This tutorial presentation was given by invitation at the annual meeting of the American College of Sports Medicine and World Congress on Exercise is Medicine. We welcome comments, questions, and ideas regarding this fast moving area.

1. Health and Fitness App Use,
Evaluation and Opportunities
American College of Sports Medicine
Annual Meeting,
World Congress on Exercise is Medicine
Orlando, FL May 2014

2. Heather Chambliss, Ph.D., FACSM
The University of Memphis
hchmblss@memphis.edu
@HChamblissPhD
Carol Torgan, Ph.D., FACSM
Kinetics Consulting
carol@caroltorgan.com
@ctorgan

3. Disclaimers
Products, sites, and tools shown or mentioned focus on
commercially available technology, and are for illustrative,
educational purposes only. The views expressed in this
presentation are solely those of the presenters, who do not
endorse or recommend any commercial products, processes, or
services. Please contact the authors for additional information
and/or permissions.

4. Outline
The apps landscape
Apps and behavior change
Apps in practice: Issues
Future
Discussion

5. WHAT, WHO, HOW
The apps landscape

6. What are apps?
A software application designed to run on
smartphones, tablets and other mobile devices.
FDA: They can also be accessories that attach to
a smartphone or other mobile communication
device, or a combination of accessories and
software.
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/MobileMedicalApplications/

7. > 56% of American adults own a smartphone
http://www.pewinternet.org/2013/06/05/smartphone-ownership-2013/

8. Health Apps Audience
Tracking for Health, http://www.pewinternet.org/2013/01/28/tracking-for-health
1 in 5 smartphone
owners has a health app
More likely to download:
• women
• under age 50
• annual household
income over $75,000
• better educated

9. App Options!

10. Most popular iTunes store categories
Category No. of Apps (% of total)
1. Games 216,598 (19%)
2. Education 121,626 (11%)
3. Business 96,413 (8%)
4. Lifestyle 93,201 (8%)
5. Entertainment 89,171 (8%)
12. Healthcare & Fitness 31,599 (3%)
17. Medical 27,686 (2%)
http://148apps.biz/app-store-metrics/ (As of 5-20-2014)

11. > 56,000 healthcare, fitness, medical apps
http://148apps.biz/app-store-metrics/ (As of 5-20-2014) * iTunes store

12. Fitness apps with > 15 million downloads*
* Sources include the company sites and press releases. Users  downloads
MyFitnessPal > 40 million users (many apps)
RunKeeper > 20 million users
Azumio > 20 million downloads (many apps)
Nike+ > 18 million users
MapMyFitness > 18 million active users (many apps)
Runtastic > 18 million registered users
(40 million downloads)
Endomondo > 16 million users

13. More than 50%of mobile health apps
are downloaded
less than 500times
But …
Patient Apps for Improved Healthcare: From Novelty to Mainstream, Oct 2013

14. Apps for consumers vs. health care providers
Number of “genuine” health and fitness or medical apps
by customer in the iTunes store as of June 2013
Patient Apps for Improved Healthcare: From Novelty to Mainstream, Oct 2013

15. Health professionals use 3 screens
Smartphone
‘Short burst’ or ‘two-click’ activities (check email, look up drug ref)
Don’t use to share info with patients (“Swivel apps”)
Don’t use for deep research, videos, inputting lots of information
Tablets
76% of physicians own
Immersion “lean back” learning
(video, eCME, journal reading)
Desktop/laptops
Sharing / patient-facing screens, have EHRs
http://mobihealthnews.com coverage of Manhattan Research Report, April 2014

16. Health care professionals and apps
“Patients currently face a dizzying array
of healthcare apps to choose from,
with little guidance on quality or support
from their doctors.”
Patient Apps for Improved Healthcare: From Novelty to Mainstream, Oct 2013

17. Health care professionals and apps
“Physicians can see the potential benefits of mobile
healthcare apps but remain wary of formally
recommending apps to patients without:
evidence of their benefit
clear professional guidelines
regarding their use in practice
confidence in the security of personal health
information that may be generated
or transmitted by the app.”
Patient Apps for Improved Healthcare: From Novelty to Mainstream, Oct 2013

18. FITNESS AT OUR FINGERTIPS?
Apps and behavior change

19. Arrange
Assist
Agree
Advise
Assess
A’s of Physical Activity Counseling
Meriwether et al. Physical Activity Counseling. Am Fam Physician. 2008;77: 1029, 1138.

