Allergy and Asthma Care in the Mobile Phone Era
Allergy and Asthma Care in the Mobile Phone Era Xinyuan Huang1,2&Paolo Maria Matricardi1
#Springer Science+Business Media New York2016
Abstract Strategies to improve patients’adherence to treat-ment are essential to reduce the great health and economic burden of allergic rhinitis and asthma.Mobile phone applica-tions(apps)for a better management of allergic diseases are growing in number,but their usefulness for doctors and pa-tients is still debated.Controlled trials have investigated the feasibility,cost-effectiveness,security,and perspectives of the use of tele-medicine in the self-management of asthma.These studies focused on different tools or devices,such as SMS, telephone calls,automatic voice response system,mobile ap-plications,speech recognition system,or cloud-computing systems.While some trials concluded that m-Health can im-prove asthma control and the patient’s quality of life,others did not show any advantage in relation to usual care.The only controlled study on allergic rhinitis showed an improvement of adherence to treatment among tele-monitored patients com-pared to those managed with usual care.Most studies have also highlighted a few shortcomings and limitations of tele-medicine,mainly concerning security and cost-efficiency.The use of smartphones and apps for a personalized asthma and allergy care needs to be further evaluated and optimized be-fore conclusions on its usefulness can be drawn. Keywords Allergy.Mobile health technology.Mobile applications.Mobile phone.Asthma.Allergic rhinitis Introduction
Allergic Rhinitis and Asthma:Poor Adherence
to Treatment
Allergic rhinitis and asthma are very common diseases,esti-mated to affect over300million individuals,and they are the most common chronic disease among children.Asthma is a public health problem for high-,middle-,or low-income coun-tries[1].Over80%of asthma deaths occur in low-and lower-middle-income countries.Asthma is under-diagnosed and un-der-treated,creating a substantial burden to individuals and families and possibly restricting individuals’activities for a lifetime[1].Most asthmatics have allergic rhinitis[2],a com-mon chronic disease having a significant negative impact on the quality of life(QOL).The level of allergic rhinitis(AR) control remains inadequate for many patients[3].
The patients with asthma and/or AR can take drugs such for example inhaled corticosteroids(ICS)to reduce inflamma-tion and beta-2agonists or antihistamines to release their symptoms,but they suffer from the disease recurrently when they stop using these drugs.Many patients need ICS for a long time,but they often forget to take them until the symptoms appear again.Poor adherence to medication leads to worse treatment outcomes,higher hospitalization rates,and in-creased health care costs[4].Therefore,the patients with asth-ma and/or AR need education programs to achieve adequate adherence to medication[5].
To control asthma and AR,patients should also monitor their symptoms,avoid triggers,and follow their treatment plan [6].Successful asthma treatment can be largely attributed to education,not only to medication.The education of patients and health professionals on the proper use of inhalers is one of the mainstays for the treatment of asthma in the pediatric pop-ulation[7].The traditional education is face to face
between *Paolo Maria Matricardi
paolo.matricardi@charite.de
1Department of Pediatric Pneumology and Immunology,Charité
Medical University,Augustenburgerplatz,1,13353Berlin,Germany
2Department of Pediatric,Shengzhou People’s Hospital,
Zhejiang,China
patient and general practitioner,nurse or professional doctors. Every patient should be directly seen by a doctor,although some patients with minor disorders undergo self-medication, independently whether this is correct or not.Nevertheless, many patients with chronic diseases have a poor adherence to their prescribed medicine after their face-to-face visits [8–10].Strategies to improve the patient’s adherence to pre-scription are therefore essential in the management of chronic disease and asthma.
The Expanding World of Mobile Phone Technology Mobile technology allowed since1980s not only real-time bilateral voice communication but also real-time bilateral transmission of written messages.In recent years,smart phone incorporated also media players,camera and flash(flashlight), video cameras and GPS navigation,NFC(near field commu-nication),gravity sensor level meter,and other features,mak-ing it a feature-rich device.Today,high-resolution touch screen and web browser can display also standard web pages and mobile-optimized website.Through Wi-Fi and mobile broadband,smart phones can achieve high-speed data access and cloud access and email handling,connect with other elec-tric devices with Bluetooth or Wi-Fi,and transfer data each other.Mobile applications B apps^extend more intelligent functions and are used in many fields.The mobile application market had a rapid development in the areas of mobile com-merce,game industry,social real-time communication net-works,and so on.Consequently,smart phone sales volume is worldwide huge(over1200million units in2014).Mobile phones are a part of people’s everyday lives and enable acti-vated requests for data wherever they are[11].This world of mobile technology is rapidly expanding,and it is changing many aspects of our daily life.
Mobile Health,Asthma,and AR
The use of smart phones has rapidly expanded also to healthcare and medicine.Mobile health(m-health)comprises the concept of utilizing mobile devices to carry out the task of viewing electronic medical records,reserving medical ap-pointments with a patient’s medical provider,and electronical-ly refilling prescriptions.The term is most commonly used in reference to using mobile communication devices,such as mobile phones,tablet computers,and PDAs,for health ser-vices and information[12].There are approximately5billion mobile phone users,and by2017,there will be B more mobile phones than people^on the planet.Then,the mobile phone with health applications will be soon the most popular mobile health device in the world[13].
A seminal study published in2004suggested that collec-tion of asthma diary data through a mobile phone and the use of short message service(SMS)as alert system is a feasible way to support the self-management of asthma in motivated and self-efficacious patients.In2015,a worldwide consor-tium,leaded by Jean Bousquet,proposed an integrated plan for the use of the mobile health technology in the management of allergic rhinitis(MASK,MACVIA-ARIA Sentinel NetworK for allergic rhinitis)[14].
This thematic review aims to summarize the impact of m-health technology on asthma and AR and to discuss some of the issues related the mobile phones and applications,includ-ing their feasibility,cost-effectiveness,acceptability,security, and perspectives.
