Mobile health — or the use of mobile devices in patient care and public health — has revolutionized the patient experience with medicine.1 Globally, there are an estimated 6.8 billion mobile phone subscribers, and nearly 40% of the world's population is online.2 As of December 2012, there were 52.4 million tablet users in the United States and more than 125 million smartphone users.3–5 Applications developed for smartphones and tablets have been incorporated into health care delivery through a variety of methods ranging from telemedicine6–9 to delivering interventions.10–12 More than 182 eye-care related iPhone (Apple, Cupertino, CA) applications have been developed, and this number continues to rise.13
One application of mobile health is self-tracking — tracking a health indicator on a mobile device or tablet for oneself or a loved one. According to a 2013 survey of more than 3,000 adults by the Pew Research Center's Internet & American Life Project, seven out of 10 Americans reported tracking. Of these trackers, 60% of them track their weight, diet, or exercise routine, and 21% use some form of technology to record health data.14
In ophthalmology, there have been many documented uses of smartphones for clinical evaluation, vision assistance, and educational tools. Such applications range from using smartphones to collect quality photographs through the slit lamp, funduscopy, and indirect ophthalmoscopy to delivering clinical tests such as Amsler grids and Ishihara color plates.15 Other studies have examined the feasibility of smartphone funduscopy and teleophthalmology assessment of diabetic retinopathy through fundus photographs.16,17
The high prevalence of self-tracking in the general population combined with the rise in applications and hardware that assist in mobile funduscopy and teleophthalmology yield potential for self-tracking in patients followed by retina specialists. However, the prevalence of smartphone and tablet ownership in the retinal clinic outpatient population is currently unknown. We examined access to smartphones and tablets in the retinal clinic outpatient population and assessed patient interest in using technology to track eye health.
Patients and Methods
The institutional review board (IRB) at Stanford University School of Medicine ruled that approval was not required for this study. All research components adhered to the Stanford University ethical human research guidelines and with the tenets of the Declaration of Helsinki. All research was conducted in a Health Insurance Portability and Accountability Act-compliant manner.
First, a seven-question survey was developed to query participants about smartphone and tablet access, comfort using these devices, and interest in using the devices for eye health tracking (Appendix). Participants were recruited from the Byers Eye Institute Horngren Family Vitreoretinal Center outpatient retinal clinic between March 1, 2013, and April 30, 2013. Every return patient in the clinic of three retina specialists was asked to participate in the study in their primary language, using phone interpreters if necessary. Subjects were excluded if they were new patients, if they were younger than 14 years old (high-school aged), or if phone interpretation was not available in their language.
Gender, age, and primary diagnosis were recorded in addition to participant survey responses. Patients who agreed to participate in the study had a one-on-one interview conducted in the examination room during their waiting period by one researcher. The same interviewer conducted all in-person interviews. A 2-month collection period was chosen to avoid potential repeat sampling of patients who return at 3-month intervals.
Survey data were analyzed using Statistical Analysis Software Enterprise Guide version 6.1 (SAS Institute, Cary, NC). All variables were graphed to assess for normal distribution. Appropriate measures of central tendency were used to describe the data, including frequencies, percentages, and proportions for categorical data. Participants who owned either an iPhone or Android-based (Google, Mountain View, CA) phone were classified as owning a smartphone. Those with an iPad (Apple, Cupertino, CA) or other tablet were classified as tablet owners. Non-whole number responses to the five-point Likert scale were rounded up to the nearest whole number. Age was examined as a continuous, binary (younger or older than the median age of 64 years old) and categorical (14 years to 54 years, 55 years to 64 years, 65 years to 76 years, or 77 years to 93 years) variable. Comfort using a smartphone or tablet was treated as a five-item categorical variable. Chi-square analyses and Fisher's exact tests were used to compare groups by age, gender, and interest in using a mobile application to track eye health. Wilcoxon Rank-Sum test was used as a nonparametric test to compare groups by age as a continuous variable. For all statistical analyses, a two-tailed P value of less than .05 was considered statistically significant.
During the 2-month study period, 103 participants completed the survey with no missing data. Participants were recruited from the Byers Eye Institute Horngren Family Vitreoretinal Center outpatient retinal clinic.
