J Med Internet Res.
2016 Aug; 18(viii): e222.
The Top Chinese Mobile Wellness Apps: A Systematic Investigation
Monitoring Editor: Gunther Eysenbach
1Division of Cardiology, Peking Marriage Medical College Infirmary, Chinese University of Medical Sciences and Peking Union Medical College, Beijing, China
2Found of Medical Information and Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Communist china
Ya Min Yu
twoEstablish of Medical Data and Library, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Hui Tong Zhao
2Institute of Medical Information and Library, Chinese Academy of Medical Sciences and Peking Marriage Medical College, Beijing, China
Zhi Rou Chen
2Constitute of Medical Information and Library, Chinese University of Medical Sciences and Peking Wedlock Medical College, Beijing, Red china
2Constitute of Medical Data and Library, Chinese Academy of Medical Sciences and Peking Union Medical Higher, Beijing, China
iSectionalization of Cardiology, Peking Union Medical Higher Hospital, Chinese University of Medical Sciences and Peking Marriage Medical College, Beijing, China
Received 2016 May 15; Revisions requested 2016 Jun nine; Revised 2016 Jul 14; Accepted 2016 Jul 29.
China’s mHealth market place is on track to go a global leader by industry size. The Chinese mobile app marketplace and health care organisation have peculiarities that distinguish them from other app markets. To engagement, Chinese mHealth apps take not been systematically investigated.
The objective of this study was to provide an overview of Chinese mHealth apps every bit of December 2015.
We identified and investigated the most downloaded apps from the iOS and Android platforms. For each app, we analyzed and recorded its main service offered, mHealth initiative, affliction and specialty focus, app cost, target user, Spider web app availability, and emphasis on information security. Standard descriptive statistics were used.
A total of 234 apps met the inclusion criteria and were investigated. The apps targeting nonhealth care professionals focused on providing telemedicine and appointment-making services. The apps targeting wellness care professionals focused on education and peer reviewed articles. The most common disease-specific apps focused primarily on diabetes, hypertension, and hepatitis management. Most apps were free and bachelor on both iOS and Android platforms.
The primary mHealth initiatives targeted by the apps reverberate Chinese patients’ demand for access to medical care. Illness-specific apps are besides representative of disease prevalence in Mainland china. Government press releases advise that new policies on the horizon may shift the manufacture.
mobile health applications, mHealth, medical informatics, China
mHealth, an area of electronic health, is the provision of health services and data via mobile technologies such as mobile phones [i,2]. mHealth apps have epitomized the typical mHealth service. These apps have the potential to cutting costs, promote patient engagement, and improve health outcomes [iii]. Much has been reported about the services in developed countries [3,4]. To our knowledge, mHealth apps in Red china have not been systematically evaluated.
Red china’southward mHealth industry is a rapidly growing sector with a year-on-twelvemonth growth rate of 29% in 2014 and a forecasted growth charge per unit of 49% in 2015 . The market place size is expected to reach ¥7.18 billion (approximately United states $one.08 billion) in 2016 and ¥12.5 billion (approximately United states $ane.90 billion) in 2017 . In Mainland china, patients frequently have difficulty gaining access to advisable medical intendance [vii-9]. mHealth has the potential to provide widely attainable services that can be individually tailored and easily adopted.
An understanding of the Chinese health care arrangement and smartphone usage provides a framework for agreement mHealth apps in China. The Chinese health care system has peculiarities that make mHealth a viable option. On the surface, the overall Chinese medical system tin be comparable with those in advanced countries. In 2011, the doctor to patient ratio was not profoundly dissimilar between China and other developed countries: i.5 per 1000 patients in China versus ii.5 in the U.s. and 2.seven in the United Kingdom . The imbalances inside the Chinese wellness care system become apparent when comparing urban versus rural areas. Health intendance expenditure varied by nearly 4-fold in 2009 between urban and rural areas [xi]. As the overall wellness care system grew betwixt 1980 and 2006, the number of beds in rural areas actually decreased. Also, the quality of care was far inferior in rural areas: the infant bloodshed rate was 16.1% in rural areas versus five.8% in urban areas [xi]. Due to the imbalance of medical resources, patients flock to urban areas seeking medical resources. The displacement of rural patients to urban areas causes difficulties in obtaining access to high-quality care, since rural and urban patients all compete for access to the same medical resources.