Methods
We used the following key words for our research strategy in Medline:B allergy,^B mobile health technology,^B mobile phone,^and^mobile application.^The restriction was B clinical trial^in B humans^in the last6years(from2010to 2015).Outcomes measured included the following:feasibility, quality of life,self-management,costs,adherence to medical therapy,exacerbations,hospitalization rates,symptoms and their severity,office visitor rates,emergency visit rates,un-scheduled visits,absence from school,or work.Studies were included if they(1)were clinical trial;(2)addressed the impact of mobile technology,using SMS,MMS,and mobile applica-tions;and(3)focused on allergy diseases(asthma,allergic rhinitis or hay fever,food allergy,atopic dermatitis).We also examined a few publications resulting from our own experi-ence but not fitting the selection https://www.wendangku.net/doc/af8424482.html,st,we retrieved a list of applications after searching the key word B allergy^in B Google Play^and B Apple App store.^
Results
Literature Search
We retrieved all the abstracts using the search terms and the restriction,and22articles were selected for full text review. Some of them were excluded because they were used some special mobile devices but not the mobile phone.Included studies came from ten countries:Germany(n=1),Singapore (n=1),Taiwan(n=1),Portugal(n=1),Canada(n=1),Italy (n=2),Sweden(n=2),China(n=2),United Kingdom (n=2),and United States of America(n=9).The final set of 22studies included10randomized control trials(RCTs)and 11controlled trials,another one was a case report with a letter, and all the studies included3411participants.These studies focused on asthma(n=16),allergic rhinitis(n=5),and asth-ma and rhinitis(n=1).All the studies found that the mobile technology was a useful tool except one.These studies were published in2010(n=1),2011(n=3),2012(n=7),2013
Clinic Rev Allerg Immunol
(n=4),2014(n=5),and2015(n=2).All the retrieved studies focus on the therapy or/and prevention,but no one focused on diagnosis(Table1).No study focused on food allergy,drug allergy,dust mite allergy or eczema,etc.
Clinical Relevance of m-Health,by Technology Used
Different m-health features were used in different studies. SMS was the most common examined feature,being used in 9out of the22retrieved studies[15–23].Seven studies inves-tigated a smartphone application[6,29–34],five telephone [24–28];one cloud-computing systems[35]was examined by only one study(Table1).
SMS
The studies that used SMS or email got as alert systems to improve adherence to medication had all a positive result.Five of these eight studies adopted a randomized controlled design [15–19].In a population of115Singaporean patients with asthma,aged21years or above,Prabhakaran et al.found that SMS was accepted by most patients and could improve the asthma control test(ACT)score and the adherence to treat-ment.The authors concluded that an SMS might be more effective than conventional nurse telephone call management [15].Among71Chinese patients with asthma,aged older than 18years,SMS improved the perceived control of asthma, follow-up rate,and asthma-specific quality of life(QOL) [16].Among370Canadian patients with asthma,aged 14years or older,De Vera et al.are running a study empowering pharmacists in asthma management through in-teractive SMS(EmPhAsIS);while the study is in progress,the authors suggest that this tool had a tremendous potential to reduce the burden of asthma by improving adherence to treat-ment.Objective conclusions would be soon drawn when the trial is completed[18].Pizzulli et al.found that internet-based telemonitoring improves adherence to NCS treatment and dis-ease knowledge among children and adolescents with season-al allergic rhinoconjunctivitis[19].Wang et al.demonstrated that a daily SMS reminder might be an effective intervention to improve adherence to medication and treatment outcomes in AR patients[17].Similarly,our group could demonstrate a higher adherence to ICS(mometasone)treatment among30 German children with seasonal allergic rhinitis,compared to 31controls receiving usual care,as they could record their symptoms and medication on a e-health platform(electronic diary(e-diary))and received SMS alerts[33].
Out of the another four trials[20–23],two used the control test with comparing to paper records[20],Facebook,Twitter, MySpace,email,and internet[21],the third one discussed the time-based SMS(messages were generated by Compliance for Life TM technology at specified times)and event-based SMS(messages whenever patients took asthma medications or experienced asthma symptoms)[22],and the last one was a nonrandomized pilot feasibility trial[23].Among53Swedish patients with allergic rhinitis,aged8–18years,Aberg et al. found that the use of SMS reminders and e-diaries was excel-lent logistics tools that could produce a significant reduction of all symptoms and specifically runny nose.The patient’s symptoms from the nose,eyes,and lower airways were lower in the group using SMS reminders and e-diaries,when com-pared to controls following usual care[20].In a population of 145USA patients with asthma,aged12–40years,Baptist et al.observed that patients with asthma consider email or SMS and social media websites as very useful tools to com-municate with medical staff[21].In a population of16USA patients with asthma,aged18–25years,MacDonell et al. found that SMS can usefully provide personalized feedback on medication adherence and could be used to tailor an inter-vention to each participant’s specific need,personal barriers to medication adherence,and patterns of medication use[22].In 19USA teenagers with asthma,SMS well supported disease self-management[23].
Telephone Voice Live and Automatic Recognition
and Response Systems
In a population of950USA patients with persistent asthma, aged3-12years,Garbutt et al.found that the coaching inter-vention may improve asthma control and disease-related qual-ity of life and reduce urgent care events for asthma care[25]. Among83USA patients with asthma,aged19years or above, Young HN et al.found that telephone consultation interven-tion was feasible and showed indicators of effectiveness,sug-gesting the design was well suited for a robust study to eval-uate its impact in uncontrolled asthma patients.Pharmacists helping patients manage asthma through telecommunications may resolve access barriers and improve care[26].