20. Assess Individual Information
 Health risks and status
 Physical activity level
 Frequency, Intensity, Time, Type
 Readiness for change
 Precontemplation, Contemplation,
Preparation, Action, Maintenance
 Behavioral factors
There’s an APP
for that!
Important for
APP selection

21. Advise on Behavior and Health
 Personalized plans based on health and behavioral
goal
 Weight management, increased fitness, posture, nutrition,
stress, sleep, etc.
 Options for physical activity
 Decreasing sedentary time, lifestyle activity, fitness
components, performance
 Considerations:
• User needs (health and self-stated goals)
• Current behavior/Stage of change
• Self-efficacy
• Best practices/physical activity guidelines

22. Education
 Tutorials
 Videos
 Blogs

23. Agree on Behavior Goal
Specific
Measurable
Adjustable
Realistic
Time frame
Self-directed
Evidence-based

24. Do Apps Address Goal Setting Problems?
 Not setting goals
 Not setting specific goals
 Not individualizing goals
 Lack of follow up or
evaluation
 Not rewarding goals
 Setting too many goals
 Not adjusting goals
 Unrealistic expectations

25. APP FEATURES:
BEHAVIORAL CONSIDERATIONS
Assist behavior change

26. Customization
 Medical history
 Body data
 Behavioral target
 Goals

27. Physical Activity
Frequency
Duration
Distance
Calories
Steps
Points
Heart Rate

28. APPlication of Behavioral Concepts?
•SELF-MONITORING +++
•SOCIAL SUPPORT + +
•SUBSTITUTING ALTERNATIVES +
•ENVIRONMENTAL CONTROL +
•REINFORCEMENT +
•SELF-EFFICACY +/-
•PROBLEM SOLVING ?
•RELAPSE PREVENTION ?

29. Physical Activity Tech
Category Examples Key Features
Activity and
Nutrition Tracking
•My Fitness Pal
•Calorie Counter
•SparkPeople
•Livestrong
Exercise and food
databases; Individual
calorie and weight goals;
Social and website
integration
GPS •RunKeeper
•MapMyRun
•Nike+
Continuous time, distance,
data; PA prompts and
tracking; Training plans
and maps
Workout •Nike Training Club
•Fitness Buddy
•Pocket Yoga
Exercise guidance with A/V
instruction; Training plans

30. Physical Activity Tech
Category Examples Key Features
Motivation •Charity Miles
•Zombies, Run!
•Endomondo
•Fitocracy
•GymPact
Entertainment /
competition features;
Charity / reward plans;
Social integration
Wearable Devices •Fitbit
•BodyMedia
•Jawbone
•Nike+ Fuelband
•HR monitors
Physiological data tracking ;
App/computer integration
Exergaming •Nintendo Wii
•Xbox Kinect
•PlayStation Move
Active games detect
movement and award
points

31. Behavioral Support
 Prompts/Reminders
 Feedback and Report Generation
 Integration with Social Media
 Competition with self and other
users
 Integration with music
 Integration with other apps /
devices
 Variation and ongoing
customization

32. Arrange Follow Up
 Personalized Reports
 Ongoing Planning
 Professional Support

33. APP Frustrations and Limitations
 Bugs
 Hassle
 Boredom
 Tech Overload
 Proprietary Issues
 Missing Features
 Storage Limits

34. APP Evaluation:
Questions for Professionals
 Do recommendations follow evidence-based guidelines?
 Is the tool accurate and reliable?
 Does the technology include behavioral elements?
 Is the technology appropriate for user abilities, preferences, and
budget?
 What non-tech support does the person need?
 Does the tool support data sharing and feedback?
 Will the tool keep user interest and be a long-term resource?
 Is the tool regularly updated?

35. APP Selection: Questions for Users
 What is your primary behavioral goal?
 What other apps do you use?
 How often do you plan to use the device?
 How much time are you willing to invest in data entry?
 How much information do you want?
 How much are you willing to spend?
 What integration / features are most important to you?
 How comfortable are you with mobile technology?

