The Journal of mHealth Vol 1 Issue 3 (June 2014) by The Journal of mHealth

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NEWS, REVIEWS, CLINICAL DATA, mHEALTH APPLICATIONS

The

Journal of mHealth The Global Voice of mHealth

June 2014 | Volume 1 Issue 3

Deploying mHealth: Overcoming Barriers to Adoption

ARTICLES

INSIGHT

NEWS

The Value of Video in Modern Health and Social Care

Lab Quality Testing in the Palm of Your Hand

Full Round Up of Industry News

Some things just... ...stand out from the crowd

Global Digital Health 250 The most innovative companies in the field of digital health For more information please contact us at thejournalofmhealth@simedics.org

Editor's Comments

Welcome The proliferation of digital and mobile technologies within healthcare is becoming more and more widespread as the industry moves to accept these solutions as part of everyday working practice. Despite this, however, there remains a considerable number of barriers that seem to continue to prevent the wider scale adoption and deployment of digital solutions. As our regular readers will know, we frequently publish reports and news articles that detail the successes of different digital health trials, from which it is easy to see the benefits of solutions in those particular circumstances. What we currently rarely seem to see, however, is reports of these types of solutions being adopted at scale.

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There are numerous reasons for this. Integration with IT (and other solutions) is often problematic, the need to accept new methods of working can sometimes be resisted by staff, or cultural change within organisations is often slow to happen.

For editorial, research and paper submissions, and advertising opportunities please contact: Matthew Driver matthew@simedics.org +44 (0) 1756 709605

We must accept that technology should not just be implemented for technologies sake. There must be tangible benefits to the way care is provided in order for a solution to be used. Equally, that solution should facilitate the care process and the working practices of care providers without introducing additional burdens. The way this should be achieved is to develop flexible, integrated, intelligent, solutions that can empower the end user. In patient solutions this may mean giving them the ability to take a greater responsibility for the monitoring and management of their condition, whilst also providing them with new ways of interacting with the different stakeholders involved with their care. For healthcare professionals it should mean providing them with solutions that compliment care provision, and which allow them new ways of working, so that they are supported by the technology, meaning they can do more with less, or provide services in improved or different ways.

Editor: Matthew Driver Design: Jennifer Edwards

Subscribe at www.thejournalofmhealth.com The editor welcomes contributions for The Journal of mHealth. Submissions can be sent to the Editor by email, images and graphics should be submitted in high resolution format.

We hope you enjoy reading!

The opinions expressed in this publication are not necessarily shared by the editors nor publishers. Although the highest level of care has been taken to ensure accuracy the publishers do not accept any liability for omissions or errors or claims made by contributors or advertisers, neither do we accept liability for damage or loss of unsolicited contributions. The publishers excercise the right to alter and edit any material supplied. This publication is protected by copyright and may not be reproduced in part or in full without specific written permission of the publishers.

Matthew Driver

ISSN 2055-270X ÂŠ 2014 Simedics Limited

Considering some of these barriers to adoption from a variety of different perspectives, we include in this issue thought-leadership articles from clinicians, digital solution providers, and industry leaders - eHealth: Accelerating Towards a Healthy Future (by Neelie Kroes Vice-President of the European Commission for Digital Agenda). As well as featuring case studies that consider the digital adoption question in the context of particular system deployments.

Editor

The Journal of mHealth

Table of Contents

In This Issue 4

Deploying mHealth: Overcoming Barriers to Adoption As part of the theme for the issue, we assess the range of different challenges and barriers that can influence adoption and deployment of mobile and digital health solutions.

The Value of Video in Modern Health and Social Care Embedding video within health and social care provision has been shown to produce significant health economic and quality benefits. This report developed with the help of healthcare video specialist v-connect considers the implications of incorporating video within modern clinical work flows.

eHealth: Accelerating Towards a Healthy Future We are very pleased to include this article written for The Journal of mHealth by Neelie Kroes Vice-President of the European Commission responsible for Digital Agenda.

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Table of Contents

Industry News

Social Networking and Alerts Technology ‘Transforms’ How Healthcare Teams Work

Samsung Launches Major Digital Health Initiative

ATA Plans to Launch Telehealth Accreditation Program

AbedGraham leads US IT Expansion towards the NHS

Medical Devices Summit West 2014

Innovative Timepiece for the Blind and Visually-Impaired

Wearable Technologies Conference 2014 – San Francisco

FDA Approval of First Mobile Platform for Real-Time Estimation of Surgical Blood Loss

Healthcare Revolutions: Big Data and Smart Analytics

Health Datapalooza Review

mHealth + Telehealth World 2014

International Digital Health and Care Congress: Improving Health Through the Use of Technology

Can We Really Deploy mHealth at Scale?

