The results demonstrate that most physicians in practices specialising in diabetes do see potential benefits of health apps for managing type 2 diabetes. Such benefits include effective reinforcement of empowerment, motivation and compliance, and also reminder and lifestyle-supporting features in disease management towards improved type 2 diabetes patients prevention and management [35, 36]. Earlier studies have demonstrated recognition amongst general practitioners and specialists as to specific usage scenarios and added value in apps [17, 20]. Younger physicians, especially in urban environments, show a favourable attitudes towards health apps and use these tools in everyday practice – a result that agrees with other studies on the subject [12, 18,19,20].

Even so, a substantial share of the respondents expressed scepticism about health apps that included user-friendliness and reliability in existing apps, legal issues such as liability, and the resulting additional workload from additional responsibility in patient counselling. A substantial number of respondents were also concerned about incorrect app use or vital parameter measurement causing risks such as misdiagnosis. The distinct scepticism regarding data privacy in health apps is remarkable considering the strict data protection standards by international comparison due to the requirements set in the European General Data Protection Regulation (GDPR), which applies in Germany. Even so, respondents showed a considerable level of insecurity on this point in particular.

Most have admitted a lack of sufficient general awareness on topic-related health apps owing to the huge and dynamic range of apps available, lack of transparency and basic orientation; this results in limited confidence in advising patients [12, 13, 17, 20, 37].

Respondents that recommended apps named various criteria that would need to be met before making specific recommendations. These criteria mainly included ease of use or usability, reliability, and data privacy guarantees.

Physicians already using apps in patient care had observed positive effects in increased compliance, earlier detection of or reduction in complications, weight reduction, and decreased HbA1c levels. These findings tally with those of other studies [38,39,40,41]. Overall, a number of studies have shown digital applications can significantly contribute to a substantial reduction in HbA1c levels, consistent blood sugar management, improved wellbeing, and lifestyle compliance [16,17,18,19,20,21,22, 25, 42,43,44,45,46,47,48,49]. Self-monitoring has also been found to result in a decrease in cardiovascular mortality with increased awareness of symptoms [42].

Besides, studies have reported forgetting to take medications and changing doses as reasons for poor compliance in chronic diseases. One such study examined seniors and their medication-taking behaviour using the MyTherapy app for self-monitoring their type 2 diabetes [24]. These seniors used the app most frequently for reminders to measure blood glucose levels and take medication, followed by exercise reminders. Using the app resulted in an improvement in psychological well-being and medication compliance. Other studies have shown the MyTherapy app to increase compliance and strengthen doctor-patient relationships in type 2 diabetes patients [23, 50].

Patient surveys have demonstrated people living in rural areas to be less accepting of health apps in general. However, these populations could benefit even more from telemedical data transmission than urban populations due to the greater distances to physicians and increasing decline in outpatient care providers in some regions [10, 16, 18, 42]. Some respondents were also aware of this by recognising possibilities for easier, low-threshold communication, strengthening the doctor-patient relationship and other benefits.

Most respondents expressed a wish for authoritative data privacy and quality standards as well as certification for new apps, requirements scientifically established in other studies including the CHARISMA study in particular [10, 11]. Many respondents saw the benefit of the national healthcare guideline explicitly addressing evidence-based use of health apps for type 2 diabetes prevention, monitoring, and management. Most respondents stated that they could imagine including health apps in patient care more intensively than before if all these conditions had been met. Other study results have also shown there to be a great desire for evidence-based integration of health apps [50,51,52].

Physicians in Germany have been permitted to prescribe patients approved digital health applications (so called DiGAs) since the summer of 2020 - a step that was unique in the world at that time and still is [53]. Since then, physicians have been able to prescribe DiGAs to patients with costs covered by the national health system. DiGAs are set to make disease diagnostics and recognition more effective, provide support in treatment, and contribute to prevention while guaranteeing high quality standards. In contrast to ordinary, freely available health apps, these prescription apps are certified as medical devices. DiGAs are reviewed in detail using a standard procedure defined by the German Federal Institute for Drugs and Medical Devices (BfArM). This requires manufacturers to apply for approval in the course of an audit process on a variety of requirements (CE markings for medical devices, data protection, security standards, information quality, usability and robustness in operation, patient safety). They are also required to provide sufficient documentation for the added value of the application in its effect on healthcare.

The range of such approved health apps is still rather limited, but diabetes-related apps in particular have become more strongly represented (apps such as Zanadio, Oviva Direkt, ESYSTA, VIDEAmellitus) [54]. These prescription health apps have been tested for effectiveness based on quality standards with approval for clearly defined specialisations, so they stand to boost willingness amongst not only diabetes patients but also their doctors in the long term. Medical concerns as reflected in the present survey may therefore be addressed far more effectively by prescription apps [55]. Initial surveys of doctors on approved digital health applications show that they are rated as significantly more trustworthy and reliable than conventional health apps. This offers new opportunities and application potential for the future integration of health apps into patient care [56].

We recruited a heterogeneous sample of physicians from practices specialising in diabetes. Even so, the present study cannot lay any claims to being representative due to the limited number of respondents.

Moreover, it cannot be ruled out that physicians with favourable attitudes and experiences towards health apps took part in the survey to a greater extent than those with negative experiences (possible selection bias).

The present exploratory survey primarily served towards gauging general opinion rather than performing a more nuanced analysis of clinical effectiveness amongst mHealth apps. The breadth and complexity of health apps as a topic limited the present study to an initial exploratory approach. The authors see a need for further, more empirically grounded intervention studies focusing on specific application and use opportunities, but also weaknesses of health apps in healthcare for type 2 diabetes patients.