In recent years, the debate about what we should do with health apps has centred around accreditation, certification or assessment. At the same time, multiple lists of health apps recommended by a range of known and recognised initiatives have been drawn up.
In this context, and with the Mobile World Congress 2017 in Barcelona in full swing, we can ask ourselves what role a Health Technology Assessment (HTA) agency has when considering mHealth.
There is a reality which we cannot evade. Any health intervention needs to be based on evidence, on knowledge of the highest quality at hand, and must be evaluated.
This cannot be done by turning our backs on the real world or innovation. A health app is a tool to carry out a health intervention and so health apps need to be seen as just another intervention, but of course, with some characteristics of their own which will mean there is an extra demand placed on one and all.
Technologists, HTA experts, professionals and citizens have the opportunity to understand each other if we want to be facilitators of recommending safe apps in health. We are not talking about initiatives that can be developed from one sector only and it is not only about apps.
Now more than ever, we need to be flexible and work from a multidisciplinary position. We already talk about co-creation and co-design; quite simply, of co-produced mHealth initiatives based on the expertise of multiple agents including, obviously, citizens.
AQuAS is participating in the assessment of several mHealth projects financed by the European Commission. The PEGASO project stands out, centred on promoting healthy lifestyles among adolescents, and DECIPHER, as an integral solution to facilitate the geographical mobility of patients with chronic diseases such as diabetes type 2 and m-resist, centred on schizophrenia and patients resistant to treatment.
We are faced with the challenge of integrating totally different fields such as the language of technologists and developers; the speed of innovation and the culture of assessment. In addition, this needs to be done without losing sight of the key role of scientific societies and the different points of view of health professionals and end users.
We know there is a lot of work to be done. Technologists and experts in health technology assessment, respectively, have the opportunity to learn a lot from each other. It is about sharing knowledge and expertise to facilitate, ultimately, health tools for citizens and professionals, which have been assessed, are based on evidence, are safe and reliable and have a strong collaborative component.
Post written by Toni Dedéu (@Toni_Dedéu) and Elisa Puigdomènech.
The Economist recently published an article in which they reported that the number of mobile health applications, or apps, was in the region of 165.000, a very high figure that poses many questions.
A large part of these apps are related to well-being and promoting healthy lifestyles, but what makes us choose one over another?
The first thing that comes to mind is that mobile health apps, being a health technology, could and should be assessed based on their impact on health and this is where we are faced with our first problem.
While there is a gold standard when assessing this impact in the area of medication and static interventions in randomized clinical trials, how is this impact assessed in a highly dynamic world? In a world that can include a range of components that users can use depending on their needs? Where pressure is added due to the fact that advances in technology are being made in leaps and bounds and we cannot wait for years before getting results? It is not that simple.
If we venture into the area of mHealth, the first thing we find is great diversity. The design, requirements and assessment of an app developed to help manage diabetes in older people is very different to an app aimed at providing a dose for some medication where improving its adherence is sought, or an app to promote not drinking alcohol among young people before sitting in the driver’s seat, or an app to manage depression and anxiety.
What are we trying to say with all this? Easy and complex at the same time: the intervention that one wants to do via a health app and the target users will determine their use and their adherence.
And we are only just beginning. Apart from aspects related to health and the suitability of content or other more technological factors such as interoperability and security -by no means simple-, other factors come onto the scene such as acceptability, usability and satisfaction, factors related to User Experience (UX).
User Experience in mHealth is essential given that the main aim of it all is to make the tools which are being developed viable, accepted and used by the population who they are meant for, and also that the aim for which they were designed be respected.
After all, the end user who has the last word in deciding whether a health app is used or not, and this is why their participation in all phases of developing these mHealth tools is crucial.
Pursuing these aims of feasibility, acceptability and usability can make us reflect on, for example, the difficulty some old-age people may have when learning to use a smartphone for the first time. However, these obstacles related to the generational factor also exist among young people with new languages.
Wesuggest let yourself surprised by this video that shows how some adolescents react and interact when using Windows 95 for the first time.
With his passing away, Dr Joan Rodés (1938-2017) will be remembered by many people in person, and in many fields, for those who had the good fortune to know him as a doctor, researcher, manager and assessor (of politicians), as his was a life full to the brim. No matter which professional activity he took part in, and with the responsibilities he took on throughout his life, he left his mark and the accolades expressed these days are a clear demonstration of this.
To AQuAS (originally AATM), Joan Rodés has been an exceptional figure and I say this without any rhetoric whatsoever. When the Agency was created in 1994, he presided its scientific board of assessors and at the end of 1999, when the institution became known as Catalan Agency for Health Tecnology Assessment and Research (CAHTA), in Catalan Agència d’Avaluació de Tecnologia i Recerca Mèdiques (AATRM), he presided its Administrative Board, a position that he held till 2010. It was in that period (2000-2006) that, due to my responsabilities within the Agency as Managing Director, I was able to get to know this great personality more closely, very much a big strong fellow (in Catalan, a homenot) was Joan, as Josep Pla would say. At that time, we saw each other often, and I had frequent exchanges with him, aside from the more or less termly meetings of the Administrative Board. I did this in that minute office of the haematology services and later in that of the General Manager at the Hospital Clinic.
