Clinician-Targeted Mobile Apps in Palliative Care: A Systematic Review

Introduction

The unprecedented digital connectivity and use of smartphone technology have transformed how people access, share, and communicate information. As of mid-2015, there were more than 165,000 mobile health applications (apps) in use worldwide. ¹ In the United States, 90% of healthcare providers used mobile devices to engage with patients in 2015; means to engage consisted of app-enabled patient portals (73%), telehealth services (62%), text communication (57%), and remote patient targeting (49%). ² Thus, mobile health technologies play an increasing role in the way healthcare is delivered and received.

A number of palliative care-related apps have been developed; however, the scope of these available apps has not been synthesized in recent years. A previous systematic review (2012) focused on smartphone palliative medicine apps targeted at healthcare professionals. ³ These authors reviewed the smartphone apps available for the five most popular operating systems (iPhone, Blackberry, Android, Palm, and Windows) and identified only six apps specific to health professionals across these operating systems. ³ Of these, one app was categorized as educational (Palliative Care), one disseminated guidelines from eight cancer networks (PalliApp), two were blog-orientated (Pallimed and Geripal), and two were opioid dose conversion apps (eOpioid and PalliCalc). The authors concluded that there was a dearth of palliative medicine-specific resources for smartphones and they could find no published studies examining the efficacy of the apps in improving outcomes such as clinical practice and professional development. ³

The purpose of this review was to identify growth in palliative care-related smartphone apps, reviewing them for purpose, compatible operating system, developer, target audience, number of downloads, and cost. We also sought to assess accumulation in health professional-targeted palliative care apps since the previously published review.

Methods

Between February and December 2016, the major smartphone application platform stores (App Store iOS, Google Play Store, Windows App–Microsoft Store, and Blackberry World App Store) were searched using the following keywords: palliative care, hospice care, end-of-life care, terminal illness, cancer, symptoms, pain, breaking or giving bad news, end-of life communication, end-of-life conversations, and advanced care planning. Utilizing descriptions of the apps from the App stores and online reviews, each app was evaluated for relevance, language, purpose, compatible operating system, target audience (healthcare professionals, patients, and/or caregivers), cost, and number of downloads [only available from Google Play Store] and developer. Only the application description was reviewed to determine its relevance to palliative care. Apps on other smartphone application platform stores such as Palm App Catalog were excluded because of their outdated features. The relevance and description of non-English apps were reviewed using Google Translate.

For the purpose of this review, if the purpose of the app was to provide education, guidelines, or clinical decision-making tools to healthcare providers, then the app was included as being clinician specific. We excluded apps that were primarily designed to provide education, support, or coaching to patients/caregivers or the general public (n = 8) and apps primarily designed an electronic way for referral to a specific hospice and/or palliative care agency, to provide information on a specific agency, or to allow for agency clinicians to perform electronic documentation (n = 80).

Results

A total of 46 palliative care apps for clinicians were identified using four different operating systems: iOS, Android, Windows, and Blackberry (Table 1). Android and iOS were the most commonly used operating systems and many apps were available for both. All of the apps were in English. The majority of the apps were available for free (n = 40; 87%).

Of the 46 applications (Table 2), 9 were designed to assist clinicians with goals of care discussions and advance care planning; 7 provide training materials for palliative care; 17 present clinical guidelines, mainly for symptom management; 6 were platforms for distributing current palliative care news, articles, and opinions; and 7 were pharmaceutical tools.

Many apps did not report adequate information to judge the evidence upon which the apps were based. Of the smartphone application platform stores, only Google Play reported the number of downloads, making it difficult to judge how often some apps were downloaded. Based on the information available, even the more established and highly rated apps, such as Pallimed, had between 1000 and 5000 installs. ⁴ More expensive apps (e.g., Oxford Handbook Palliative Care, $52.79) had fewer than 50 installs. ⁵

Discussion

The number of apps available for palliative care has increased dramatically in recent years. For instance, a previous review, published in 2012 of palliative medicine apps targeting health professionals using the most common operating systems (iPhone, Blackberry, Android, Palm, and Windows), identified only six apps. ³ Of these, 60% were available for a cost. Our review, using a similar search criterion, identified 46 apps—which represents an almost eightfold increase. Of these, only 15% have an associated download cost. The previous review noted apps in the categories of clinical guidelines, education (palliative care training), opioid dose conversion, and blogs. All of the categories have seen significant growth since that review, with the category of clinical guidelines showing the largest growth. In addition, apps designed to assist with communication and advance care planning (ACP) are an entirely new category since the last review and account for 17% of the clinician-targeted apps available. The quality of available apps is mixed; however, some are based on or endorsed by more established programs. For instance, the “VitalTalk Tips” derive from the widely disseminated Vital Talk ⁶ program and could easily be used by medical students and clinicians to strengthen their communication skills in giving serious news. Similarly, “Health Communication” app is endorsed by the End-of-Life Nursing Education Consortium (ELNEC). ⁷

Some apps offer great promise in advancing the Dying in America recommendations to generate interoperable systems and registries for communication of patients' wishes.^8–10 For instance, “emPOLST” is a free mobile app that allows health professionals and emergency responders to store and access Physicians Orders for Life-Sustaining Treatment forms for easy sharing across care settings.

In the clinical guidelines' domain, “Symptom Management Guides” is the most downloaded app; however, the focus on cancer may limit its usefulness to nononcology clinicians. “PalliAGED,” however, is designed to assist general practitioners to incorporate palliative care into their routine care, making it more broadly applicable. For pharmaceutical tools, “Orthodose” is the most widely used app and the only one that is freely available for all users on both Android and iOS platforms.

Limitations

Although we employed a comprehensive set of relevant key words, it is possible that we may not have captured certain relevant apps. There is also a potential for misclassification of apps, especially those in non-English language, although these apps were independently validated using Google Translate by two of the authors (S.H.M. and M.A.M.). Although we present number of downloads (Table 2), the number of downloads does not indicate how often an app was used (an app may be downloaded and then never or rarely used). Also, a number of apps had not received enough consumer ratings to display an average for the current version of the apps. Also, questions have previously been raised about the reliability and utility of the rating system. ¹¹ Indeed, in reading through the reviews, it appeared that many consumers rated the app before fully using it. In reporting on the cost, we utilized the listed cost of the app, but this does not preclude the possibility that some apps contain in-app purchases.

Also, since the scope of this report was mobile applications, we did not include important online training not available through app marketplaces, e.g., the online curricula from the Center to Advance Palliative Care ¹² and ELNEC (Relias Learning), ¹³ which can be accessed using a mobile phone for training in core palliative care skills.

Conclusions

There has been a rapid proliferation in the number of apps available in the field of palliative care for the past few years. In the new media and digital age, the number of apps targeted to clinicians will continue to increase. However, it is not clear how palliative care apps will shape clinical practice, patient referrals to hospice, and palliative care or patient/family outcomes. Overall, there is little information readily available on the utility and evidence base for the majority of these applications. If the app industry is going to proliferate, as has been demonstrated in the past few years, there should be a concerted discussion within the professional community about developing a rating system for the quality of palliative care apps.