Engaging Patients Using mHealth

Understanding Stress and Posttraumatic Growth

New Diagnostic Device Aims to Deliver Lab-Quality Results at Patient Bedside New US Study Shows 70% of People Tracking Their Health and Fitness Daily Using Apps Global Mobile Subscriptions Reach 7 Billion

$150 Smartphone Spectrometer Can Determine the Number of Calories in Your Food

Low-cost Motion Controller Provides a Unique Approach to Physical Therapy

A Clinician’s Guide: How to Enhance Adoption and Diffusion of Technology in Healthcare

Global mHealth Market Expected to Reach $49 Billion by 2020

Lab Quality Testing in the Palm of Your Hand

App Offers Interesting New Way for Doctors to Learn

The Changing Face Of Healthcare: Quality in Medical Applications

New Method for Lowering Blood Pressure Without Side Effects

'Grip Chips' Let Hand Prostheses Think for Themselves

US and UK Working to Strengthen Use of Health IT for Better Patient Care

China: A Market for mHealth?

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Deploying mHealth: Overcoming Barriers to Adoption

Deploying mHealth: Overcoming Barriers to Adoption It is now widely accepted, amongst the wider healthcare profession, that the socalled ‘Digital Revolution of Healthcare’ is, and will continue to be, an essential mechanism, necessary to help overcome some of the many challenges facing modern medical provision. Every democratic society has to address practical questions about the availability and distribution of medical services. Life expectancy is projected to increase from an estimated global average of 72.6 years in 2012 to 73.7 years by 2017, bringing the number of people over age 65 to around 560 million worldwide, or more than 10 percent of the population. In Western Europe this proportion will hit 20 percent, and in Japan 27 percent[1].

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With ageing populations comes an increase in those afflicted with chronic ailments, that require increases in health care spending. When this is combined with heavy government debt and constraints on tax revenue, it is forcing health providers to make difficult decisions, in order to provide more services with fewer resources. Across the world, healthcare systems have recognised the need for innovation, yet, despite the promise and potential of mobile and digital health solutions, as a means of changing the ways in which care is delivered, there remains a significant number of ‘barriers’ that continue to hinder adoption and dissemination of technology. This edition of The Journal

of mHealth considers some of these issues from a range of relevant perspectives. In this article we briefly consider some of those barriers and challenges.

PRIVACY AND DATA OWNERSHIP A technology-enabled healthcare system produces immense volumes of information and data, and with the collation of data comes a complex series of considerations for each stakeholder in the supply chain. Solution developers and provider organisations must determine what data is stored and then implement the necessary steps to ensure that, that data is subject to the necessary levels of control and oversight.

Deploying mHealth: Overcoming Barriers to Adoption Many medical disciplines are now underscored by the use of data-driven systems, yet the data, itself, can be the source of problems. New care and insurance models, electronic information transmission, and inter-connected boundaries among industry participants increases the complexity of managing protected health information. The consequences of digitising healthcare means that there are an ever-increasing number of networked connections within the system, which in turn is increasing the chance of data breaches, malware infections, and vulnerability to unauthorised access. As technology disseminates beyond the confines of the hospital or GP practice the challenges of maintaining data integrity become even more difficult. Introducing mobile and digital solutions to a range of stakeholders, using different technology providers, decentralises the role of data management, which can in turn result in greater opportunity for breach. Similarly, where organisations use ‘bring-your-own-device (BYOD)’

Applications must be able to communicate, which means developers and system providers need to use internationally accepted standards, in order to ensure that they can be easily adopted. These standards become even more vital when organisations begin to demand and implement a multi-system solution, and require those solutions to inter-connect. In order to be effective, technology must also integrate within work flows. Healthcare professionals are unlikely to use a system that places unnecessary, additional, burdens on their time or working practices. Careful strategic management is needed to ensure that a solution does what it is designed to do; that in doing so it does not add additional complication to existing care packages; and that the necessary support structures are instigated to help deliver seamless deployment. This may mean using small trails to test deployment, and determine implementation strategies. It may also mean ensuring that the necessary training and assistance is in place, to help

considered proprietary and is held within compartmentalised silos, all of which have different ownership, management and processing protocols. It is recognised, that for a true digital revolution of healthcare, it is necessary for the many different IT, mobile/ digital systems, and networks to interact, and exchange data, with one another. In doing so this delivers systems that are able to analyse, and utilise, data in order to derive useful insight. This exchange of data across networks is something that has traditionally been problematic, and despite some changes for the better, remains a major barrier to deployment.

