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Viewpoint
November 14, 2019

The Potential of Object-Relations Theory for Improving Engagement With Health Apps

Author Affiliations
  • 1Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
JAMA. 2019;322(22):2169-2170. doi:10.1001/jama.2019.17141

Digital health has much to offer medicine, but object-relations theory has much to offer digital health. The potential of digital health for reducing health disparities, increasing access to care, and offering innovative interventions has triggered myriad novel approaches using smartphone apps and connected devices. But as digital health evolves beyond the novelty of technology alone, new challenges have emerged. In this Viewpoint, we explore the challenge of engagement and suggest how a theoretical approach can offer a concrete path forward.

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    2 Comments for this article
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    Engagement of Doctors to Increase the Value of Health Apps
    George Anstadt, MD | University of Rochester
    Engagement is a marketing term for attracting and pleasing customers. Cohen and Tourus provide anecdotal accounts of disappointingly poor patient engagement with stand-alone high quality mobile health apps. “Health Apps by Design: A Reference Architecture for Mobile Engagement” by Chindalo et. al. reaches a similar conclusion:  “…most health apps have not gained traction”. Yet, this technology is powerful and the number of health apps is growing rapidly due to patients' underserved need for good prevention and disease management information at modest cost. Often this algorithmic knowledge is powerfully enhanced by sensors that collect biomonitoring data that is app-processed into additional useful information.

    Why is engagement poor? Most companies market directly to the consumers. Patients don’t know which apps to trust. Some conflict with their physician’s recommendations. Most importantly, there is no patient outreach by a trusted figure, such as the physician. There is no trusted sales force.

    Motivating patient engagement and compliance with care recommendations is a core element of the art of medicine. Patients who feel protected and cared for by the physician respond with their own positive behaviors, including engagement with care. We physicians have an exciting new opportunity to leverage the value of our doctor-patient relationships by prescribing high-quality personal electronic device apps that are appropriate to their patient’s diagnoses. Patient trust of the physician can be transferred to trust in the object / app, based on object-relationship theory.

    Another opportunity is emerging, the physician-patient-app. A few apps now allow facile physician-patient interaction e.g. the patient data generated by the app can be reviewed by the doctor within the EMR, or an in-app physician messaging capability allows the physician to give patients feedback and motivational messaging. This has great promise.

    Bottom line: patient app engagement can be enhanced by physician engagement. Physician app engagement strategies: summaries of patient data generated by the app appear in the EMR; a physician in-app patient messaging capability; CME and decision support tools for the physician embedded in the app; and strategies for physicians to share the financial value they create by increasing the app’s patient appropriateness and engagement.
    CONFLICT OF INTEREST: None Reported
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    Role of Primary Care Physician
    Andrew Pickens, AB, MD(cum laude) | Retired psychiatrist and psychoanalytic psychotherapist
    This excellent article focused on the use of cell phone and apps as transitional objects linked to the "researcher." What was not explored is the importance of primary physicians as parental figures regarding the emotional needs of patients and the positive and negative transferences from those patients to the physician.

    Primary care doctors are too often overworked and unduly focused on forms and computer screens.

    It would be profoundly beneficial if the physician would spend 5 or 10 minutes with each patient to personalize the relationship. Asking personal questions, making human connections, sharing appropriate personal
    information, and explicitly stating: "I care about your welfare. Advice I give you is because I want you to have a good health outcome. Never hesitate to question me or to verbalize disagreement. I believe this is and should be a partnership."

    My educated guess is that this almost never happens!

    Without a connected relationship, a positive use of phone and apps as transitional objects will not be optimized. With that approach, there would be better compliance and health outcomes, fewer patient complaints and fewer unnecessary patient demands. It is known that "clinging and demanding" children have had impaired emotional attachment with their parents, especially mother. They don't have normal transitional object experiences.
    CONFLICT OF INTEREST: None Reported
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