No matter what the position he occupied, he was always watchful -very much so- of events at the Agency, being a great facilitator of its duties. It was like this, without a doubt, because with Joan Rodés there was no need to convince him of the importance of informing well about decisions taken in the health services, using the most updated and precise knowledge that was available, not only that regarding the benefits and risks to health of medical interventions, but also in terms of its economic, ethical and social impact. For him and I quote his words literally from the AATRM Newsletter, 10 years of the Agency, of November 2004:
“critical assessment and continued learning are basic tools that need to be maintained and improved, not only by the Agency, in its everyday activity, but also by all the multiple actors and stakeholders in the health system (professionals, managers, politicians and citizens) that wish to continue sustaining this element of such importance for our social well-being”
I said this because of his role of facilitator as highest representative of the Agency giving constant support to the activities it carried out, but also because of his extensive experience and network of relationships that contributed to giving strength to many initiatives that were then being undertaken, especially in the field of research and its assessment. I was able to discuss this with him on many occasions at a later date, and I never once perceived an interventionist or managerial attitude; quite the opposite, always with a laissez-faire approach where each one had to do their assigned task (the technicians and managing director of the Agency, the scientific board and the administrative board) while facilitating that of others.
It has always been a great pleasure for me -a privilege better said- to have maintained contact at dinners and get-togethers, even during the last period in which his respiratory illness worsened, but he would still go to IDIBAPS from time to time despite this. I cannot end without saying that during those times when we would talk about any and everything (medicine, science, politics, society, the past, present and future) we had a really good laugh. Then as now that you have left us, you are and will very much be in my thoughts.
What lies behind a significant volume of hospital readmissions? What makes a service present a good healthcare praxis? What obstacles are there when changing to a healthcare model such as in major out-patient surgery which encourages patients to go home on the same day as their operation? Do managers and nursing staff have the same opinion about what efficiency is in an operating theatre? What is the perception of professionals of the possible benefits of people-centred attention?
Do we all see a dragon?
Reality is complex and therefore approaches are needed which facilitate the interpretation and understanding of that reality. With qualitative research, places can be reached otherwise unattainable when using other methodological aproximations. When answering questions like those we asked ourselves previously, a truly qualitative approach is required. We need to make the approach using an adequate and credible technique to validate the process of all those involved and to ensure precision in results as is done in quantitative research but not forgetting that we need to be critical and independent in the analysis made.
We will briefly outline the evolution of the qualitative approaches in the context of the assessment of health services. A reflection on the usefulness of qualitative techniques in the assessment of health services or medical technologies is not a new one and you can find a series on this subject in the British Medical Journal of 1995 and in the Health Technology Assessment report of 1998.
Health assessment agencies have given great importance to questions about the scientific evidence available when talking about the efficiency and safety of treatments and biomedical interventions of a clinical nature. Randomized controlled trials and systematic reviews are considered to be the reference standards for causal atributions of the benefits of an intervention for the improvement in the health status of patients.
Society has evolved and the needs of the system adapt to this. We formulate new questions related to the preferences and expectations of users facing treatment and how different professionals contribute to providing better results in patient health care. One must bear in mind that when assessing the benefits and results of attention given, many factors come into play.
In this context, the paradigm of evidence based medicine and the supposed superiority of quantitative approaches and of some study designs above others, have created obstacles in the application of qualitative research. In this sense, the letter to the editors of the British Medical Journal signed by more than 70 researchers of reference for giving their support to qualitative research is clear proof of this remaining obstacle.
Questioning the efficacy of a medical drug cannot be answered using a qualitative approach but we can broaden the scope of questions that we pose ourselves.
For example, we can consider asking ourselves questions, among others, about the preferences of patients, the perception of the benefits of a medical drug, the expectations or opinion of professionals that prescribe it or the possible reasons for a low adherence of the medical drug.
Another scenario could be that of a patient with osteoarthritis who has undergone a knee replacement (arthroplasty) and who is being attended by several professionals such as the primary care doctor, the traumatologist surgeon, the anaesthetist, the nurse, the physiotherapist and other professionals if the patient has other comorbidities. That patient has certain preferences and expectations which need to be understood and then give the health care to cover those needs, which can go beyond the mere surgical procedure.
With qualitative research we develop a discourse, texts, opinions and perceptions of people, communities, with images, perspectives, ideologies and complexities. We must guarantee rigour and that the photograph and interpretation of reality that we make remain valid and coherent for the research group and the populaton or group of people that we are assessing.
The application of qualitative techniques has been on the rise using interviews, semi-structured questionnaires, field notes, focus or discussion groups to gather the opinion of different groups of professionals and users.
From my point of view, there are three examples which can be of great use to know the approach and the process in carrying out an assessment of services with a qualitative approach:
Avoiding the classic metrics means being able to measure in an alternative or complementary way by combining different approaches be they qualitative or quantitative. I find the introduction to qualitative research we find in René Brown’s TED talk the power of vulnerability. This qualitative researcher recommends we measure that which is apparently unmeasurable and go more in depth into the complex phenomenon of vulnerabilty.
We broaden perspectives by understanding the reality from within, by bearing in mind the multiple existing points of view to improve that which is disfunctional or by identifying better practices to spread them. We can measure what we want to measure. It will be necessary to adapt the approach to the context and audiences and to continue progressing to show with rigour and practice the usefulness of qualitative approaches.
We continue learning. This time, it has been at the Congrés Iberoamericà de Recerca Qualitativa en Salut (in Twitter #IICS2016) held in Barcelona, 5-7 September. The Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) and the Agència de Salut Pública de Catalunya (ASPCAT) shared the stand to explain their experiences.
Post written by Vicky Serra-Sutton (@vserrasutton), sociologist PhD in AQuAS.