In a group of48USA patients with asthma,Raju et al. found that asthma management using the Asthma Control Score(ACS)and the Asthma Action Plan(AAP)actively administered during telephone calls with an operator was a feasible and accepted strategy for the patients to improve their asthma control without the need for an office visit[24]. Among53USA adolescents with asthma,Mulvaney et al. also used a voice response system(Telesage)to assess asthma symptoms and adherence.Telesage system was administered through the adolescents’mobile phones and gave a quantita-tive and qualitative assessment of asthma symptoms and ad-herence conduction with daily calls to patient’s mobile phones for1month.The result was that mobile phones provided a feasible method to assess asthma symptoms and adherence in adolescents.And results provided valuable insights regarding the context of adherence decision making that could be used clinically for problem solving or as feedback to adolescents in a mobile-or web-based support system[27].Furthermore,a
Clinic Rev Allerg Immunol
Table1Details of the included studies
Author[ref] (year),country Disease Study design
(No.of patients
trial duration)
Technology
Frequency;
Period
Outcomes and/or conclusion
SMS alert systems Randomized controlled trials
Prabhakaran[15] 2010;Singapore Asthma RCT
115;12weeks.
SMS
1/day;2weeks
1/week;10weeks
?improved asthma control score
?service was accepted by most patients and maybe more effective usual care
Lv[16] 2012;China Asthma RCT
71;12weeks.
SMS
2/day
?the QoL PCAQ-6score improved more in the SMS group than in controls
(p<0.05)
?SMS group had the highest AQLQ(S)score and follow-up rate after12weeks
Wang[17] 2014;China AR RCT
50;30days
SMS?self-reported adherence to medication was significantly higher in the SMS vs
control group
?the clinic attendance rate was higher in the SMS vs controls(72vs40%,
p=0.02)
?V AS score improvement was significantly bigger in SMS group than that in
the control group
?authors’conclusions:a daily SMS reminder may improve adherence to
medication
De V era[18] 2014;Canada Asthma RCT
370;12months.
SMS?study in progress(2014)
?this is the first study of an intervention based on mobile communication
technology involving community pharmacists in asthma management
?considering the non-adherence problem in asthma,and the availability of
effective treatments,there is a tremendous potential to reduce the burden of
asthma through improving adherence
Pizzulli[19] 2014;Germany AR RCT;
63;1month.
SMS+app?objective adherence to medication was significantly higher in the SMS group
vs controls
?disease knowledge improvement was significantly higher in the SMS vs
control group
?Authors’conclusions:(AllergyMonitor TM)improves adherence to NCS
treatment and disease knowledge among children and adolescents with
pollen allergy
Not-randomized controlled trials
Aberg[20] 2011;Sweden AR CT
53;4weeks
SMS
3/day
?a significant reduction in total symptom scores and specifically for runny nose
?all symptoms were lower in the active group
?the best effect was seen after days with low or moderate pollen counts
?no clinically significant adverse effects were seen.SMS communication on
mobile phone for reminders and recording symptom scores was an excellent
logistics tool
Baptist[21] 2011;USA Asthma CT
145;
SMS,email,
?text messaging,email,and Facebook were used at least weekly by a majority
of respondents
?Email was clearly the most preferred method to receive asthma information
and to communicate with a physician
?there was some interest in using Facebook or text messaging,whereas
Myspace and Twitter had minimal interest
?on logistic regression analysis,female and Black or Hispanic participants were
more likely to have an interest in the use of electronic media for asthma care
?frequent users(>1×/week)of each electronic media type had greater enthusiasm for
their incorporation into asthma care free text entries revealed that many
participants felt social media sites were for connecting with friends rather than for
health care,and privacy concerns were also raised
MacDonell[22] 2012;USA Asthma CT
16;14days
SMS?event-based messages were relatively low
?time-based messages were very high
?All participants expressed positive feedback about the program
?though40.0%reported confusion with event-based messages and most pre-
ferred time-based messages
?low medication adherence rates and reasons for missing medication consistent
with previous research with youth with asthma
Britto[23] 2012;USA Asthma CT
19;3months
SMS?no teen made changes to their original text messages or delivery schedule on
their own
?they gave high ratings on the usefulness,acceptability,ease of use of the text
messaging system
?allowing teens to control the timing and content of reminder text messages
may support self-management of chronic disease
Clinic Rev Allerg Immunol
Table1(continued)
Author[ref] (year),country Disease Study design
(No.of patients
trial duration)
Technology
Frequency;
Period
Outcomes and/or conclusion
Telephon coaching and consultation,recognition and response systems
Raju[24] 2012;USA Asthma CT
48;5months
Telephone call
1/day
?asthma controlled proportion improved from69to78%
?asthma management using the phone is a feasible strategy
?phone calls are accepted by patients and improve asthma control without an
office visit
Garbutt[25] 2012;USA Asthma RCT
950;12months.
Telephone-
coaching
?the coaching intervention may improve asthma control and disease-related
QoL and reduce urgent care events for asthma care
Young[26] 2012;USA Asthma CT
83;3months
Telephone-
coaching
1/month.