The smartphone usage rate is also unique in People’s republic of china. In 2014, 62% of the Chinese population betwixt 16 and 59 years old owned a smartphone. By city tiers, smartphone buying amongst the same age range was 94% in tier 1 cities and 75% to 88% in tier ii cities, while the charge per unit in rural areas was 32% . Also, the Android platform holds a strong foothold with approximately 70% share of the smartphone market [xiii]. The main Android app stores in China are operated by Baidu, 360, and Tencent; Google Play has been absent since a 2010 censorship dispute . The app markets in China, whether iOS or Android, all take multistep quality and content screening before apps are showcased in the store [15-18]. Withal, the specific rejection criteria differ beyond each shop and are summarized in Multimedia Appendix 1.
The purpose of this report was to provide an overview of the leading mHealth apps in People’s republic of china every bit of Dec 2015. This study investigated each app with regard to availability, service, and data security to understand the electric current state of the Chinese mHealth marketplace. In this study, we focused on medical-related apps instead of general health intendance. Hereafter, mHealth refers to mobile apps equally they pertain to medicine.
Pick of Apps
We sampled apps from both the Android (Google, Mountain View, CA, USA) and iOS (Apple Inc, Cupertino, CA, U.s.) mobile phone app stores. For Android, we sampled apps from the iii largest Android app stores in China operated past Tencent (Tencent Holdings Limited, Shenzhen, People’s republic of china), Baidu (Baidu, Inc, Beijing, Prc), and 360 (Qihoo 360 Engineering Co. Ltd, Beijing, China). The 3 stores make up nearly 60% of the Chinese Android market share . For iOS, we used App Annie (App Annie, San Francisco, CA, U.s.a.) to gather the list on Red china’south iOS market. Nosotros obtained the sample of apps on December 5, 2015.
We collected the top 100 apps co-ordinate to each app store. The Android stores listed complimentary and paid apps together. The iOS apps separately listed complimentary and paid apps; thus, we nerveless both the summit 100 free and top 100 paid apps. We systematically evaluated the free apps and but did simply a cursory assessment of the paid ones.
We selected apps from the medical category for further evaluation. We so reviewed the apps for potential inclusion into the report. The inclusion criteria were equally follows: simplified Chinese language, service tailored toward Mainland People’s republic of china (excluding Taiwan, Hong Kong, and Macau regions), and services pertaining to health care and medicine, not general health. For case, nosotros omitted weight loss, exercise, smoking cessation, and menstrual wheel management apps (Figure 1).
The initial screening was completed by 4 authors: LD, YYM, ZHT, and CZR. The apps included for further evaluation were randomly assigned to these four authors. Each app was reviewed using information from the app store description, the app’s website (if bachelor), and the app itself. Nosotros so reviewed each app collectively to ensure accuracy. If discrepancies existed, the particular app was discussed and a consensus was reached. For each app, nosotros identified the main service offered, mHealth initiative, illness and specialty focus, app cost, target user, Web app availability, and emphasis on information security.
Categorization of Apps
We recorded what service was offered based on the app store description and assigned the app to a respective mHealth initiative. mHealth initiative describes where an app’southward service lies along the continuum of medical service delivery. In this study, we adopted the categorization of mHealth initiatives from ii previous reports [i,half dozen] and tailored information technology for the Chinese market. The 10 health initiatives used in this study were as follows: (1) appointment making, (two) reminders, (iii) telemedicine, (4) records and patient monitoring, (five) pharmacy, (6) affliction awareness, (7) clinical decision back up, (eight) discussion forums, (nine) medical education and scholarly articles, and (10) other (Tabular array ane). Each app could take one or more identified mHealth factors.
|Previously published categoriesa||Categories adapted for this study|
|Call center||Engagement making|
|Records||Records and patient monitoringb|
|Patient monitoringb||Records and patient monitoring|
|Decision support||Clinical decision back up|
|Discussion forum||Discussion forum|
|Scholarly manufactures||Medical instruction and scholarly articles|
We assessed the disease and medical specialty of an app past the app’due south name, app shop clarification, and website. We matched the diseases we identified to its closest
International Nomenclature of Diseases, Tenth Revision
App cost referred only to the toll at download. Additional fees incurred after usage were difficult to systematically evaluate and thus were non considered. We considered cost to exist a binomial variable.
