Deriving a practical framework for the evaluation of health apps

The rise of digital health, fuelled by access to smartphones and connectivity to apps, has resulted in a plethora of mobile technology-based innovations. The US Food and Drug Administration (FDA) estimates that in 2018, 1·7 billion people downloaded mobile health apps. With over 325000 to choose from across all health domains and many updating as frequently as every week, finding and keeping up with useful mental health apps is a challenge.

For patients and clinicians, picking the most suitable apps is difficult because of evolving evidence, emerging privacy risks, usability concerns, and the fact that apps constantly update and change. To help guide selection, people typically rely on the use of star rating systems and user reviews in app stores, despite strong evidence that such evaluation methods are misleading. 

The FDA has realised the diminished value of traditional evaluation approaches and the challenge of regulating apps. To solve this problem, the FDA has begun piloting a novel certification programme, PreCert, that shifts the scrutiny from the apps themselves to the developers. Despite this effort, the programme is nascent, with just nine companies partaking. The UK National Health Service has released a second version of its App Library as another solution.

In this void, numerous app evaluation frameworks have emerged. Although some frameworks have been published in peer-reviewed journals, many live in the grey literature. A systematic review examined existing evaluation frameworks for mobile medical apps, identifying 45 unique frameworks. Not surprisingly, the study found gaps in each framework. Given the obvious need for a more comprehensive evaluation framework, a novel approach is necessary.

We have reframed the app evaluation process away from picking the best-rated app and towards making an informed decision on the basis of clinically-relevant criteria. Just as no single best antidepressant or therapy exists, no single best app exists to treat all patients or mental illnesses. Clinical presentation, patient preferences, technology literacy, accessibility, and treatment goals are all important factors that determine the best course of care for any patient. Such factors must be considered when deciding what the most suitable app might be for a patient in any given situation.

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