?this telepharmacy intervention is feasible and showed effectiveness;the design
is well suited for a robust study to evaluate its impact in uncontrolled asthma
patients
?pharmacists helping patients manage asthma through telecommunications may
resolve access barriers and improve care
Mulvaney[27] 2013;USA Asthma RCT
53;30days
V oice Response
System(VRS)
1/day
?VRS can assess asthma symptoms and adherence in adolescents
?VRS maybe more expensive than traditional retrospective self-report
?possible bias in missing data
Bender[28] 2015;USA Asthma RCT
899;24months
Speech
recognition
(SR)
?inhaled corticosteroid adherence was higher in the intervention group than that
in the usual care group(44.5vs35.5%;P<0.001)
?asthma-related urgent care events did not differ between the two groups
?strong potential for low-cost SR adherence programs integrated with an e-
health record
?SR may reduce health care use in a population with less-controlled asthma
Web-platforms and mobile applications Asthma self-management
Liu[29] 2011;Taiwan Asthma RCT,
89;6months
App PEFR
1/day
?PEFR and FEV1significantly increased in mobile telephone group vs controls
?QoL was significantly higher in mobile telephone group vs controls
?fewer exacerbation and unscheduled visits in mobile telephone group vs controls
?daily dose of systemic or inhaled corticosteroids in mobile telephone group vs
controls
Ryan[30]
2012;United Kingdom Asthma RCT
288;6months
App
2/day
?no significant difference in the change in asthma control or self-efficacy between
patients monitored with an app(e-diary)and those using a traditional diary
?exacerbations,steroid courses,and unscheduled consultations similar in both
groups
?mobile phone service was not cost-effective
Licskai[31]
2013;United Kingdom Asthma CT
22;3months
App?mean asthma QoL questionnaire score improved from4.3to4.8(p=0.047)
?app can support knowledge translation at the patient and provider levels
Burnay[6] 2013;Portugal AR and
asth-
ma
CT
8;4months
App?app can receive information and news about disease,define medication and tasks
notifications,and synchronize all records at network with an online database
?may contribute to patient enablement
Assisted care
Haze[32] 2013;USA Asthma CT
20;2months.
App+SMS
communication
?can improve nurse-patient relationship
?teenagers could ask more questions and quicker response times
?RN care coordinators perceived improved ability to contact teenagers and
improved accuracy of assessment data
Tripodi[33] 2014;Italy AR Historical
comparison
27;9months
App+SMS?can improve adherence to sublingual immunotherapy
?facilitate direct communications between doctors and patients through a chat
messaging system
Costa C[34] 2014;Italy AR Pilot study
21;91days
App?can predict the presence or absence of symptoms up to4days before the event
?predictive performance tended to improve when the degree of individual
allergic susceptibility was also taken into account
Lucas[35] 2015;Sweden Asthma Case report
1;3months
Cloud-computing
smartphones
?discover sensitive environmental triggers of asthma for individual
?proactively improve asthma control,management,and quality of life
?pollen and air quality data collection networks need improvement
?cloud-computing smart phones may be crucial in personalized health care
AR allergic rhinitis,ACT asthma control test,CT controlled trial,EMA ecological momentary assessment,RCT randomized controlled trials,App mobile phone application,PEFR peak expiratory flow rate,QoL quality of life,SMS short message service,SP A smart phone application,SR speech recognition, VAS visual analogic scale
Clinic Rev Allerg Immunol
speech recognition system was used by Bruce G.Bender et al., in a study of3-to12-year-old patients with a persistent asthma diagnosis in USA.Speech recognition telephone calls were directed to the parents in the intervention arm when an inhaled corticosteroid refill was due or overdue.Calls were automat-ically tailored thanks to information obtained from the elec-tronic health record and from the answers of the parents them-selves to questions on refills,parents’desire to learn more about asthma control,or speak with an asthma nurse or phar-macy staff member.The study found that inhaled corticoste-roid adherence was higher in the intervention group than in the usual care group,showing that the speech recognition system had a strong potential for the implementation of low-cost self-report adherence programs integrated with an electronic health record.According to the authors,the interventions might re-duce health care utilization when applied in a population with less-controlled asthma[28].
Applications
Mobile applications(apps)are the third and the most interest-ing technology recently investigated in patients with asthma and allergies.Studies can be divided in two categories respec-tively focusing on(a)B self-management^of asthma[6, 29–31],and(b)doctor-or nurse-driven management of asth-ma and/or allergic rhinitis[32–34].
Apps for Asthma B Self-Management^Many apps provide tools for daily self-monitoring of symptoms and consequent adjustment of the therapy for a better asthma control. However,only a few studies have investigated whether this approach is useful or not.
&In2011,a prospective,randomized,controlled study inves-tigated the impact of an application supporting self-management in89Taiwanese patients with moderate-to-severe persistent asthma[29].Half of the patients were con-trols following usual care methods,and the other half were assisted by an electronic diary(e-diary)to record patient’s daily asthma symptom score.This app daily measured the level of asthma control and immediately displayed the con-sequent clinical advices based on the international guidelines for asthma management(GINA).The patients in the B mobile telephone^group had better quality of life after3months, less asthma exacerbations,and unscheduled visits than the control group.The authors concluded that the mobile telephone-based interactive self-care system provides a con-venient and practical self-monitoring and self-management and improves asthma control[29].
&A prospective,single-center,not-randomized,pre-post in-tervention study also used an app consisting in an asthma action plan.Adult Canadian patients with asthma(n=22) registered daily their symptoms and peak flow data and
automatically received from the system control assess-ment,advice about treatment,and environmental alerts
(e.g.,air quality).Most patients reported that the app was
easy to use,clarity,and timeliness and asked to continue using the app after the study;both,asthma control and asthma-related quality of life,improved during the study.
The authors concluded that the app could successfully integrate the asthma action plan and support knowledge translation at the patient and provider levels[31].
&By contrast,a large randomized,controlled trial,involving 288adolescent and adult British patients with poorly con-trolled asthma,reached opposite conclusions[29].In this study,patients had been randomized to recording symp-toms,drug use,and peak flow either on a classical diary or through an e-diary.Both diaries provided the patients with immediate feedback for action,when necessary.No dif-ference in asthma control or self-efficacy between the two groups was observed,and the authors concluded that mo-bile technology was not cost-effective[30].
&Last,a small but instructive pilot study in eight Portuguese patients with asthma and allergic rhinitis showed that the app called B m-CARAT^might usefully contribute to patient enablement[6].This app allows patients to answer a ques-tionnaire on their disease,record daily symptoms and medi-cation,record an attack and the respective trigger,alert about medication,and monitor drug intake.The authors announced further prospective studies and developments of this app[6]. Doctor-or Nurse-Driven Management of Asthma and Allergic Rhinitis Some apps have been recently designed to facilitate the communication between the doctor(or the nurse) and the patient with asthma.