For target users, we classified apps as existence focused on health care professionals (HCPs), non-HCPs, or both. HCPs referred to those included in the World Health Organization’due south wellness professional person categorization . Since clinicians in public Chinese hospitals are typically required to conduct research [4,21], we besides included clinical inquiry-focused apps, even though the WHO categorizes this profession under life sciences. Apps identified as “both” had an HCP and a non-HCP version available.
For Spider web app availability, we examined the app store and website to determine whether a Web-based version of the app was available.
Finally, we examined whether an app emphasized information security. Cathay lacks an industry standard or legislation regarding medical data safety or privacy similar to the Health Insurance Portability and Accountability Act in the United States . Thus, for information security, nosotros evaluated whether each app self-reported relevant data security measures. Nosotros labeled information security for each app every bit absent, present, or complete. For apps to have complete information security, they had to present documentation or a link referencing a 3rd-political party auditor.
Categorizations were fabricated based on the description in the respective app store. For apps that were present in multiple app stores, we ensured the consistency of the descriptions across stores and eliminated duplicates. Some apps had a patient and a clinician version. Nosotros evaluated these as one entry. Descriptive statistics were used to describe the characteristics of the apps. Estrus maps were used to identify the areas of the marketplace receiving the nearly traction.
At that place were 241 unique apps that met the inclusion criteria. When we analyzed the apps, 7 were not bachelor or had been taken offline, and thus nosotros eliminated them from the final list. We analyzed a full of 234 apps. Of these, 195 were available in both iOS and Android app stores. Withal, 22 (9.4%) and 17 (7.3%) of the apps were bachelor exclusively in the iOS and Android app stores, respectively.
The virtually common medical initiatives were telemedicine, affliction awareness, appointment making, and records and patient monitoring (Effigy two). The least mutual service factors were reminders and clinical decision support. Apps classified under other services included pharmaceutical drug data, drug commitment, insurance plans, and online-to-offline (O2O) wellness checkup services. We subdivided each medical initiative into the corresponding target user. Autonomously from clinical decision support and medical instruction, which primarily focused on HCPs, all other wellness initiatives were mainly aimed at not-HCP users.
Of the apps, 185 targeted non-HCPs, while 34 targeted HCPs, and fifteen had both versions available. A full of 210 (89.7%) of the mHealth apps in Prc were free. All the paid apps were from the iOS app store. Nearly one-third (154/234, 65.viii%) of the apps had both a mobile and a Web-based version. 227 of 234 apps (97.0%) of the apps did not mention information security (Figure 3). Of the 7 apps (iii.0%) that mentioned information security, none had undergone external auditing.
Nosotros created estrus maps to examine the distribution of apps along the medical initiative, and the illness and medical specialty spectrum. The well-nigh common diseases were diabetes, hypertension, liver affliction (general), and infertility (Figure 4, top). For diabetes, the apps were focused on record keeping and patient education. The most common specialties were general medicine, obstetrics and gynecology, endocrinology, pharmacology, and traditional Chinese medicine (Effigy four, bottom). Apps classified under full general medicine covered an array of specialties without an emphasis on whatsoever particular one.
This report provided a snapshot of the Chinese mHealth industry in December 2015. The master mHealth initiatives targeted past the apps reflected Chinese patients’ demand for access to medical intendance. The main initiatives were telemedicine, disease sensation, date making, and tape keeping, followed by medical education and scholarly information. The overwhelming bulk of the apps were not specific to a medical specialty. Notwithstanding, the apps that targeted a disease reflected prevalent weather in Prc such every bit diabetes, hypertension, and hepatitis. The target users amongst apps were mainly non-HCPs. An overwhelming majority did not mention data security. Nosotros discuss each aspect further below.