ADOPTION AT SCALE The ability to deploy mobile and digital health solutions across a small number of users, is relatively straight-forward. Difficulties arise when trying to deliver those same solutions at scale, to a much larger user base. Increasing users, raises the amount of data produced, as well

Despite the promise and potential of mobile and digital health solutions...there remains a significant number of ‘barriers’ that continue to hinder adoption and dissemination of technology methods to deploy mobile technologies then it becomes necessary to implement robust models for asset management, policy enforcement, and distributing profiles, apps and content. Potential patient safety, economic, and reputational damage may arise if organisations lack appropriate security and privacy controls.

INTEGRATION The ability to effectively integrate mobile and digital health solutions within existing infrastructure is critical. Integration encompasses both the technological and the human factors of care delivery.

users adapt to the technology.

DATA SILOS The current rise of data-driven solutions in healthcare is resulting in the creation of large volumes of clinical, personal, operational, and institutional data that is growing at a rapid pace. As more digital solutions are deployed then consequently the amounts of data will continue to rise. Data can obviously have very significant and beneficial outcomes on health, however, it can also be problematic. As we discussed earlier there are the issues of data management, but one must also consider the challenges of cross network data connections. At present much of the data collected via digital systems is

as the required number of connections involved. It also means that there are greater burdens on networks, an increased potential for security breaches, as well as difficulties integrating with other care provision. Each issue grows exponentially with the addition of users. When you consider how many potential users there are for these systems, then it becomes possible to foresee some of the problems facing a scaled-approach. Whilst developers can individually manage their own system usage, the responsibility for efficacy ultimately falls with the care provider. Leaving them a considerable management task, in order to coordinate the control, maintenance, and Continued on page 6

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Deploying mHealth: Overcoming Barriers to Adoption Continued from page 5

oversight of multiple systems.

EASE OF USE The manner and style in which a user interacts with the technology is a significant factor in terms of adoption. It is critical that a solution can be easily integrated into existing care pathways without necessitating additional burden or complication to the user. Usability factors are a major obstacle to health information technology adoption. While health IT such as mHealth tools can offer potential benefits, they can also interrupt workflow, cause delays, and introduce errors[2][3]. Lack of attention to health IT evaluation may result in dissatisfied users, decreased effectiveness, and increases in error costs. While the promise of mobile health is that we can leverage the power and ubiquity of mobile and cloud technologies to monitor and manage side effects and treatment outside the clinical setting, it is essential to be attentive to usability, keeping in mind its intended users, task and environment. User interface design can be even more contentious when dealing with patients as the end user. In a professional environment there is often technical support available should it be required, however, a patient at home is often unlikely to have access to similar resources. Therefore, the solution must be designed so that it can be easily understood, and so that it performs the task required without the need for unnecessary intervention from the user. Intuitive systems, that can perform complex monitoring and analysis, should be built into back-end elements of the solution, leaving the user-facing aspects to be simple and user-friendly. Designers also need to accept that users will have different social and technological intelligence, meaning that a solution needs to be designed so that it will perform, as desired, for different users.

Small text, poor colour contrast, overly complex menu systems, confusing settings, extended load times, and connection problems, can all cause difficulties. As a result, research must be undertaken in order to ensure that mobile health technologies are appropriately designed and targeted to the end-users’ needs, before they are used as health inter-

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ventions[3].

QUALITY Increasing numbers of healthcare professionals are using smartphones and their associated applications in daily clinical care. While these medical applications hold great potential for improving clinical practice, little is known about the possible dangers associated with their use. Breaches of patient confidentiality, conflicts of interests and malfunctioning clinical decision-making tools could all negatively impact on care. A significant number of medical applications lack authenticity details; authors, manufacturers and distributors are not listed, and references are unavailable or out-ofdate[4]. It has been proposed that medical applications should be peer-reviewed by clinical experts and that regulatory measures should be increased in order to safeguard quality of care. This would allow healthcare professionals to be made aware which digital solutions lack evidence and professional involvement in their design and development[5]. (See article: “The Changing Face Of Healthcare: Quality in Medical Applications” on page 45).