&In the USA,a pilot study investigated the clinical impact of an app on25teenager patients with asthma.The app ad-dressed four functions:(1)health assessment,(2)personal-ized health plan,(3)disease-specific education,and(4)com-munication for follow-up evaluation.Accordingly,the pa-tient could(1)complete a questionnaire assessing asthma control in which most recent answers were displayed on the dashboard,(2)view a personalized asthma action plan,
(3)select short education modules(i.e.,segments of educa-
tion already used in the existing asthma management pro-gram)of either a slide or a video clip on a selected asthma topic,and(4)send a text message using short message ser-vice.From the dashboard side of the secure web site,the registered nurse(RN)care coordinator could(1)enroll the patient;(2)input patient-specific information;(3)view any patient use of the application;and(4)text message the pa-tient,including asking the patient to complete a control ques-tionnaire or education module within the application.Most patients indicated a positive impact of the app on their
Clinic Rev Allerg Immunol
interaction with the nurse and appreciated the chance of ask-ing more questions and receive quick answers.The nurse noted an improved quality of the communication and of the data assessed by the teenagers.The authors found that the app improve the nurse-patient relationship[32].
&We recently completed a randomized controlled study on the use of an e-health platform(AllergyMonitor?)aimed at improving the interaction between patients with allergic rhinitis and their doctor[19].The study population consisted of63patients aged5–18years with moderate-to-severe SAR to grass pollen requiring daily administra-tion of nasal corticosteroid(NCS)(mometasone)during the pollen season.The patients were assisted in a special-ized care unit in Berlin,and they were randomized to tele-monitoring or usual care.In a6-week-long monitoring period,the patients in the tele-monitoring group had a better adherence to NCS treatment and achieved a better disease knowledge than those in the usual care group[19].
The same app might improve adherence to sublingual im-munotherapy(SLIT)[33]and may be useful in predicting symptoms exacerbations in polysensitized patients with pollen allergy[34].
Other Allergy and Asthma Apps Available on the Market Many more asthma and allergy apps are available on the mar-ket but have never been tested in clinical studies.Statistics from an application data tracking company(AppFigures)sta-tistics showed that in2014,the total android applications in Google Play reached1.43million,while the total iOS App Store application was1.21million.On8December2015,we searched the key word B allergy,^B asthma,^B hay fever,^and B rhinitis,^on Google Play,iTunes,and we retrieved136ap-plications[Table2;the first and second part].Food allergy (n=68)is the most targeted area of interest,followed by pol-len allergy(15),allergic rhinitis(6),asthma(5),allergic rhini-tis and asthma(4),drug allergy(3),and mite allergy(2).A heterogeneous group of33applications targeted allergic dis-eases in general.Most applications provide information for patient’s education or prevention.A few are directed to treat-ment,some are more complex electronic diaries,and most of those focusing on pollen provide local bulletin with updated information on pollen counts.There is an enormous heteroge-neity in the diffusion of these applications,with a few downloaded more than100,000times,and many downloaded less than100times.A detailed classification and analysis of all these apps is beyond the scope of this review.
i-Cloud
Cloud technology is the most advanced of all the features linked to m-health.The only study so far published and based on this technology has involved a Swedish patient seeking care in an allergy clinic because of his asthmatic symptoms. The study highlighted the potential of cloud-computing and smartphones to improve the management of asthma.In par-ticular,cloud-computing initial results suggested that strong associations exist between asthma exacerbations and environ-mental factors[35].The system actively acquired daily infor-mation on the environmental exposures and the patient’s con-dition,processed them automatically,and provided the patient with systematic and timely advice about its asthma condition and the corresponding management.The authors also sug-gested that more advanced smartphone application and cloud-computing functionalities can be used to capture geospatially and temporally relevant environmental data and help health care professionals to better understand some of the environmental stimuli that trigger their personal exacerbations [35].
Shortcomings and Limitations
The enormous advantages of new technologies should be matched always against their potential or real disadvantages and limitations.
&A telephone will never substitute the power of a direct human contact between patient and medical worker[31].
Common sense says that clinicians and patients must be face to face in many occasions,or the doctors would get a mistake diagnosis.Doctors need inspection,palpation, percussion,auscultation,and comprehensive analysis be-fore diagnosis.Therefore,we thought this may be an im-portant limitation to mobile phone in health.
&The SMS did not reduce the number of emergency depart-ment(ED)visits or hospital admissions during a short-term study lasting[15].
&Many older patients did not have mobile phones,or if they had one,most of them did not know how to use the SMS or were non-English speaking[15].
&The SMS procedure was assumed to be too complicated and time-consuming for the children[20].
&Some patients reported confusion with event-based SMS
[22].
&Chinese academics found no significant differences in the changes of FEV1%and sputum eosinophil counts and neutrophil counts after using SMS technology in asthma patients[16].
&Ryan et al.found that app mobile phone-based monitoring did not offer any advantages over and above paper-based care when guideline standard clinical support services were provided;mobile technology group was not cost-effective[30].
&In some public school,many students were not able to use their mobile phone at school[27].