Age of participants graphically exhibited a left-skewed distribution (Kolmogorov-Smirnov tests for normality; P = .02) with a median subject age of 64 years (range: 16 years to 93 years; interquartile range [IQR]: 23 years). The table describes the baseline characteristics of survey participants. In total, 62 participants (60.2%) were female and 41 participants (39.8%) were male. The most common diagnoses were age-related macular degeneration (AMD) (31 participants; 30.1%), proliferative diabetic retinopathy (eight participants, 7.8%), and retinal detachment (seven participants; 6.8%). Overall, 43 participants (41.7%) reported ownership of a smartphone, with 31 (30.1%) in possession of an iPhone and 12 (11.7%) in possession of an Android or Windows-based smartphone. An additional 22 (21.4%) reported other cell phone ownership. A total of 29 (28.2%) participants reported ownership of an iPad and six (5.8%) another form of tablet. Among individuals who reported that they did not own a smartphone or tablet, 20 (40%) reported that someone in their household owned one of these devices that could be used to track eye health. Overall, 75 participants (72.2%) reported either owning a smartphone or tablet or having access at their household to a device that could be used to track eye health.
Smartphone Ownership Demographics
We found a significant difference in median age among those who reported smartphone ownership (55; IQR: 31) and those who did not (69; IQR: 20.5) (Wilcoxon Rank-Sum test, P < .0001). We also found a non-significantly greater percentage of women in the non-smartphone owner group (40; 66.7%) compared to the smartphone owner group (22; 51.2%) (Chi-square statistic; P = .1129). Furthermore, tablet ownership was significantly different between smartphone owners and non-owners, with 53.5% of smartphone owners (23 of 43) also owning a tablet compared to 20% of non-smartphone owners (12 of 60) (Fisher's exact test; P = .0003).
The majority of patients who owned a smartphone and/or tablet reported a comfort level of four to five (out of five) with using a smartphone or tablet (62.5%; 45 of 72) (Figure 1). However, 27.8% (20 of 72) of smartphone and/or tablet owners reported a comfort level of one to two with using a smartphone or tablet. All (100%; 31 of 31) non-smartphone/non-tablet owners reported a comfort level of one with using a smartphone or tablet.
Patient comfort using a smartphone or tablet (n = 103). Patients were asked to rank their comfort using a smartphone or tablet on a five-point Likert scale (1 = not comfortable, 5 = very comfortable).
Mobile Health Application Interest
The majority of participants (67%; 69 of 103) reported interest in using a mobile application (smartphone or tablet) to track their eye health (Table). We found a significant difference in interest in using a mobile application to track eye health among those who reported smartphone ownership (93%; 40 of 43) and those who did not (48.3%; 29 of 60) (Chi-square statistic; P < .0001). Of 55 owners of any smartphone and/or tablet, 51 (92.7%) reported interest (Figure 2). Of 48 participants who did not own any smartphone or tablet, only 18 (37.5%) reported interest.
Patient interest using a mobile application to track eye health (n = 103). Patients were asked whether they would be interested in using a mobile application to track eye health.
We found that the majority of patients surveyed had access to a mobile device (smartphone or tablet), and that the majority would be interested in using a mobile device to track eye health. Those who owned smartphones were younger and more likely to also own tablets compared to non-smartphone owners. The majority of patients who owned smartphones felt comfortable using them. Though all non-owners reported feeling very uncomfortable using a smartphone or tablet, 38% of non-owners still reported interest in using a mobile application to track eye health.
The percentage of smartphone owners in this population (41.7%) is similar to that found in the United States population as a whole (39.2%).3 An analogous relationship between age and smartphone ownership has previously been reported, though the current trajectory predicts that more than 95% of people older than 60 years of age will have a mobile phone in 5 years.18,19 If accurate, this trajectory will mean an even greater potential impact of mobile applications to track eye health in the near future.
Smartphone applications provide patients with the ability for ophthalmologic testing and transfer of testing data remotely to physicians.4 Kaiser et al. performed pilot studies demonstrating compliance in remote daily monitoring with mobile devices for AMD.20 Likewise, Wang et al. demonstrated accessibility and validity of handheld shape discrimination testing on an iPhone for self-tracking of AMD and diabetic retinopathy.21 Furthermore, using smartphone adapters, researchers have demonstrated feasibility of mobile device ophthalmoscopy — though current studies only involve imaging performed by ophthalmologists.22–24 The safety of retinal exposure due to smartphone funduscopy was evaluated by Kim et al., who found it to be an order of magnitude less than that from indirect ophthalmoscopy.25
The strengths of our study include the fact that one interviewer conducted all in-person interviews, with no missing data. Additionally, our survey contains questions unlikely to be limited by recall bias. As with all surveys, our study is limited by data derived from a sample of the overall population of study. Although effort was expended to provide interpretation and include all patients presenting to the clinic to ensure a diverse sample, the potential for bias with regard to diversity of participants exists. Furthermore, data were not collected on the number of patients who refused participation leading to the potential for participation bias. Lastly, patients with advanced retinal diseases often have low vision. Therefore, it is possible that they may not be capable of adequately self-tracking, though they have a desire to do so. The design of self-tracking applications must account for this fact, providing audible instructions, size-adjustable visual instructions, and/or the ability for family members or caregivers to assist with self-tracking.
