Using mobile phone apps to deliver rural GP services: a critical review using the walkthrough method (Preprint)

BACKGROUND The widespread use of mobile phones in modern society represents new frontiers for improving access to healthcare. This includes using mobile phone applications (apps) to deliver GP services in rural areas as a means of reducing rural health inequalities. But the wider adoption of app-based GP services relies on understanding how they might intersect with the expectations of care within rural health systems. OBJECTIVE This research aimed to critically review a range of GP-service apps in current use, to explore strengths and challenges for use in a rural health service context. METHODS The sample three GP service apps in the top 100 list in the Medical Category Apps in the Apple store, Australia, June 2020. The Walkthrough Method was applied to extract data and critique the explicit factors such as the app interface elements and implicit factors such as the embedded cultural features related to use for people in rural settings. Findings were compared and contrasted between three researchers and with reference to the broader literature, over the course of 6 months, using critical reflection. RESULTS Apps may increase the availability of GP care; however, use leads to being charged out of pocket costs with not rebates, may not be affordable for all rural patients. They mainly applied fixed appointments that mismatch rural need in a context where patients often present late, with complex multi-morbidities. Apps interfaces have limited tailoring to the cultural dimensions of rural healthcare, nor do they collect information to understand the context of a rural consumer (such as town name, access to a regular GP or hospital). The latter could place patients at risk if emergency follow-up services are needed. Patients generally self-select into use with limited support, potentially leading to inappropriate use especially by rural cohorts with limited health literacy. Although apps claimed to avail most GP services, (70-80% in some cases), it emerges after enrolling in these services, that emergency, complex and serious conditions may be excluded, to avoid taking longer than 15 minutes. Apps may also show limited information about continuity/coordination of care potentially imposing fragmented and low-quality care on rural patients. There is commonly no assurance of rural skills/experience of app-based medical staff despite the wider scope of skills needed to be effective in rural general practice. CONCLUSIONS Service apps may increase the availability of GP services but for engaging and being useful in a rural context, they may require more rural-tailored interfaces, capacity to tailor appointment times and costs to patients with complex needs. They could also aid appropriate use through decision-making tools and setting clearer exclusions up front. Finally, for quality, information about doctors’ rural training/experience and a plan to integrate with in-person rural services, is critical. CLINICALTRIAL not applicable