Clinic Rev Allerg Immunol
Table2Allergy apps on the market(2015)
Costs User Comment Download Target Apps name Android iOS Main keyword€star number times First part
Asthma Edu AASC●○pollen0––10–50 Edu50Eduallergy&asthma
associates of SCA
○●relief,California0–––
Edu asthmaMD○●journal,diary,trigger0–––
Edu KEMILEX●○Denmark0 3.3 3.31–5K
Pre The allergy,Asthma and Sinus
Center
○●pollen count,location0–––
Allergic rhinitis and asthma DI Allergy Diary by MACVIA
ARIA
●○allergic rhinitis,asthma,symptoms0–110–50
Edu Allergy Control●○respiratory,allergy0 4.2251–5K Pre Allergy Track●○translates,religious,dietary0 3.1365–10K Tre allergy ke upchar-remedies of
allergy
○●solution,skin allergy0–––
Allergic rhinitis DI Hay Fever Diary Lite●○track,symptom,pollen0439110–50K DI Hay Fever Diary Pro●○hay fever 2.49 4.3540.5–1K
Pre Allergic Rhinitis●○allergic rhinitis0 2.52100–500
Pre Allergy Alarm●○allergic rhinitis,treatment,prevention0–8100–500
Pre Hay Fever Allergy●○hay fever0––10–50
Tre spring allergy remedies●○remedies0–150–100
Pollen-related disease DI AllergyMonitor●●monitor0 4.6741–5K Edu Allergy Pollen Count●○pollen,count0 4.41025–10K PB Pollen●○Austria,Germany,Sweden0 3.6743100–500K PB Pollen allergy warning Sweden●○Sweden0 3.1955–10K PB Pollen-News●○Switzerland,forecasts0 3.614210–50K PB Pollen-Radar●○Germany,forecast0 3.626650–100K Pre air quality and pollution○●air,quality0.99–––Pre AlertaPolen●○pollen,Spanish0 3.131710–50K Pre AllergiePass●○digital form0560.5–1K Pre Austin Allergy●●forecast,Texas,pollen,mold,forecast0 3.914610–50K Pre Hooks-Alerts for Everything●○alert0 3.92232100–500K Pre Husteblume●○Vienna0 2.911710–50K Pre Livocab?direkt-Pollen-Alarm●○alert,forecast0 3.83605–10K Pre pollen allergy○●grass,tree,spores,weed0–––Pre skin and allergy news○●news,dermatology,skin0–––
Mite allergy Pre Allergy Expert●○doctor,medical personnel0––10–50 Pre MilbenCheck●○personal allergen,mites0 2.4141–5K Food allergy DI Allergy Diary●○recording,graphical statistics0 3.7221–5K DI Food Diary●○food,track,symptom 2.49 4.2181100–500
Edu Allergies Advise●○food0––5–10
Edu allergy ally○●create and edit,caregiver0–––
Edu Allergy Analyzer●○relationships,symptoms,food0 3.1191–5K
Edu Allergy Analyzer Tab●○relationships,symptoms,food0 3.1100.5–1K
Edu Allergy Andy●○food0–550–100
Edu allergy FT:allergy food
translator
○●egg,fish,milk,peanut,shellfish 2.99–––
Edu allergy guard lite○●food,ingredients0–––
Edu Allergy Tracker(Ad Free)●○food 1.63––1–5
Edu Allergy Traveler Language
Pack
●○food 1.5–3100–500
Edu Bugabees-Friends w Allergies●○food 3.75––10–50
Edu dairy allergy○●Food,Translate0–––
Edu iAvoid Food allergy○●eight,food allergies0–––
Edu I have a nut allergy international
translation HD
○●translate,56languages0–––
Edu Medrills:Allergic Reactions●○3days reactions,causes,treatments 3.02–210–50
Edu My Allergy Menus●○filters,restaurant menus,ingredient,
GPS
0–110–50
Edu seafood allergy EMBE○●seafood0–––
Edu Shellfish Allergy●○shellfish0–110–50
Edu Sjekk matvaren for allergier●○scanner,bar code5 3.9381–5K
Edu User's Guide to Allergies●○education 1.63–––
Clinic Rev Allerg Immunol
Table2(continued)
Costs User Comment Download Target Apps name Android iOS Main keyword€star number times Second part
Food allergy Edu WITS?Healthy Food
Ingredients
●○scan,ingredient0 2.8385–10K
Pre Allergy Alert●○allergy recall news0–21–5K
Pre Allergy Dictionary●○food0––10–50
Pre Allergy Free●○food0–7100–500
Pre allergy journal○●journal,food,allergy0.99–––
Pre Allergy Scan●●wheat,gluten,soy,shellfish,tree,nut0–3100–500
Pre Allergy Traveler●○translates,religious dietary0 3.1141–5K
Pre allergy watch○●food,cosmetics,drugs,mold,pets,bee0–––
Pre AllerTrack-Meal Log IBS/
Celiac
●○IBS,celiac disease,lactose0–50.5–1K
Pre Asian Food Allergy●○Asian0–110–50
Pre AYRTEC ALLERGYCAST○●baby,food,track0–––
Pre baby food allergy tracker○●baby,food0.99–––
Pre Biomed Allergy Translator●○food0–40.5–1K
Pre BiteAppy:Allergy Diet Eating●○search,restaurant04401–5K
Pre cook it allergy free○●cooking,gluten0–––
Pre Dia’s Allergens●○popular foods,drink0 2.6131–5K
Pre Egg Allergy Disease&
Symptoms ●○egg gluten,wheat,egg,milk,nut,
peanut,soy,shellfish
0––10–50
Pre fast food&restaurants gluten&
allergy free
○●fast food0–––
Pre Fast Food Allergies●○menus,restaurant,USA,Canada,UK0.77 3.714100–500
Pre food allergy menus○●food,safety0–––
Pre Food Allergy Safety●○track 5.25––1–5
Pre Food Allergy Tracker Free●○translate,dietary,abroad0 3.9611–5K
Pre Food Allergy Translate●●food,translate 1.47–250–100
Pre Food Allergy Translate Free●○lactose,histamine,sorbitol,personal
threshold
0 2.2101–5K
Pre Food and Symptoms Diary●○celiac disease,lactose 2.88 4.5181–5K
Pre food diary(free)●○scans,supermarket,labels0 2.918110–50K
Pre Food Thumb●○track,statistically,analyze,habits0–9100–500
Pre Food.Symptoms&Allergy
Diary
●○food,beverage,ingredient0 3.6111–5K
Pre healthy diet&gluten○●restaurant,dietary0–––
Pre Interactive Food Allergy Menus●○restaurant,dietary0 2.9381–5K
Pre Intolerance Food Diary●○monitor,isolate0 3.817010–50K
Pre Kafoodle●○suit,allergy,intolerance0–6100–500
Pre Latex Allergy Information●○latex0–350–100
Pre Milk Allergy●○milk0–1100–500
Pre Milk Allergy Information●○milk0––100–500
Pre my allergy menus○●restaurant,dietary,real-time0–––
Pre My Food Allergies●○narrow,intake0.74–150–100
Pre My Gluten Free Me●○ingredients,gluten0 2.8295–10K
Pre My Gluten Free Me●○national institutes of health0 3.6115–10K
Pre Peanut Allergy●○peanut 1.97––5–10
Pre peanut allergy EBME○●peanut,symptoms,label synonyms,
hidden sources
0–––Pre Peanut Allergy Information●○peanut0––50–100
Pre Recipes by Ingredients●○recipes0 3.62371100–500K
Pre Seafood Allergy●○seafood 1.97––1–5
Pre Shellfish Allergy Information●○shellfish0–110–50
Pre Wheat Allergy Information●○wheat0––100–500
Tre Allergy Relief Handbook●○food0––1–5 Drug allergy Pre Drug Allergy Information●○drug,information0–1100–500 Pre https://www.wendangku.net/doc/af8424482.html, Medication Guide●○search,drug,information0 4.294020.5–1M
Pre Penicillin Allergy Information●○penicillin0––100–500 Clinic Rev Allerg Immunol
&Medical staff has not much time to accept calls or to reply SMS[32].