ENGAGEMENT Maintaining engagement with digital solutions is essential to ensure that they continue to be useful. Among patients in particular, the initial enthusiasm for using digital health applications to manage their own health, tends to wane fairly quickly. Developers and solution providers must therefore design systems in ways that continue to engage with users, and

to encourage long-term adherence. This is an area that a number of companies are successfully beginning to navigate, by developing a whole range of ways to incentivise and encourage active engagement (See article: “Engaging Patients Using mHealth” on page 35).

CONSUMERISATION OF HEALTHCARE The changing demands on healthcare systems are forcing providers to begin to consider patients as consumers. Techsavvy patients are used to managing so many aspects of their lives, with the assistance of technology, that they are beginning to demand to do the same with their health. As a result providers need to consider new ways of engaging and providing access to services, which means laterally diversify into offering technology to support their core competencies. As we have already discussed many difficulties can arise when you begin to scale these types of technologies. As a result healthcare professionals and care organisations should not have to be distracted from their main care priorities, by issues of technical management. In order to prevent this from happening care organisations need to enter into strategic partnerships with technology and digital solution providers, who can handle the technical aspects of deployment. Partnership strategies can work very effectively, but, they do still require significant oversight and central management, by the care organisation, in order to ensure that a coherent package of services is delivered. Commissioning partnerships also requires service level agreements,

Deploying mHealth: Overcoming Barriers to Adoption technical/maintenance contracts, training provision, and regulatory adherence, all of which further complicate deployment and lead to additional management tasks within the organisation. That said by implementing a digital commissioning strategy, much of the bureaucracy can be standardised, and the overall process streamlined to encourage more rapid adoption.

LIABILITY AND LEGAL IMPLICATIONS The legal and regulatory landscape surrounding digital and mobile health solutions is still very much in its infancy, leaving considerable uncertainty for care providers and solution developers. At present this means many solutions are potentially being deployed without the necessary regulatory oversight to ensure that they are fully fit for purpose.

Problems arise when there is a need to change workflows and clinical pathways in order to incorporate the technology. When solutions are considered from this context, the short-term expenditure necessary for implementation e.g. equipment, staff training, policy changes, and changes to working practices are often viewed by commissioners as prohibitive, rather than as precursory enablers of long-term investment. The only way to change this perception of cost, is to introduce policy that encourages the use of innovation, whilst accepting that initial investment needs to be weighed against longer term returns. A number of western countries have begun to adopt this outlook, but it requires vision from multiple stakeholders throughout the healthcare system hierarchy, initiated at government level, to successfully ensure that the cost implications are acknowledged.

Potential patient safety, economic and reputational damage may arise if organisations lack appropriate security and privacy controls.

Where a solution has been designed to deliver clinical monitoring, analysis, and/or insights then it is vital that the technology is reliable and effective. This necessitates a robust testing and quality control strategy, as well as significant multi-agency regulatory oversight. Should a solution fail to perform as designed then the question of where liability falls is questionable, i.e. the care organisation or the developer.

COST IMPLICATIONS The implementation of mobile digital solutions is often seen as a double-edged sword when it comes to the issue of costs. Many of the solutions that are currently in use, or which are being developed, promise to significantly reduce the costs of delivering healthcare. This means that they are attractive to providers and payers, as a means of containing expenditure.

HEALTH ECONOMICS In a similar manner, the way in which provider reimbursements are handled also need to be assessed, in order to accurately calculate the value of mobile digital health solutions. Many secondary care organisations around the world are reimbursed for their services, either by central funding or insurance payments, based upon the number of patients they treat, as well as a number of key, care quality, criteria. At present, many of these methods for calculating reimbursements are actually prohibitive of digital health solutions, despite their ability to improve patient outcomes, reduce hospital visits and reduce readmissions. By keeping patients in their homes for longer or by treating them away from traditional care environments, digital solutions actually reduce the number of patients that are physically coming through the doors of hospitals. Outdated reimbursement tariffs can sometimes then fail to acknowl-

edge that treatment has been provided. This is a barrier that can be easily overcome, through central initiative, in order to invoke new ways of calculating the health economics of mobile digital health solutions and integrating them into a fair method of reimbursement. In turn this would facilitate the commissioning process and significantly accelerate the rate of adoption.

GOVERNMENT POLICY AND PAYMENT Never in human history has the general health of most ordinary people been better than it is now. But paradoxically, there can scarcely ever have been a time when health care has been a more difficult political problem for the governments of advanced countries than it is now. It is precisely because of the advances in the treatment of disease that the role of government has become so contentious. With the scope for life-prolonging medical intervention now virtually limitless – and thus spending on it being potentially limitless as well – there are moral and practical questions about its availability and distribution which every democratic society has to address. The task for government is to balance the distribution of all healthcare solutions including digital to ensure that resources are well distributed, and access to services is equitable.