Future studies are needed to examine the feasibility and validity of self-tracking using mobile devices for a broader range of retina pathology. A successful self-tracking program must minimize false-negative reports, to avoid missing critical changes in pathology, as well as false-positive reports, to avoid unnecessary additional visits. Self-tracking software and hardware that assists in objective measures such as retina imaging should be assessed to increase sensitivity and specificity of mobile health tracking. This survey should be replicated amongst patients in the setting of rural and public hospitals to increase the generalizability of the results to a greater population of patients in the U.S.
Mobile health has the potential to prevent disease progression and increase the efficiency of patient-physician interaction. Self-tracking allows patients to closely monitor changes in vision between visits to their ophthalmologist. Moreover, self-tracking allows patients who might otherwise have difficulty getting to clinic due to vision loss the ability to undergo components of their visual examination remotely. Therefore, using mobile devices to track eye health may provide ophthalmologists with the opportunity to detect worsening vision before changes become irreversible.
As the number of mobile health applications rise, we must examine the target patient population's perspective. The results of this survey suggest strong patient access to and interest in the use of mobile devices to track eye health.
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- comScore. 2013 Mobile Future in Focus. 2013. Available at: http://www.comscore.com/Insights/Presentations-and-Whitepapers/2013/2013-Mobile-Future-in-Focus. Accessed September 7, 2015.
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|By filling out this questionnaire, you are participating in a research study. You do not have to participate and you do not have to answer all of the questions. No personal information will be collected with the survey, and your medical care will not be affected if you do not wish to participate. If you have questions about this research, please contact the Principal Investigator: Theodore Leng, MD, at 650-498-4264.|
|Do you own an iPhone?|
|Do you own an Android-based phone? (Samsung Galaxy, Google Nexus, etc.)|
|Do you own an iPad?|
|Do you own an Android or Windows-based tablet? (Samsung, Google, Amazon Kindle, Microsoft Surface, etc.)|
|If you do not own an iPhone or iPad, does someone in your household own one of these devices that you can use to track your eye health?|
|Would you be interested in using a mobile application to track your eye health?|
|On a scale of 1–5, how would you rate your comfort with using a smartphone or tablet?|
|Not comfortable||Very comfortable|
Baseline Participant Characteristics
|All Participants||Smartphone Owners||P Value|
|n = 103 No. (%)||Yes (n = 43)||No (n = 60)|
| Median (interquartile range)a||64 (23.0)a||55 (31.0)||69 (20.5)||< .0001|
| Age > 64 yearsb||52 (50.5)||17 (39.5)||40 (66.7)||.0063|
| Age by Quartilec|
| ≥ 14 and < 54 years||26 (25.2)||20 (58.8)||6 (13.6)||< .0001|
| ≥ 55 and < 64 years||27 (26.2)||8 (23.5)||13 (29.6)||< .0001|
| ≥ 65 and < 76 years||23 (22.3)||0 (0.0)||4 (9.1)||< .0001|
| ≥ 77 years||27 (26.2)||6 (17.7)||21 (47.7)||< .0001|
| Female||62 (60.2)||22 (51.2)||40 (66.7)||.1129|
| Male||41 (39.8)||21 (48.8)||20 (33.3)||.1129|
| iPhone||31 (30.1)||31 (72.1)||-||-|
| Android or Windows-Based||12 (11.7)||12 (27.9)||-||-|
| Other Cell Phone Ownership||22 (21.4)||-||22 (36.7)||-|
| No Cell Phone||38 (36.9)||-||38 (63.3)||-|
| iPad||29 (28.2)||21 (48.8)||8 (13.3)||0.0003|
| Other Tablet||6 (5.8)||2 (4.7)||4 (6.7)||0.0003|
| No Tablet||68 (66.0)||20 (46.5)||48 (80.0)||0.0003|
|Smartphone or Tablet in Householdd||20 (40.0)||-||20 (40.8)||-|
|Interest in Mobile Health Trackingb||69 (67.0)||40 (93.0)||29 (48.3)||< .0001|
Baseline Participant Characteristics