An Empirical Review of the Top 500 Medical Apps in a European Android Market

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Dr Vivian Obiodu MD^1,2,Emeka Obiodu MSc^3
1East and North Hertfordshire NHS Trust, England, UK, ²Institute of Orthopaedics and Musculoskeletal Science, University College London, UK, ³Warwick Business School, Coventry, UK
Corresponding Author: obiodu@doctors.org.uk
Journal MTM 1:4:22-37, 2012
DOI:10.7309/jmtm.74

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Introduction

The growing adoption of smartphones and the proliferation of mobile phone apps, especially since Apple’s launch of its Appstore in 2008, have created new opportunities for healthcare delivery and medical education¹. As healthcare practitioners and policy makers explore how apps can play a role in healthcare delivery or training, developers are pushing an ever growing number of apps to the market. Research2guidiance reported that the market for apps designed for the healthcare market increased by a factor of 7 to reach US$718 million in 2011². Apple’s appstore and Google’s Android market are the two most dominant app marketplaces, although there are other markets for applications such as Microsoft’s Windows marketplace and independent ones such as GetJar³.

A growing number of papers or reports have reviewed specific apps^4,7_, apps for specific healthcare disciplines^8-13 or the general market/trend for healthcare apps^14-17. These demonstrate the pervasiveness of apps, and how different healthcare disciplines are finding niche uses for mobile phone apps.

This paper seeks to further that research and is designed to investigate healthcare apps from a multidisciplinary perspective. It empirically reviews the top, consecutive 500 medical apps as displayed on the Italian Android market. It then uses the resulting metrics to determine how popular the apps are, their quality, their uses and potential concerns about them. These metrics are then used to engage in a broader discussion on the trajectory of medical apps and the opportunities and challenges that lie ahead.

Methods

Choice of application market

While both Apple’s appstore and Google’s Android market have substantial number of apps dedicated to the healthcare sector, the Android market was selected for the following reasons.

1. Unlike Apple’s appstore, the Android market is more open about sharing download metrics. As such, this gives an immediate and exact idea how many times an app has been downloaded.
2. The Android market offers a better medium to appraise concerns about the unregulated nature of the apps market and the, often unverified, claims made about healthcare apps. While Apple’s curated appstore offers a semblance of control, providing a presumed check on the quality of apps that are available, the Android market offers no check on the apps that are submitted, potentially making it vulnerable to hackers¹⁸.
3. Given the prevalence of English apps, the Italian Android market was selected as it offered an opportunity to appraise a standalone market that was big and wealthy enough to support own-language apps instead of being inundated with English apps that can be used across all English-speaking countries.

Populating the database

Having selected the Android market, a search of the website of the Italian Android market was done on 16 March 2012. Details of the first 500 apps displayed were then entered into an MS Excel database. This approach was used as any app outside the top 500 as viewed on the Android market website is unlikely to show up in the much smaller smartphone screen.

Download statistics

Although Android gives an idea how many apps have been downloaded, it only provides this information in distinct intervals of an upper and lower limit. Accordingly, the midpoint of each interval is selected as the approximate number of downloads for the app. This is then used to estimate the volume of downloads for all the 500 apps in the database. Table 1 is a conversion table from Android intervals to number of downloads.

App Categories

Each of the 500 apps was individually reviewed by two graders to determine the healthcare discipline it is most suited for, or the primary use of it for the general population. In many cases, this was straightforward. But there were several apps that transverse specific discipline or that did not easily fit into any of the broad categories. These outlier apps were grouped into special categories as shown in table 2.

Prevalence of apps

The bulk of medical apps (53%) were mainly designed for healthcare professionals. Within the professional category, it is not a surprise that ‘medical tools’ (12%) and reference (7%) were the most common category of apps in the market. But the prevalence of cardiology (5%) and radiology (4%) apps is interesting. For the former, there are a sizeable number of apps focused on the Echocardiogram while for the latter; it is all about viewing DiCom (Digital Imaging and Communications in Medicine) images on the mobile phone. Pharmacy apps for professionals (3%) focus mostly on helping doctors in understanding and prescribing drugs.

