Through blogs and comments, patients and experts explore what it takes to find good health care and make the most of it.

An Open Letter to Mobile Health App Developers and Their Funders


article image
Follow us on Facebook

Dear Mobile Health App Developers,

We—patients and caregivers—need your help to reduce the demands of self care. Mobile health (mHealth) apps have enormous potential to lessen our burdens. But our needs are often only loosely related to what clinicians and/or the evidence expect us to do. Most mobile app developers have ignored this fact by designing tools that primarily reflect the imperatives of clinicians and evidence with little or no consultation with us patients about our experiences, our wishes or our requirements.

While I can't promise you that consultation with us is the magic key to successful, well-used apps, I can tell you that without it, your app doesn't stand a chance.

Two recent experiences prompted me to write you. Each illustrates the gap between the promise of mobile health apps to help us care for ourselves and our spotty uptake and use of them.

First, I recently got a new phone and found myself unwilling to load even a single one of the 23 health-related apps that I had carefully chosen and used from the old phone to the new.

Second, I have recently been approached by a number of mobile app developers looking to speak with a real patient about their projects. While talking to potential users is generally a good idea, these developers weren't interested in my needs but rather were seeking endorsement of the beta version of their new apps.

These experiences left me ornery and impatient about the current state of mHealth apps. Why haven’t they just taken off?

Now, I am a member of your target audience. I have a number of chronic conditions that require me to do many tedious tasks every day to take care of myself. I am fairly tech-savvy and would really like to make use of new mobile technologies to reduce the time and effort I expend. In addition to living with the effects of four cancer diagnoses and their treatments, I spend a lot of time listening to people describe their experiences with illness and health care.

Here are three observations that might help you:

1) We will not use mobile apps that add to the time we spend caring for ourselves.

Being sick is a tremendous time-drain for us and our caregivers. It requires us to do many repetitive tasks: take medications, eat special diets, do various exercises and so on. These consume far too much of our days, even if we cut corners. Many mobile apps, however, require that we spend a long time figuring out how they work and take additional time to use properly.

Here's an example: My endocrinologist asked me to keep a food diary for a week, so I downloaded a popular diet/exercise app. I am recovering from stomach cancer and I have to eat every hour, so I have to plan what to eat for the day and pack it up, decide what I'm willing to eat each hour, and then eat it s-l-o-w-l-y. Doing this interrupts my work. It is inconvenient. It is often impolite.

To keep track of this already disruptive task, every hour I had to find my phone, open the app, locate each of the food items, estimate the amounts and accurately record them. 60 minutes later...wash, rinse, repeat. It took more time to enter what I ate than it did to eat it.

I used the app for three days before I resorted to pen and paper. I deleted the app.

2) We do not respond well to nagging.

Sick or well, we have come to love our mobile devices. They are a source of immediate gratification: a powerful link to those we love, access to pictures, sports scores, movies and gossip about friends. That little device is so positive, so beloved. It connects us to the world.

But the moment an app on that device in any way resembles the voice of our mom reminding us for the fourth time to make our bed, that's the end of the app.

Here's an example: An interviewee told me about an older friend who was having trouble remembering to put in her eye drops every day at 3:00. My contact offered to program her friend's cell phone to chime at 3:00 every day as a reminder to use the drops. "Great idea!"

When my contact called her friend the following week, the phone wasn't taking messages. Same thing a week later. The following week they saw each other at an event.

"I've been trying to get in touch with you! Are you OK? Is there something wrong with your phone?"

Well, that chime drove her nuts. It went off at the library, during her nap, at Tai Chi. It didn't help her; it bothered her. But she didn't know how to turn it off, so she drained the phone battery and put it in a drawer.

It's a fine line between welcome reminding and intrusive nagging. Many of us are already nagged by our caregivers, family members, co-workers and clinicians to do what we are supposed to, and we are particularly sensitive to that form of communication. We don't like it.

My contact's friend deleted the app.

3) We favor apps that are linked to (or associated with) our clinicians.

For many of us, our clinicians are the gatekeepers to the technologies and drugs that reduce our symptoms and contain our disease. They are our valued partners in our effort to feel well enough to live as fully as we can. To the extent that any mobile health app supports, facilitates and extends that relationship, we will be more likely to use it.

I interviewed someone who carefully tracked her blood pressure three times a day over a six week period on a mobile app at her physician's request. She brought a beautifully detailed chart to her physician who glanced at it, said, "Looks better," and tossed the chart in the wastebasket.

"Don't you want to put this in my record?" she asked.

"There's no way for me to do that. Keep up the good work," he replied.

She deleted the app.

Friends, I understand your desire to develop an app that is wildly popular and that changes the landscape of patient engagement nationwide. But the things that apps do – remind us, nudge us, identify patterns for us, help us monitor symptoms, send data to our doctor for us – constitute tiny fragments of days that we spend gasping for breath in our chairs, lying on our couches in pain or forcing ourselves to slog through endless uncomfortable chores. To be unwell is to be uncomfortable. It is sometimes frightening and always a drag.

