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Discussion
This study aimed to examine the extent to which diabetes mobile apps have conformity with components of the CCM. From online supplementary table 2 it is clear that the ‘proactive follow-up’ element in ‘delivery system design’ component has been covered by different features: it might be due to a mobile app’s ability to provide necessary services to patients in the absence of doctors and in the patient’s private life.36 The other elements in the ‘delivery system design’ component may suggest providing team-based services, and since one of the goals of mobile apps is patient-centred care, this feature has been mostly covered in a patient-centered manner.
The second component of CCM includes some strategies that help patients improve their self-care. Applied new technologies empower patients in learning new skills, thus it is supposed that mhealth enhances self-care abilities.34 Some elements of a self-care strategy’s component such as ‘collaborative decision making with patients’ or ‘patient activation/psychosocial support’ can be satisfied by special feature including colour coding or messaging. Hence, the ‘delivery system design’ and ‘self-care strategies’ are two components that have almost been implemented in diabetes mobile apps.
In the features of studied mobile apps, almost none of the component of ‘decision support and expert system’ were considered. Fundamentally, the CCM’s decision-making is based on guides, evidence-based guidelines, protocols and standards; usages to provide the required care.17 Despite the importance of this issue, however, many mobile apps did not apply even elementary proposition of guidelines in their design.31
The fourth component, ‘information support’, has three elements which correspond to the collection, integration and distribution of information. Institutional and personal information would be used to make a proper decision and treatment. As a result, it is better that an app has specific capabilities such as synchronisation with some tools such as social network, electronic registries and electronic health/medical records. The rate of adoption of these registries and records is less than what was expected in mobile apps, this issue partially could be related to usability issues such as national infrastructure, security and privacy considerations, and other obstacles.37 Having a personal health record (PHR) that can be kept by the patient and his family can support the maintenance of more complete and accurate health information. These personal files can also be kept on the mobile device, but there are various challenges. Patients or their family may find it difficult to understand the medical terminologies. Another challenge is to provide support and assistance to patients as real- time support might be very costly. Another challenge is security and privacy of the data and ensuring that the data is entered correctly by users in such systems. On the other hand, the creation and maintenance of these cases is a partnership of patients and care providers, while patients are not specialised in medical matters.38
However, it should be taken into consideration that the use of electronic tools such as electronic health record (EHR) in gathering, storing and sharing data can be helpful to cover this component and it is better to invest in these facilities as soon as possible.39
‘Community linkage’ would provide information about community resources to support patients’ needs or provide services or programmes for the community. There is still a research gap to examine the effectiveness of online communication systems to support self-care.40 More studies are needed in this regard.
Regarding the last component, ‘health system support’, there is little information about how to design mhealth interventions that integrate with healthcare systems in the field of chronic care disease.17 It seems that the essential features such as personalisation and decision support features in apps have important effects on care improvement and these features are also recommended in the guidelines.31
Many researchers suggest involving innovative and inclusive technologies and tools for their positive impact on self-care diseases such as diabetes due to their direct effects on lifestyle. Mobile phone interventions provide an inexpensive and effective role in encouraging patients to promote self-care41 42 and better interactions between the patient and the physician through the effective integration of patients’ daily monitoring.43–46 This will increase the patients’ awareness about their condition.47 Therefore, these possibilities make an opportunity to record disease-related information and transfer it to healthcare professionals. Another reason for the use of these technologies is the inherent characteristics, such as powerful technical capabilities, availability in all locations, people’s dependency on, and the possibility of, customisation. Technical functions of mhealth can provide access to customised intervention based on different parameters such as age, sex, and health status of patients at both individual and social level. Also, it can be used for short message services (SMS), software applications and multimedia, such as image and video. These technologies provide direct interaction between the patient and the healthcare and provide real time and immediate assistance when needed by the patient.48 49
Health mobile apps can provide cost-effective foundation for caring for patients affected by chronic disease such as diabetes.28 For example, it can be available in low-income areas and even a large number of people to monitoring and healthcare.48 Also it can be useful for adherence to drug prescriptions, encourage them to have healthy lifestyles, and improve their knowledge and self-management abilities.50 Reports of the cost effectiveness of health mobile apps like these, have been proven in some studies, but not in all of them.51
Nevertheless, in spite of all of these potential advantages regarding mhealth, the role of mhealth and apps in diabetes management has not yet been widespread.52 53 This is not only due to the lack of CCM consideration in apps development, as far as we know, other requirements are also needed to implement the optimal usage of health mobile apps to diabetes care. These requirements which are shown in CCM may include constructive interaction between the informed and active patient, and the experienced and prepared healthcare team. These factors, in addition, to consider CCM’s components in the mobile app architecture, are effective and important to achieve the desired results. If we design a diabetes app architecture along with all CCM’s components’ consideration, the data may not be still forwarded completely and accurately to be monitored by the service provider and the ultimate goal of the CCM, which is improving the patient ability to manage her/his own chronic illness truly, would not be covered.
The data produced in the process of interaction between the provider and the patient can be collected, analysed and retrieved in a database. Statistical and mathematical algorithms might be used in order to develop intelligent modelling and provide a prediction of diabetes-related outcomes such as blood glucose, weight, calorie intake and even HbA1c levels to achieve the ultimate goal of the CCM. This is possible when data are collected longitudinally and build a rich database. Therefore, to achieve such an ideal output, cost and time are needed, but ultimately, when the system reaches the degree of automatic operation, can improve outcomes and processes of care smartly based on the CCM approach.
Despite the advantages of many mobile-based systems for improving healthcare, if not properly understood and used, could lead to misdiagnosis and increased risk. The US Food and Drug Administration (FDA) consider the same risk-based approach to mobile phone apps such as other medical devices as well. It even announces a list of apps as an example that has been able to receive FDA approval and describes how to get the confirmation. This file has been edited in its latest version on 8 October 2018.54 In addition, the security and privacy of the information that patients enter is also another challenge. Although many researchers have suggested state-of-the-art technologies such as the use of intelligent lenses for continuous monitoring of patients, it has always been advised that patients themselves are aware of what information is being collected and for what purpose it is used.8 55 So, as one of the most crucial aspects of using these tools, it should be resolved by considering secure transmission and secure and private data storage. Therefore, the relevant laws and regulations should consider all of these and show that the patient’s safety is a priority.56 Nevertheless, many medical apps have not passed the necessary regulatory control and might be dangerous for patient safety.57 Legal frameworks developing to prevent the introduction of unsafe and high-risk programmes also need to allow further innovation.58 Surveillance should be based on a patient-centred approach, while keeping up-to-date with relevant laws and protecting the safety of the patient.59
We considered the date of the latest app update to review and report, but of course, the number of apps and their updates keeps changing. Also, some features are just from published descriptions or articles. There are variances between the explanation in the article and the actual features. We did not have the time and resources to install and test every app. This study was limited to Google Play Store for android apps and can be extended for other app stores in future. Further study may address the trend of apps improvement according to their progress towards CCM conformity.
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