you should do this,” and this commitment came out of our clinicians,” Kraft said. “And so, we’re able to say to other clinicians in the future that we’ve heard from a therapist at this medical center [to say] ‘I want you to us this app two to three times a day for five to ten minutes, this is your prescription.’ They’re like, oh yeah, okay, it’s not coming from designers, it’s coming from other physicians.”

Beyond direct feedback and user experience, the team said that they consulted literature from professional organizations on how best to incorporate digital therapeutics in care. Histon also highlighted the team’s focus on apps that provide evidence of improved outcomes among users, but lamented the dearth of robust data pertaining to specific digital tools and products. To help providers find the most effective apps and employ them in their practice, she said digital therapeutics makers and the wider digital health industry will need to raise the bar when it comes to proving efficacy.

“One of the challenges in digital therapeutics is they’re unlikely to develop a sham version of their project for a control group, so we also need to evolve our thinking of what’s a randomized control trial look like in the era of digital health, and how do we push that standard and develop that,” she said.