Table 2 Potential stakeholders and roles in improving app quality along the app lifecycle
Stage in app lifecycle | Stakeholders | Potential quality improvement processes | Examples of these processes |
|---|---|---|---|
 1. Development | Developers, users, clinicians, standards bodies | Involve clinicians and users Refer to engineering standards Understand app quality criteria Develop and evaluate app using appropriate framework | BSI app standard PAS 277 [47] RCP checklist [19] MRC digital intervention development process [38] |
 2. Uploading to app repository | App repository owners | Check technical aspects Check privacy Check developer qualifications Check CE mark | Apple App Store excludes drug-related apps unless developer is a product licence holder (see Box 2) |
 3. App rating and review | Raters | Wisdom of the crowd Use explicit criteria | Can fail [13] RCP checklist [19] |
 4. Selection from the app repository | App repository owners | Check quality Check CE mark, intended app user, training needed, etc. | Complete app risk checklist [27] Check if needs CE mark |
|  | Users | Consider risks Check reviews | Read iMedicalApps review Select from a curated app repository Seek doctor’s advice RCP checklist [19] |
 5. Using app for self-management | Users | Use with caution Notify doctor or regulator of errors or near-misses | RCP guidance for physicians [19] |
 6. Removal from app repository | Regulators, app repository owners | Respond to reviews, reports of adverse events, lack of evidence to support claims | Apple’s stance on health related apps (see Box 2) Banning of some ineffective acne apps [43] |