Amy Tenderich, founder of Diabetes Mine, once told me, "We will use tools that answer our questions and solve our problems. We will avoid tools that help us do what you think we should do and we won't use tools that add to the work of caring for ourselves."

Even the most successful mobile app can, at best, hope to tweak that experience and make it easier for us to solve the problems we identify that will help control the disease or the symptoms and thus allow us to better enjoy our days.

Many of us anxiously await the fruits of your work.

Jessie Gruman

More Blog Posts by Jessie Gruman

author bio

Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman

Tags for this article:
Health Information Technology   Participate in your Treatment   Inside Healthcare   Patient Engagement  

Comments on this post
Please note: CFAH reserves the right to moderate all comments posted to the Prepared Patient® Blog. Any inappropriate postings will be removed.

Donna Sofaer says
February 14, 2013 at 1:06 PM

Great post. Relevant and timely.

Ben Underwood says
February 17, 2013 at 7:01 AM

Dear Dr Gruman

I have just read your excellent article above and thought you would be interested in the free app I have developed called Brush DJ.

The main feature of the app is a timer, which plays 2 minutes of music taken at random from the user’s device. This makes the mundane task of brushing for the correct length of time more fun and therefore more likely to happen. The app also contains the evidence-based oral health advice given in the Department of Health document ‘Delivering Better Oral Health’. Reminders can be set to prompt twice a day brushing, when to change toothbrushes, visit the dentist and hygienist.

This short video gives an overview of all the apps features

The first in a series of videos showing how to carry out basic oral health tasks has just been uploaded to YouTube The next version of the app will have a link to this video and 5 others showing how to carry out basic oral hygiene tasks effectively. The video along with lots more information can be found on the website and on the Brush DJ Facebook and Twitter pages.

Launched at the start of 2012, Brush DJ has already been downloaded in 150 countries on to over 33,000 devices and received mainly 5 star reviews in the app stores. Just before Christmas the app received the Dental Hygiene&Therapy award for 'Best Dental Innovation’.

If you would like any further information or could suggest ways to increase awareness of Brush DJ please contact me.

Kind regards


Ben Underwood BChD MFGDP (UK) DipHE
Website: &

Khurt Williams says
February 20, 2013 at 9:13 AM

Spot on! This is why I help fund Nial Giacomelli's , The Diabetic Journal, project. Nial is a developer with Type 1 diabetes who was equally frustrated with the current set of apps for people with diabetes. He's developing a FREE app to solve his itch and the itch of each one of us living with diabetes.

Tasha says
February 20, 2013 at 3:01 PM

Thank you for your perspective. I've quoted this in my new blog,
& would welcome your follow on twitter, @360lean.
Regards, Tasha

kevin says
February 21, 2013 at 6:22 PM

hi jessie

i can sort of understand how such things can be a punish at times, but i suspect it's just that - of its time. Reminds me of the early (quite recent) days of the internet when real world schools and unis etc rushed to put up internet courses but thinking all they had to do is upload their real life course content. They did this without taking into consideration neither the structure of the internet nor it's unique exciting new possibilities. I suspect we're still at that stage with phone / tablet apps. Even organisations like WebMD, Medscape, iTriage etc don't seem to have quite made the transition from online computing to mobile phones with their apps. But it will happen. And gentle nudges from people such as yourself should help it happen sooner and better.

and a few comments about your 2nd example about nagging if i may? I have to agree about our connection to such devices. On the 2 occasions my smart phones had to go in for repair for several weeks at a time - i damn near had to have grief counselling i was so beside myself. As for the example itself of the older woman's phone alarm being set to a 3.00pm reminder? Personally i think that this was actually quite productive. Tai chi? Napping? Library? What am i missing here? It would seem that 3.00pm was a totally inappropriate time given for her to use her eye drops. She was always in the middle of some activity that often made it impractical or impossible to use the drops then. She now has the opportunity to choose a more sensible time to have a phone reminder set, and to use the drops - at a time of day when she is home and not napping - say tea time or lunch time or ..... ? And finally, as for the app being deleted, i'm guessing that your aquaintance used the woman's phone clock to set a reminder alarm. Only the alarm event would be deleted, i'm not sure you can delete the alarm & clock itself since it's an integral part of the phone's rom rather than an app?

anyways, i enjoyed your blog and can only agree - when someone comes up with an app that does what a person / patient wants - it'll become byword
:- )


Marco says
February 22, 2013 at 3:41 AM

Great post!

If you want to check out patient centric mHealth and a company that fits the bill, take a look at mySugr which will soon launch in the US.

They're like 20 people and half of them are type 1 diabetics themselves… Been using the app for a few months. Really good stuff.