36. Reality Check for the “Virtual” World
 The “look and feel” is
important
 Users may be unwilling to pay
 More options = greater
expectations
 Easy come, easy go
 Top lists and user reviews
influence selection
 Friend recommendations and
“buzz” matter
 Techies look for the next “best”
thing

37. Downloaded and Used?
 Match the method to the individual
 KISS – Keep it simple and streamlined
Behavior
Technology
 Anchor to an established habit
 Keep proximal to behavior
 Choose an app with “can’t live without” features

38. ISSUES AND CONSIDERATIONS
Apps in Practice

39. Regulation of apps by FDA
Mobile medical apps (MMAs) medical devices that are mobile apps,
meet the definition of a medical device and are an accessory to a regulated
medical device or transform a mobile platform into a regulated medical device.
Apps that don’t need approval
Provide access to information
Provide simple tools to organize and track health info
Help show or communicate potential conditions to clinicians
Automate simple tasks for health care providers
Interact with PHRs or EHRs
Apps Requiring Approval (examples)
Use attached sensors for diagnostic testing (EKG, EEG)
Use attachment to track glucose levels
Connect to bedside monitors, transfer data to viewing station for
patient monitoring
www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/MobileMedicalApplications

40. “MapMyFitness is Under Armour's new data
center.”
– Owen Thomas, Editor-in-Chief, ReadWriteWeb
“We know when you work out and how you
work out, and a company like Under Armour
is really interested in understanding that to
help them to sell apparel, help them to make
you perform better, and help them to make
you into a better athlete.”
- Kevin Callahan, MapMyFitness co-founder, VP of
Innovation Strategy
Data Issues
http://mobihealthnews.com, http://readwrite.com
Under Armour acquired MapMyFitness Nov 2013 for $150M

41. Data sharing example: Alivecor
www.alivecor.com

42. Data selling example: Strava
http://metro.strava.com/ http://bikeportland.org
Location of tracked runs and rides
(stripped of personal info)
Analyze patterns by time of day, day
of week, season, local geography
Oregon Dept of Transportation paid
$20,000 for 1-year license of dataset
Includes activities of ~17,700 riders
and 400,000 individual bicycle trips
logged on Strava in 2013.
“… the data could revolutionize how
ODOT makes decisions about their
policies, plans, and projects.”

43. Literacy, numeracy issues

44.  Accuracy (content, measurements)
 Compliance
 Safety
 Security
 Privacy
Other Issues

45. The Future of Apps

46. The future: smartphones get smarter
Now
accelerometer, gyroscope, magnetometer
temperature, humidity, atmospheric pressure
ambient light, camera, video, voice
Next
Environment around us: air, water, pollution, UV light
Environment inside us: heart rate, respiratory rate …

47. The future: human bioenergy harvesting
body heat
foot strikes
joint movements (knee)
sound pressure waves (inner ear)
sound vibrations (talking)
breathing
heart beats
blood flow
Image: Starner, T., Human Powered Wearable Computing, IBM Systems Journal, 35, p618, 1996.
Utilize the human body as source of energy to
generate and store energy to power mobile
equipment and small devices (pacemakers)

48. Integrate with sensors, wearable tech
www.pinterest.com/caroltpin/wearable-tech/

49. Integrate with the Internet of Things (IoT)
Objects have network connectivity, can send & receive data
Lean more: www.theinternetofthings.eu Image courtesy Axel Tregoning, Flickr
locks
thermostat
frig
chairs
mattress
flooring
lights
toilet
forks
blender
barbells
toothbrush
pill bottles
pets

50. The future of apps: collaboration?
Consumers
Researchers
App
Developers
Product Sales
Systems /
Organizations

51. WHAT DO YOU THINK?
Beginning a Dialogue

52. Should fitness & health apps be certified?
Should apps be reviewed and certified?
Why or why not?
Should an organization rate them or give them a seal of
approval?
Should an organization provide
developers with guidelines?
If so, what categories should be reviewed?
What about content accuracy, safety, security, privacy?

53. Should health apps be prescribed?
Should apps be recommended?
By who?
For who?
What are the potential liabilities / responsibilities?

54. Should app data be shared?
Who should it be shared with?
Primary care provider / EHR (Electronic Health Record)
Personal trainer / gym
Friends
Family
What data should be shared and how should it be used?
Location
Exercise amounts
Health outcomes
Compliance
Who should decide this?

55. What app would you design?
What features do you use the most?
What features do you need / want?
What features make you mad?
What’s missing from currently available apps?

56. Questions or ideas? Contact us!
Heather Chambliss, Ph.D., FACSM
The University Of Memphis
hchmblss@memphis.edu
@HChamblissPhD
Carol Torgan, Ph.D., FACSM
Kinetics Consulting
carol@caroltorgan.com
www.caroltorgan.com
@ctorgan