Through the oestrus map and mHealth initiative analyses (Figure 4), we establish that among the nigh common mHealth initiatives were telemedicine, appointment making, and medical educational activity. Telemedicine can broadly be defined equally the use of telecommunications technologies to provide medical information and services . The use of telemedicine to diagnose and prescribe medication has yet to be legalized in Communist china. This implies that the actual service delivered in telemedicine was limited to full general medical inquiries, with limited medical deportment involved. Appointment making reflects a phenomenon beyond Mainland china of patients lacking admission to clinicians [7,ix].
Here, nosotros discuss the role and background of hospital appointment making. In 2009, the Chinese Ministry building of Health required all public hospitals of level three  or college to let date-making services and prohibited partnering with third-party agencies to profit from these services . In recent years, for a given public hospital, bachelor appointment dates have been provided straight on the hospital’s appointment-making system, public (municipal or provincial) third-political party systems, or private tertiary parties such as apps. (Of note, in the Peking Union Medical College Hospital in detail, the ratio of cocky-distributed to public third-party distribution is 7 to iii.) These apps obtain a number of appointments past signing agreements with hospitals or with individual doctors. Apps solve the problem of difficult admission by (ane) aggregating hospital date availabilities on their platform, thus preventing patients from waiting at fully booked hospitals or (2) partnering with individual doctors to provide consultations on personal complimentary time.
Apps focused on medical education and scholarly articles targeted 2 key demands in the Chinese health intendance marketplace: access to reliable information, and clinicians’ need to publish peer reviewed articles. The proliferation of discussion forums and unregulated “medical” manufactures on the Internet and apps makes reliable information a rare commodity. The abundance of medical education apps appears to target this need.
On the other mitt, a clinician’south professional advancement is dependent on many factors, of which publishing peer reviewed articles is crucial [21,26]. The availability of apps to provide manufactures and aid with the writing process can be an endeavor to supply this demand. These apps provide writing resources such equally editing and actual writing, and provide access to scholarly manufactures. This access is often through a Chinese translation or a summary of the original article (about often in English).
Disease- and Specialty-Specific Apps
We examined the distribution of diseases and medical specialties in the mHealth industry through a heat map plotted against medical initiative. When examining the frequency of apps on a disease ground, we adamant diabetes to be the most common, followed by hypertension and hepatitis. This is consistent with epidemiological surveys pointing to these diseases as the most prevalent in Mainland Cathay. According to a report from the Chinese Heart for Illness Control, the prevalence of hypertension amid Chinese adults was 33.5% (amounting to roughly 330 million hypertension patients) . A recent study showed the prevalence of type 2 diabetes at 11.6% of the population (amounting to nearly xc one thousand thousand diabetes patients) . Since mHealth apps for these diseases focused almost exclusively on illness monitoring and recording, market forces driven by pharmaceutical drug sales may not be the primal cistron for app providers. Rather, it may be the distribution of monitoring devices. Diabetes is monitored by glucometers and single-utilize dispensable test strips, versus repeated-use blood pressure level machines for hypertension. The market place opportunity for diabetes in mHealth is believed to be greater than that for hypertension due to the nature of disease direction and monitoring, despite hypertension having nigh triple the patient volume.
Unlike many developed countries in the globe, in Communist china hepatitis B is endemic. Approximately 1-third of worldwide cases are in Mainland Red china . A study noted 120 1000000 carriers of hepatitis B virus in Red china and 30 1000000 patients who are chronically infected . The beingness of apps targeting hepatitis is consistent with the illness’s endemic nature in Mainland china.
The heat map of medical specialty by health initiative provided more information nigh the industry equally a whole. By far the most heavily targeted specialty, or lack thereof, is general medicine. The apps here mainly focused on appointment making and telemedicine. The telemedicine services offered were frequently a “lite” version of medical history taking, since patients were provided with general answers and so encouraged to seek specific guidance through in-app appointments. Thus, despite telemedicine and appointment making having lexical and implicit differences, Chinese mHealth apps providing telemedicine services were more synonymous than they appeared based on the to a higher place analysis. This finding reinforces the difficulty of accessing care.
