Lack of Adoption of a Mobile App to Support Patient Self-Management of Diabetes and Hypertension in a Federally Qualified Health Center: Interview Analysis of Staff and Patients in a Failed Randomized Trial

Abstract

BackgroundThousands of mobile health (mHealth) apps have been developed to support patients’ management of their health, but the effectiveness of many of the apps remains unclear. While mHealth apps appear to hold promise for improving the self-management of chronic conditions across populations, failure to balance the system demands of the app with the needs, interests, or resources of the end users can undermine consumers’ adoption of these technologies.ObjectiveThe original aim of this study was to evaluate the effectiveness of a commercial mHealth app in improving clinical outcomes for adult patients in a Federally Qualified Health Center (FQHC) with uncontrolled diabetes and/or hypertension. Patients entered clinical data into the app, which also supported messaging between patients and providers. After a 4-month period of vigorous recruitment, the trial was suspended due to low enrollment and inconsistent use of the app by enrolled patients. The project aim was changed to understanding why the trial was unsuccessful.MethodsWe used the user-task-context (eUTC) usability framework to develop a set of interview questions for patients and staff who were involved in the trial. All interviews were done by phone and lasted 20 to 30 minutes. Interviews were not recorded.ResultsThere was a poor fit between the app, end users, and recruitment and treatment approaches in our setting. Usability testing might have revealed this prior to launch but was not an option. There was not sufficient time during routine care for clinical staff to familiarize patients with the app or to check clinical data and messages, which are unreimbursed activities. Some patients did not use the app appropriately. The lack of integration with the electronic health record (EHR) was cited as a problem for both patients and staff who also said the app was just one more thing to attend to.ConclusionsThis brief trial underscores the pitfalls in the utilization of mHealth apps. Effective use of mHealth tools requires a good fit between the app, the users’ electronic health (eHealth) literacy, the treatment approach, staff time, and reimbursement for services. The last 3 are contextual factors of the setting that affected the adoption of the app and context is an important factor in implementation science. We recommend that researchers address contextual factors in the trial and adoption of mHealth technologies.

Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study (Preprint)

“…For example, increased workload is a common factor for poor uptake of new health technologies [14,15,[18][19][20][21][22]. In this study, PCPs anticipated an increase in workload, particularly in the initial stages of implementation, and argued that their acceptance of this increase was contingent on the perceived benefit of the app for the patient.…”

“…In this study, PCPs anticipated an increase in workload, particularly in the initial stages of implementation, and argued that their acceptance of this increase was contingent on the perceived benefit of the app for the patient. PCPs also emphasized commonly reported strategies to reduce workload, such as automating processes where possible and integrating the app into existing software [14,22].…”

“…Health care providers value self-management apps because they perceive that they encourage patient engagement, provide them with a deeper and more reliable understanding of their patients' behaviors, and improve communication during consultations by providing visualizations of patient data [14][15][16][17].…”

“…This could include the overwhelming complexity of the data that is available to health care providers, provider responsibility to respond to shared self-monitoring data, and health care provider perceptions of poor motivation on the part of patients [14,16]. Overcoming the challenge of poor provider uptake is crucial as strong provider endorsement is in turn a key factor for patient uptake of online tools [23].…”

A Behavioral Lifestyle Intervention Enhanced With Multiple-Behavior Self-Monitoring Using Mobile and Connected Tools for Underserved Individuals With Type 2 Diabetes and Comorbid Overweight or Obesity: Pilot Comparative Effectiveness Trial (Preprint)

“…In the diabetes population, a study planning to use a mobile application to support patient self-management did not recruit enough patients [28]. We recruited our 27 patients in less than one month and those who participated in the mobile group had high adherence rates to all components of the intervention over 6 months.…”