&Mobile technologies cannot be easily integrated in the existing hospital informatics systems.If the two systems are isolated,it will have big problems of security and signifi-cantly increase the workload of medical workers[32].
&The last,but not the least,in all the22studies,only4used apps that could provide environment data in real-time [19,33–35].Security and Costs
Security means—in this area—data safety collection.After all,mobile technology is a program that needs to transform clinical symptom or sign into data and a computer language, and then the data can be used.Relevant clinical phenomena must be accurately converted to machine language,and we have to ensure that the data remain completely protected and reliable from the phone to the server during their transmission.
Table2(continued)
Costs User Comment Download Target Apps name Android iOS Main keyword€star number times
All kinds of allergy DI Allergy Pal●○allergies,translate,English,French,
Spanish,German
0 3.4151–5K Edu Allergies101by
GoLearningBu
●●rhinitis,skin,food,mold032100–500
Edu Allergies Disease&Symptoms●○symptoms,causes,tests,diagnosis,
treatments,home,rem
0–3100–500 Edu Allergies Tips Guide●○dust mites,pet dander,mold0––100–500 Edu allergy academy○●deliver,course0–––Edu Allergy Glossary●○reference,guide 1.27––1–5 Edu Allergy Journal●○scientific journal0.74314100–500 Edu Allergy Risk●○allergy information,child0–110–50 Edu allergy track○●symptom,monitor,manage,track,
doctor
0–––Edu allergy track○●journal,track,Google Health0–––Edu Audiobook-Allergies●○audio book0 3.76410–50K Edu Common Allergy Myths●○allergy,myths0––100–500 Edu e-symptoms●○electronic log0 3.4175–10K Edu Mount Sinai Guides:Allergy●○diagnosis,management26.97––1–5 Edu pediatric allergy and
immunology
○●journal,children,immunity0–––
Edu Simple Allergies●○symptoms,common,allergies0––1–5 Edu Smart Allergy Taming●○allergic rhinitis,sublingual,
immunotherapy
0––50–100 Edu Tell the Doctor:Allergy●○record,automatically,doctor0––5–10 Edu Angioedema Allergy●○information,signs,symptoms,
diagnosis,management
0––10–50
Pre Allergies●○allergy,at hand 1.77–51–5 Pre allergy free dessert○●recipe,collection,milk,egg,soy,
peanut
1.99–––
Pre AllerKey●○NFC tag0–210–50 Pre AllerKey●○worldwide,diagnoses,medications0–210–50 Pre CosmEthics●○scan,bar code0 3.9811–5K Pre CosmEthics●○eye0 3.8171–5K Pre Sun Allergy Disease&
Symptoms
●○sun0––10–50
Pre TreeID●○trees 1.45 1.9341–5K Tre ALLERGY Acupressure
Treatment Free
●○acupressure,relieve0 4.1445–10K
Tre ALLERGY Acupressure
Treatment Pay
●○acupressure,relieve 2.19––10–50
Tre Allergy Release Hypnosis●○audio,hypnotherapy0.87––10–50 Tre,
Edu
Allergy Release Hypnosis○●Acupressure,Relieve0–––
Tre,
Edu
no allergy-instant acupressure
self-treatment
○●Acupressure,Relieve0–––
Tre,
Edu
别过敏症○●Chinese medicine0–––
DI diary,PB pollen bulletin,Edu education,Pre prevention,Tre treatment;(K1000,M1000,000)
Clinic Rev Allerg Immunol
Licskai et https://www.wendangku.net/doc/af8424482.html,ed the smartphone application(SPA)that ap-plied standard3DES encryption and secure socket layer net-work transmission security protocols in an IBM Domino en-terprise application server architecture,with an integrated lightweight directory access protocol for authentication ac-cording to user name and encrypted passwords[31].
Ryan et al.concluded that the use of their app had produced no clinical advantages but increased the care costs,because of the expenses linked to tele-monitoring.In their study,the use of m-health(compared to the use of a traditional clinical diary on paper)has not been cost-effective[30].Similarly, Mulvaney et al.considered a voice response system more expensive than traditional retrospective self-report;however, they also concluded that this m-health technology should be investigated for its added value in clinical practice and integrated with tailored mobile intervention techniques to improve adherence[27].