Another pop surface area was pharmacology. The apps in pharmacology provided patients with admission to online or offline pharmacies and provided clinicians with pocket drug references. Pharmacology-related apps aimed to provide convenience for patients who crave drug refills and cannot repeatedly travel to community pharmacies or hospitals. Community pharmacies oftentimes do not deport a full repertoire of prescription drugs, and the current state insurance policy covers in-hospital prescriptions for fourteen days for able-bodied patients and upwards to 30 days for disabled patients. On the other hand, pharmacology apps targeting clinicians, pharmacists, and other HCPs provided references for dosing, interactions, and alternative drugs. The incorporation of pharmacology apps into HCPs’ daily exercise appears to exist a mainstay in China and many other countries [31,32].
Accessing an app from different media can allow users to experience the app differently and can serve dissimilar purposes. The apps in this study focused on mobile phones. However, about 1-third of the apps besides had a Web-based version. The main difference between the Spider web app and mobile app was the ability for users to view historical data organized in reports or graphs in the Web-based version. It has been reported that data visualization and context awareness could enhance an app’south utility .
Target User and Payment
An app’s target user tin can provide information about market place opportunities and underlying market forces facing app developers. Our analysis showed that app developers preferred targeting the not-HCP user, mayhap due to easier user acquisition and a larger potential user base. The HCP-oriented apps mainly provided services through medical education or scholarly articles. Few focused on medical care delivery or integration into hospital intendance. This can be explained by financial compensation related to publication requirements [21,26]. A physician’s compensation is directly tied to his or her position in a hospital hierarchy. Among many factors, publication quotas are mandatory evaluation metrics in many hospitals. We believe that this demand on physicians compliments an app developers’ need to grow and retain a steady user base. In that location were 10 apps with both an HCP and a non-HCP version available. These apps all allowed communication between the two parties.
Almost apps in Communist china were complimentary for users to download and use. All apps surveyed from the Android app stores were complimentary. Chinese users are likely accustomed to using costless apps.
We examined the lack of information security from two perspectives: market forces and regime regulations. About all apps failed to mention on their website or user understanding course about securing the users’ data. This tin imply gross negligence from the programmer or use of the data for other purposes. The latter is likely the underlying motive considering, as noted past notable industry agencies, data tin can be knowingly or unknowingly sold to marketers for fiscal gains .
We besides considered data security from a policy perspective. Nosotros examined policies pertaining to medical apps by reviewing documents from the People’s Republic of China Country Council’s official website  dated between 2013 and 2015. The search was limited to “Net,” “Net plus wellness intendance,” and “Net plus medicine.” All results were read and screened by a Chinese Wellness Intendance Policy analyst (author LD) for relevance. Among the more than three grand policies and documents available, no straight laws governing medical apps, let lonely mHealth security, were establish, and only xi official releases were identified that tin can direct or indirectly affect the operation of medical apps (Table two).
Tabular array 2
|Document content||Targeted industry|
|1||Net plus action program||Manufacturing, transportation, information technology|
|ii||Activeness outline on promoting the evolution of large information||Manufacturing, transportation, it|
|three||Medical services and wellness care system planning guideline (2015–2020)||Wellness|
|4||Circular on boosting the development of due east-commerce||Comprehensive government affairs|
|v||Guideline on strengthening back up for consumer services to upgrade consumption||Commerce|
|6||Guideline on further boosting consumption every bit a key component in driving economic evolution||Commerce|
|7||Guideline on pushing integrated medical and nursing intendance for the elderly||Health|
|viii||Circular on strengthening the Patriotic Hygiene Campaign in the new era||Health|
|9||Opinions on using big data technology to improve the authorities’s supervisory responsibilities and services for market place entities.||Manufacturing, transportation, it|
|10||Opinions on cracking down on infringement of intellectual holding rights and the production of fake and junior commodities in cyberspace to safeguard the good for you development of e-commerce||Science, instruction, intellectual belongings|
|xi||The legislation working plan of 2015||Full general|
The scope of mHealth apps can cross into many industries. Documents mentioning mHealth targeted industries such as it, manufacturing, health care, commerce, and intellectual property. The fact that many policies, across various industries, mention mHealth suggests that the Chinese authorities recognizes the future potential of the industry but has all the same to dictate a articulate stance on how to regulate this relatively new manufacture. The lack of specific policies toward mHealth may be due to the difficulty in pinpointing which industry it lies in.