Apps designed for personal health (45%) were grouped into fewer categories. Many of them can be described as educational resources (14%) that seek to tap into the public’s obsession with bodily welfare ¹⁹.  There were 58 apps (12%) that provide a sort of diary for users to track various aspects of their health. About 6% of the apps are for women affairs, trying to help women manage their fertility and pregnancy records. There were a surprisingly high number of apps that claim to help people to sleep. These were the main components of the ‘therapy’ category (4% of total). Also, 3% of the apps are pharmacy services, reflecting the attraction of Italians to services that can enable them to locate or interact with their nearest pharmacy.

Seven apps were aimed at animal owners, offering them assistance on how to take care of their animals or providing veterinary services

Popularity of apps

There are no surprises in the app categories that have achieved the most downloads. The mean values show this to be Emergency Assistance, Women’s Health and Reference, each with over a mean 175,000 number of downloads.

But as the median values show, the reality is slightly different. The presence of blockbuster apps with millions of downloads have skewed the mean value for most of these categories. Accordingly, the median values show that no category achieves download volumes of over 30,000 (an interval of 10,000 – 50,000 on the Android market).

Using the median values, the most popular apps are those for Body Care, Women’s Health and Reference.

Ratings of apps

If rating is used as a proxy for quality, it is commendable that the average ratings of the apps were 3.9/5 (mean) and 4.1/5(median). The lowest median rating of 3.5 was recorded for Histology although the sample size for it is too small to make any reasonable conclusion. Accordingly, it is plausible to regard Body Care (median rating of 3.7 and mean rating of 3.6), as the lowest rated category with a decent sample size.

User engagement with apps

Expectedly, the number of reviews matches closely the volume of downloads for each app category. Using the mean data, Emergency Assistance, Women’s Health and Reference apps received the most number of reviews. The median data says otherwise although it mostly skews the data to give a better performance for categories with small samples.

Price of apps

Contrary to popular opinion about how much money apps make, the reality is that most apps would need to be given away for free – 77% in this case. While the mean data gives an idea of how prices vary, the median data shows that on average, apps in only three categories (Anatomy, Infectious Disease, Pediatrics) can be expected to be sold for money.

Concerns about medical apps

While some of the papers cited above refer to how healthcare practitioners use apps, there is a wider question of whether these apps offer good value to professionals at their place of work. Are these apps necessary, and are they simply replicating existing data? For the general public, many of the apps purport to provide information that is already available online. It thus begs the question whether these apps even necessary.

But the much bigger problem occurs when apps make medical claims, which can pose serious public health safety issue as well. For example, while several of these apps suggest they can be used for activities that would have required medical training and supervision, they do not have any official approval. Although some developers try to circumvent this concern by incorporating disclaimers, there is growing research, especially at John Hopkins University, and official interest, led by the US FDA, into medical apps ^{20 –22}.

However, any official clampdown may struggle to achieve its aims without stifling innovation. Mobile apps are intangible, software products and will thus prove difficult to police, just like websites. The alternative of leaning on app market owners such as Apple or Google to vet medical claims is feasible, but risks a consumer backlash. A middle way might be for authorities to provide guidelines on evidence-based/best-practice approach to app development for the healthcare sector. The public will then be encouraged to always evaluate any healthcare app based on the guidelines.

Future studies

Apps only debuted in the market in its current format in 2008 and so research into mobile apps in general, and healthcare apps in particular, are just starting. Future research should seek to include Apple’s appstore (because of its preeminence) and other emerging app markets such as Microsoft’s. Greater proliferation and use of smartphones and apps means there are many opportunities to look at how healthcare practitioners, in different healthcare systems, are using apps. Likewise, concerns about public safety will present fertile grounds for future research on mobile apps.

Conclusion

Apps are playing an increasing role in healthcare delivery and also for the training of healthcare practitioners. This review of the top, consecutive 500 ‘medical’ apps in the Italian Android market shows that a majority of the apps are designed for healthcare professionals. On the average, a typical medical app will be downloaded 3,000 times, reviewed 16 times, rated 4.1/5 and given away for free. While there are many benefits to society from medical apps, there are also concerns so as not to endanger healthcare delivery or jeopardize public health and safety.

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