GUIDING PRINCIPLES FOR PHYSICIANS RECOMMENDING MOBILE HEALTH APPLICATIONS TO PATIENTS
This document is designed to provide basic information for physicians about how to assess a mobile health application for recommendation to a patient in the management of that patient's health, health care, and health care information.
These guiding principles build on the Canadian Medical Association's (CMA) Physician Guidelines for Online Communication with Patients.1
* Mobile health applications, distinct from regulated medical devices, may be defined as an application on a mobile device that is intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. The functions of these applications may include:
o The ability to store and track information about an individual or group's health or the social determinants thereof;
o Periodic educational information, reminders, or motivational guidance;
o GPS location information to direct or alert patients;
o Standardized checklists or questionnaires.2
* Mobile health applications can enhance health outcomes while mitigating health care costs because of their potential to improve a patient's access to information and care providers.3
* Mobile health applications are most commonly used on a smart phone and/or tablet. Some may also interface with medical devices.
* The use of mobile health applications reflects an emerging trend towards personalized medicine and patient involvement in the management of their health information. By 2016, 142 million health apps will have been downloaded.4 According to some industry estimates, by 2018, 50 percent of the more than 3.4 billion smartphone and tablet users worldwide will have downloaded at least one mobile health application.5
* While mobile health application downloads are increasing, there is little information about usage and adherence by patients. It is believed that many patients cease to use a mobile health application soon after downloading it.
* Distributers of mobile health applications do not currently assess content provided by mobile health applications for accuracy, comprehensiveness, reliability, timeliness, or conformity to clinical practice guidelines.6 However, mobile applications may be subjected to certain standards to ensure critical technical requirements such as accessibility, reachability, adaptability, operational reliability, and universality.
* Increasingly there are independent websites providing reviews of medical apps and checklists for health care professionals. However, the quality criteria used by these sites, potential conflicts of interest, and the scope and number of mobile apps assessed are not always declared by these groups.
To date, randomized controlled trials are not usually employed to assess the effectiveness of mobile health applications. Some believe that the rigorousness of this type of assessment may impede the timeliness of a mobile health application's availability.7
* Some examples of the uses of mobile health applications include tracking fitness activities to supplement a healthy lifestyle; supported self-management of health and health information; post-procedure follow up; viewing of test results; and the virtualization of interaction between patients and providers, such as remote patient monitoring for chronic disease management. Some mobile health applications may be linked to a patient profile or patient portal associated with a professional or recognized association or medical society or health care organization.
* Some mobile health applications may be an extension of an electronic medical records (EMR) platform.
* The objective of recommending a mobile health application to a patient must be to enhance the safety and/or effectiveness of patient care or otherwise for the purpose of health promotion.
* A mobile health application is one approach in health service delivery. Mobile health applications should complement, rather than replace, the relationship between a physician and patient.
* No one mobile health application is appropriate for every patient. Physicians may wish to understand a patient's abilities, comfort level, access to technology, and the context of the application of care before recommending a mobile health application.
* Should a physician recommend a mobile health application to a patient, it is the responsibility of the physician to do so in a way that adheres to legislation and regulation (if existing) and/or professional obligations.
* If the mobile health application will be used to monitor the patient's condition in an ongoing manner, the physician may wish to discuss with the patient what they should watch for and the steps they should take in response to information provided.
* Physicians are encouraged to share information about applications they have found effective with colleagues.
* Physicians who require additional information about the competencies associated with eHealth and the use of health information technologies may wish to consult The Royal College of Physicians and Surgeons of Canada's (RCPSC) framework of medical competencies, CanMEDS.8
* Physicians may wish to enter into and document a consent discussion with their patient, which can include the electronic management of health information or information printed out from electronic management platforms like mobile health applications. This agreement may include a one-time conveyance of information and recommendations to cover the elements common to many mobile health applications, such as the general risk to privacy associated with storing health information on a mobile device.