Most apps were available on both app platforms. Android dominates the Chinese smartphone market at over seventy% market share . The iOS app store is known to accept more apps available than the Android store. However, many are not specific to the Chinese market. It is possible that mHealth app companies are developing the apps domestically and targeting consumers on both platforms.
There are limitations to this report. Get-go, the number of apps sampled is small and cannot fully explicate the marketplace. This study was meant to provide a snapshot of the manufacture as a whole rather than details along each medical specialty. To fully understand the availability and characteristics of the apps for each specialty, the analysis should be done in disease or specialty verticals. Second, this study focused on medical apps while excluding full general health apps. This immune for a more homogeneous analysis, since apps targeting healthy users and sick users are likely different in nature. However, we excluded a large portion of apps from the analysis.
In the future, a shift in mHealth apps from delivering purely online services to an O2O approach is expected. O2O, a concept common in Chinese e-commerce, refers to an integration of offline businesses into online commerce [36,37]. Online services in health intendance can refer to mobile apps, websites, or other digital tools. Offline services include services delivered in physical sites such as hospitals, clinics, pharmacies, and wellness centers. The idea of O2O in mHealth refers to the integration of online services delivered via apps with “traditional” health service providers. Possible applications include prescription apps that let patients with existing prescriptions to have their drugs delivered past a local pharmacy, and tertiary-political party apps that provide electronic health records services linked to the electronic medical records of a regional clinic.
As of July 2016, the government released legislation banning mHealth apps from providing appointments for patients. The legislation requires appointments to be fabricated directly through the infirmary, not a 3rd-political party provider. The reasons backside the ban were to ensure the integrity of the hospitals and protect patients’ interests. Most Chinese hospitals are nonprofit public institutions. Providing public resources to partnering companies for financial gain violates their nonprofit nature. In addition, third-party appointment-making apps commonly tack on a cost premium for each service-seeking patient. Finally, allowing tertiary-party appointment-making apps to serve individuals who tin beget a premium is a detriment to nonpremium-paying patients. Thus, information technology behooves the government to ban this service to protect the general public and preclude private-public partnerships from hoarding publicly available resource.
A growing tendency, internationally and domestically, is allowing clinicians to send prescriptions via apps. Services offered in this space have obvious financial incentives and safety risks. The development of the prescription app manufacture is expected to grab the regime’due south attention. There is precedence for the regime to interject and control specific health markets. How or when that will occur is to be determined. As policy shifts loom on the horizon, mHealth providers must react. One common theme found in Red china and in the United states of america is that the “grassroots entrepreneurial nature of the market”  appears to be the main commuter of the mHealth industry.
mHealth in China is a large and continuously growing marketplace. The potential to disrupt the traditional wellness care market exists. At the terminate of 2015, the Chinese mHealth market targeted the nonprofessional user. The services offered heavily focused on the demands of HCPs and non-HCPs, such equally publishing peer reviewed papers and gaining access to clinicians, respectively. Besides, a unifying policy or standard from the Chinese central government or the China Food and Drug Administration to govern this industry is defective, but show shows that the government is cognizant of the potential this industry and regulations may have in the nigh time to come.
This piece of work was supported past the National Natural Science Foundation of China (81250010 and 81470426), the Beijing National Science Foundation (7132221), the Peking Union Medical College Infirmary Young and Center-anile Investigation Fund (PUMCH-2013-016), the Peking Union Medical College Youth Fund, the Primal Research Funds for the Central Universities (20122012J01 and 3332013102), 2012 Janssen Enquiry Council China (JRCC), and the project sponsored by the Scientific Research Foundation for the Returned Overseas Chinese Scholars, Land Educational activity Ministry (SRF for ROCS, and SEM) to Wei Chen.
|HCP||health care professional person|
Multimedia Appendix one
Common reasons for app rejection across iOS and Chinese Android app stores. Android app stores include 360, Baidu, and Tencent.
Conflicts of Interest: None declared.
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