Discussion
Notwithstanding the great number of asthma and allergy apps available in the market,we found only22studies examining their impact on the management of allergic diseases.Moreover,most studies focus on asthma,a few on allergic rhinitis,and almost none of them on food allergies.We also observed that most,if not all studies, focus on monitoring patients after the diagnosis and pre-scription of therapy.We can therefore draw conclusions around the role of m-health in awareness,education,and adherence to treatment in patients with asthma.M-health technology seems to play a role in educational reminding, guiding role of medication,and enhancing patients’adher-ence to treatment.M-health may therefore play a crucial role in asthma management,especially of adolescents and young adults,who tend to discontinue the medication as their symptoms improve[20,27,32].These patients tend to undergo more emergency or unscheduled visit,exacer-bations,hospitalizations.The regular use of SMS(includ-ing MMS),voice reminders,and apps supporting self-management has improved patients’understanding of the disease and their adherence to medication[6,15–18, 20–22,24,27–29,31,32,35].
Most of the studies performed so far concluded that m-health is useful in the management of allergic diseases. Nevertheless,one of the best trials so far published has reached three negative conclusions.In this trial,m-health (1)did not improve asthma control or self-efficacy;(2)did not reduce acute exacerbations,steroid courses,and un-scheduled consultation;and(3)was more expensive than the use of a traditional diary[30].One may explain this conclusion with a low recruitment rate or with the inter-ference of chronic obstructive pulmonary disease(COPD)on symptoms severity.Interestingly,controls were also monitored on a daily basis with a classical clinical diary using a paper support,instead of a modern electronic di-ary using a mobile phone app.Then,this study demon-strated that B the diary^itself,and not the way it is real-ized(on paper or electronic,traditional,or innovative),is essential for a treatment success.The point is that in our fast society,in the real life,and outside clinical trials,the patients do not normally dedicate time to fill regularly a paper-based diary,and above all,doctors have no time to read them,draw complex curves,and calculate outcomes. In real life,both the traditional and the electronic diaries are B useful^but only the electronic diaries are feasible, and B usual care^does not contemplate a clinical diary. Studies comparing an e-diary against usual care(unfortu-nately not including a diary)would be very informative and useful to understand the impact of m-health in real-life clinical practice.
Our review also highlights the lack of studies investi-gating the impact of medical devices connected to a mo-bile phone.Nowadays,wearable medical devices have been invented that can monitoring heart rate,pulse,tem-perature,blood pressure,blood sugar,patient’s location, etc.[36].Many devices are being developed that can change the way we can monitor respiratory allergies. These include peak expiratory flow(PEF)or peak nasal inspiratory flow(PNIF),respiration parameters,breathing sounds and remote auscultation,image exchange,and so on.These devices can exchange data with smartphone apps via Bluetooth,and the apps can exchange data with the corresponding server through the internet.Then, through cloud-computing technology and exchanging data between servers,the cloud could integrate and analyze data real-time and dynamically,then pushed information through servers to the patient and his/her doctors. Servers or the doctors can elaborate the signal and give to the patient a personalized feedback or recommendation through the phone itself or by voice,or its wearable de-vice(Fig.1).There is a huge expansion in this area that will increase the impact of m-health on allergies but that it still not the object of clinical trials and related publications.
Apart from the beautiful study from Ryan et al.[30], none of the other studies examined in this review made a direct cost-benefit evaluation.Therefore,we would be tempted to predict or to suggest that cost-benefit studies prospectively investigate whether m-health could cost-effectiveness of asthma and allergies treatment in public health care https://www.wendangku.net/doc/af8424482.html,rmation is needed to ascertain whether m-health can:
1.reduce episodes of asthma exacerbation and unscheduled
visits[29]
Clinic Rev Allerg Immunol
2.improve asthma control by reducing the need for an office
visit [24]
3.reduce the number of atopic dermatitis patient referrals to
specialists [37]
4.better support self-management of chronic disease [23]
5.improve self-reported adherence to medication [17]
6.improve adherence and reduce the burden of asthma
[18,28]
7.promote personalized health care [35]
As Lucas RW et al.have noted,m-health may proac-tively improve the patient ’s asthma control,management,and quality of life when the patients know their level of exposure to triggers and how to avoid them [29].Emphasis and resources should therefore be allocated to the improvement and support of data collection networks.It is essential to made available to any individual patient,through his/her smart phone,pollen,and air quality infor-mation.The implementation of cloud-computing and smartphone technologies had the potential to become a game-changing advance in the provision of personalized health care,but needed to be evaluated on a larger scale [35].
We look forward in the future to have more applied research on cloud-computing technology in the medical field and more ability to effectively integrate all the rele-vant departments,to integrate all of the public health re-sources and real-time,and dynamically push message to the patient ’s phone.Cloud-computing technology could automatically push message to the patient disease
information (images,sound,video,and other forms of multimedia)-related education.So it could improve patient awareness of the disease and treatment compliance.Patient could visually see the relevant information on the phone screen and feedback in a variety of ways,such as input-ting text message,recording voice,taking photos,record-ing video,and uploading.Then,it formed a good interac-tion in the patient and the medical workers and the sys-tem.These were feasible by using cloud-computing tech-nology and mobile applications.We hope the early arrival of this wisdom medical health system.
Conclusion
The studies on the impact of m-health in asthma and allergies are still very few.The mobile health technology has an enormous potential and may be in the future a feasible,cost-effective,useful tool for not only allergic disease,but also for many other diseases.It has some questions about personality and security.We need integrate the public health departments and use cloud-computing technology to overcome all the shortcomings.Patients with asthma and allergies will obtain all the relevant informa-tion of their disease,and this information were dynamical-ly updated in real https://www.wendangku.net/doc/af8424482.html,ernment ’s funding,adequate coordination,and clinical studies are required to use the best and sustainable use for all the patients of the fantastic progress of mobile phone
technologies.
Fig.1Cloud-computing technology,mobile phone and mobile health applications
Clinic Rev Allerg Immunol
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