Characteristics of a safe and effective mobile health application
A mobile health application does not need to have all of the following characteristics to be safe and effective. However, the more of the following characteristics a mobile health application has, the likelier it will be appropriate for recommendation to a patient:
1. Endorsement by a professional or recognized association or medical society or health care organization
As recommended by the Canadian Medical Protective Association (CMPA), it is best to select mobile health applications that have been created or endorsed by a professional or recognized association or medical society.9 Some health care organizations, such as hospitals, may also develop or endorse applications for use in their clinical environments. There may also be mobile health applications associated with an EMR platform used by an organization or practice. Finally, some mobile health applications may have been subject to a peer review process distinct from endorsement by an association or organization.
There are a number of usability factors than can complicate the use of mobile applications, including interface and design deficiencies, technological restrictions, and device and infrastructure malfunction.
Many developers will release periodic updates and software patches to enhance the stability and usability of their applications. Therefore, it would be prudent for the physician recommending the mobile health application to also recommend to the patient that they determine if the application has been updated within the last year.
Physicians considering recommending a mobile health application to a patient may wish to ask about the patient's level of comfort with mobile health technologies, their degree of computer literacy, whether or not the patient owns a mobile device capable of running the application, and whether or not the patient is able to bear potential one-time or ongoing costs associated with use of the application.
Physicians may consider testing the application themselves beforehand to understand whether its functionality and interface make it easy to use.
3. Reliability of information
Physicians considering recommending a mobile health application may wish to understand how the patient intends to use the information, and/or review the information with the patient to understand whether it is current and appropriate.
Information presented by the mobile health application should be appropriately referenced and time-stamped with the last update by the application developer.
4. Privacy and security
In 2014, the Officer of the Information and Privacy Commissioner of Alberta assessed approximately 1200 mobile applications and found nearly one-third of them required access to personal information beyond what should be required relative to their functionality and purpose, and that basic privacy information was not always made available.10
Physicians entering into and documenting a consent discussion with their patients may wish to include the electronic management of health information in the scope of these discussions, and make a notation of the discussion in the patient's health record.
Some mobile health applications may feature additional levels of authentication for use, such as an additional password or encryption protocols. If all other factors between applications are equal, physicians may wish to recommend that patients use mobile health applications adhering to this higher standard of security.
5. Avoids conflict-of-interest
Physicians may wish to recommend that patients learn more about the company or organization responsible for the development of the application and their mandate. There is a risk of secondary gains by mobile health application developers and providers where information about patients and/or usage is gathered and sold to third parties.
A standardized conflict of interest statement may be made available through the mobile health application or on the developer's website. If so, physicians may wish to refer the patient to this resource.
Physicians who develop mobile applications for commercial gain or have a stake in those who develop applications for commercial gain may risk a complaint being made to the College on the basis that the physician engaged in unprofessional conduct if they recommend mobile health applications to their patients in the course of patient care.
6. Does not contribute to fragmentation of health information
Some mobile health applications may link directly to an EMR, patient portal, or government data repository. These data resources may be standardized, linked, and cross-referenced.
However, health information entered into an application may also be stored on a mobile device and/or the patient's home computer, or developers of mobile health applications may store information collected by their application separately. While there may be short-term benefits to using a particular mobile health application, the range of applications and developers may contribute to the overall fragmentation of health information.
If all other factors between applications are considered equal, physicians may wish to recommend mobile health applications which contribute to robust existing data repositories, especially an existing EMR.
7. Demonstrates its impact on patient health outcomes
While not all mobile health applications will have an appropriate scale of use and not all developers will have the capacity to collect and analyze data, physicians may wish to recommend mobile health applications that have undergone validation testing to demonstrate impact of use on patient health outcomes. If mobile health applications are claiming a direct therapeutic impact on patient populations, physicians may wish to recommend that their patients seek out or request resources to validate this claim.