Enjoyed the article, but consider this:
Half the pills are taken
Most of us with diabetes don't log, even if we should
If you don't want to spend more time caring for yourself? See where this goes?

Using stuff like striiv, nike running etc we start exercising. The same effect is what stuff like mySugr can have and has had at least on me. Great stuff.

Thanks again for writing this article, made me think!

Carolyn Thomas says
April 2, 2013 at 10:20 AM

I've observed that whenever a common-sense post like this appears (on Linked In groups, most famously) - the inevitable response is a little flurry of tech hypemeisters jumping in to say 'Great post! - and here's a link to MY superior self-tracking app!"

And I too get very cranky when solicited by an increasing number of those "mobile app developers looking to speak with a real patient about their projects". In 100% of these solicitations that have come my way recently, the project's already underway, the website's live, the sales team's out hustling at tech conferences - and NOW they're suddenly interested in running their idea past a Real Live Patient? It's offensive and annoying.

Thanks so much for writing this important message, Jessie. My hope now is that somebody, anybody, in Silicon Valley will actually read it, preferably out loud to their startups.

Leslie Kernisan MD MPH says
April 10, 2013 at 2:32 PM

This post is spot-on and should be required reading for all app developers who want to help real patients. Well done!

Carolyn Thomas says
April 24, 2013 at 10:28 AM

Hello Jessie - I've reposted this article today at:

Many thanks once again - this is spot on.

Orville says
June 8, 2013 at 4:52 AM

Greetings! I’ve been following your site for a while now and finally got the bravery to go ahead and give you a shout out from Atascocita Tx! Just wanted to mention keep up the great work!

docweighsin says
August 8, 2013 at 9:42 PM

Jesse, you nailed it with this blog - it is a message all app developers should read and one of the reasons Health Tech Hatch advocates for patient & clinician codesign. These apps can't be designed in isolation if they are to have any chance of actually being used. Pat

Memo says
September 6, 2013 at 4:23 PM

Hi DanI have had a Android app ready if I knew it could be consistent on 3G. All my tetsnig has more failures and problems than successes. I may put out a Buyer Beware WiFi only, with a min bandwidth needed version. I am still working on it sorry.

Lori Schneider says
January 23, 2014 at 1:20 AM

Spot on!! As an avid app user in search of the ideal device/app for BP, pulse and sleep recording (not just logging) - you hit in so every good points.
We need apps we can share with our docs. Currently, the only app/device that has this sharing feature for the purposes I need are Withings...but, the BP cuff was very inaccurate and could not take standing pressures. Fatal flaw for someone with an autonomic condition...we need lying/sitting/standing BPs.
I currently use an iHealth product for BPs..- but there is no way to share the info with docs. I continue to use my Withings scale and the info is automatically sent to my doc. Sweet.
Now, if ALL app/device developers would build this into their designs...more folks would use it...a win-win-win for all!!!(you-doc-app company)!!

Alex Wyke of says
March 8, 2014 at 7:03 PM

Your experiences are echoed on this side of the pond. However I would make the following remarks. In a cross stakeholder meeting we hosted with the UK gov agency KTN Connect we found the following
* Developers who genuinely try to talk to clinicians and patient groups to get their input so apps can be made more relevant are often rebuffed, mostly because they do not have sufficient credibility to attract interest.
* The question of technical upgrades is a tricky one. Savvy developers do try and update their apps so they harmonise with the latest mobile developments. However, this comes at a cost. And the great thing about apps and self-care is that most apps are free. It is also worth point out most other medical applications, like drugs or medical devices, once approved for use by patients do not get upgraded as the world around them changes.
* Your point about time, is bang on. Apps should make life easier not harder. One of the difficulties at present is that we have apps for lots of different facilities. So blood pressure monitors are kept in separate data files on the phone to ones that measure say, exercise or breathlessness. What is needed is for all this data to marry up.
* No to nagging. That is why the supposed sms text reminders never really got off the ground.
* Networking. The best apps allow networking not only with doctors but with family and friends, carers so you can build a community around yourself.

Johan Goris says
May 15, 2014 at 11:16 PM

Hello from Belgium,

I get your point, there is a clear need to develop open user centric solutions instead of pre-determined closed APP's.

Please describe what you need to support you in your daily workflow as detailed as possible and we could try developping what's feasable today within the existing legal and technical framework.
When the framework evolves, your APP should too ...

Our team already developped an open communication tool for homecare that allows exchange of non-medical data between patient, family, friends and professional caregivers, litterally everyone that takes care of the patient at home. Thus enabling all these people to keep informed about who visited, patients mood, sleep, eating, well being, ... with simple status indicators.
Its open, so interfaceable to external inputs and outputs (already iOS, Android, Windows Phone 8, text and web interface).

Tell us what you need and we promise we will listen!

Twitter @Johan_Goris