1 Canadian Medical Association. Physician guidelines for online communication with patients. Ottawa: The Association; 2005. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD05-03.pdf?_ga=1.32127742.1313872127.1393248073
2 US Food and Drug Administration, Center for Devices and Radiological Health, Center for Biologics Evaluation and Research. Mobile medical applications: guidance for industry and Food and Drug Administration staff. Rockville (MD): The Administration; 2015. Available:
3 Canada Health Infoway. Mobile health computing between clinicians and patients. White paper. Toronto: The Infoway; 2014 Apr. Available: www.infoway-inforoute.ca/index.php/resources/video-gallery/doc_download/2081-mobile-health-computing-between-clinicians-and-patients-white-paper-full-report
4 iHealthBeat. 44M mobile health apps will be downloaded in 2012, report predicts. Available: www.ihealthbeat.org/articles/2011/12/1/44m-mobile-health-apps-will-be-downloaded-in-2012-report-predicts
5 Jahns R-G. 500m people will be using healthcare mobile applications in 2015. Research2guidance. Available: www.research2guidance.com/500m-people-will -be-using-healthcare-mobile-applications-in-2015/
6 Lyver, M. Standards: a call to action. Future Practice. 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
7 Rich P. Medical apps: current status. Future Practice 2013 Nov. Available: www.cma.ca/Assets/assets-library/document/en/about-us/FP-November2013-e.pdf
8 Royal College of Physicians and Surgeons of Canada. The CanMEDS 2015 eHealth Expert Working Group report. Ottawa: The College; 2014. Available: www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framework/ehealth_ewg_report_e.pdf
9 Canadian Medical Protective Association. Managing information to delivery safer care. Ottawa: The Association; 2013. Available: https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/managing-information-to-deliver-safer-care
10 Office of the Information and Privacy Commissioner of Alberta. Global privacy sweep rasies concerns about mobile apps [news release]. Available: www.oipc.ab.ca/downloads/documentloader.ashx?id=3482
Re: Standing Committee on Health’s study on violence faced by healthcare workers
Dear Mr. Casey:
I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for
consideration by the Standing Committee on Health (the Committee) as part of the study on violence
faced by healthcare workers.
The CMA is deeply concerned with the state of workplace safety in all health care settings, including
hospitals, long-term care, and home care settings. As in all experiences of violence, it is
unacceptable for healthcare workers to be victims of violence in the provision of care to patients.
While there is limited data nationally to understand the incidence of violence against healthcare
workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity.
A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in
the previous month, nearly one-third of respondents had been exposed to some form of aggressive
behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family
physicians in active practice are subjected to regular abuse from their patients or family members of
These concerns were brought to the CMA’s General Council in 2015, where our members passed a
resolution calling for:
“the federal government to amend the Criminal Code by making it a specific criminal offence to
assault health care providers performing their duties.”
The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a
recognition of the role of the workplace, primarily health care settings, and safe working conditions as
having an important influence of physician health and wellness.
1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family
Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9).
Mr. Bill Casey
Addressing violence against providers in healthcare settings will require action from both federal and
provincial/territorial governments. In light of the above, the CMA respectfully submits the following
recommendations for consideration by the Committee in its study on violence against healthcare
1) The CMA recommends that the Committee on Health support the call to amend the Criminal
Code of Canada to introduce a new criminal offence for assault against a healthcare
provider performing their duty.
2) The CMA recommends that the Committee on Health support establishing monitoring of
violence against healthcare workers, that is consistent across jurisdictions, and have an active
role in responding appropriately to trends.
3) The CMA recommends that the Committee on Health support federal leadership in a pan-
Canadian approach to support workplace safety in healthcare settings, including
collaborating with the provinces and territories to improve violence prevention.
Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by
Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy
to address growing incidents of violence against health care workers.”
In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the
Committee’s report on this topic and the opportunity to collaborate on federal and
provincial/territorial action in this matter.
F. Gigi Osler, BScMed, MD, FRCSC
c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health
Don Davies, M.P., Vice Chair Standing Committee on Health