REFERENCES 1. Global health care outlook – Shared challenges, Shared Opportunities. Deloitte Report 2014 2. Patterson ES, Et al. 2002. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc; 9: 5, pp. 540–553 3. Kushniruk A, Et al. 2004. The relationship of usability to medical error: an evaluation of errors associated with usability problems in the use of a handheld application for prescribing medications. Studies Health Technol Inform; 107 (Pt 2), pp. 1073–1076 4. Buijink AW, Et al. 2013. Medical Apps for Smartphones: Lack of Evidence Undermines Quality and Safety. Evidence-Based Medicine; 18: 3 5. Visser BJ, Buijink AW. 2012. Need to Peer-Review Medical Applications for Smart phones. J Telemed Telecare; 18: 124. n

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INDUSTRY NEWS News and Information for Digital Health Professionals

Samsung Launches Major Digital Health Initiative opportunity for the brightest minds in the technology world to come together to develop the products that will, for the first time, put individuals in the driver's seat in understanding their own health and wellness,” said Young Sohn, president and chief strategy officer of Device Solutions at Samsung. “At a time when healthcare spending is at record levels and when the number of people over the age of 60 worldwide is expected to exceed more than 1.2 billion by 2025, digital health is an incredibly important area for innovation. We believe this initiative will be an essential first step and we invite developers and partners across the globe to join us in creating the technologies of the future that will help make people's lives healthier.”

OPEN HARDWARE PLATFORM Samsung Electronics has launched a bold initiative aimed at directing the resources and innovation of the global technology industry toward empowering individuals to better manage their own health and wellness. The Samsung Digital Health Initiative is based on open hardware and software platforms that will accelerate the development of advanced sensors, algorithms, and data collection and analysis.

At an event in San Francisco this month, Samsung's Strategy and Innovation Centre team demonstrated its open platform in a wearable wristband form factor, showing devices built, based on this reference-design 'blueprint', could be used to track measurements such as heart rate, respiratory rate and blood pressure. The company also demonstrated its open software architecture and how it could be used to collect data from a variety of sources, aggregate it and display it in a form that consumers can use to better understand what is taking place within their bodies. The open platforms, combined with agreements like the one recently announced by Samsung and the University of California, San Francisco (UCSF) to validate new approaches to personal health and wellness, are designed to help developers bring innovative products to market more quickly. “Samsung's Digital Health Initiative provides an exciting

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Samsung's Simband is an open hardware reference design for wearable technology, capable of integrating the most advanced sensing technologies in the world. Simband is being designed in a modular way, allowing for innovation in areas like battery life, form factor and noninvasive sensor technology by different companies. Innovators are being invited to use the reference platform to create and contribute their own advanced sensors, algorithms and other technologies. Simband is a reference design Samsung and third-parties will use to develop products. It will not be sold commercially. This approach is intended to lead to the creation of a hardware and algorithms ecosystem that will enable new technology and innovation to be easily built into finished products.

OPEN SOFTWARE ARCHITECTURE The Samsung Architecture for Multimodal Interactions (SAMI) will be a cloud-based open software platform capable of bringing together fragmented data from a variety of sources for analysis. It will allow devices and sensors to securely store data in the cloud regardless of the source's format or structure. SAMI's job is to make more information available, to break open information silos and give applications and services access to large amounts of data to provide better insights. Under Samsung's

Industry News “Our bodies have always had something to say, but now with advanced sensors, algorithms and software, we will be able to tune into what the body is telling us,” says Dr. Michael Blum associate vice chancellor for informatics at UCSF. “Validation of these technologies will improve the quality of data collected and help advance the ability to bring new products to market quickly. UCSF is pleased to play an important role in this effort to focus increased technology resources on digital health.”

CLIP-ON CHARGER

approach, SAMI will allow data to be controlled by the individual generating it and not by third-parties, so that personal health data can be better protected. The combination of Simband-designed sensor technologies and algorithms and SAMI-based software will take individual understanding of the body to a new level – for the first time giving voice to a deeper understanding of personal health and well being. In addition, through the development of new sensing technologies and software, it is possible that entirely new and previously unimagined insights into health and wellness could be generated.

To avoid a repeat of criticism levelled against its existing smartwatches, Samsung suggested that a magnetic battery charger could be attached to the device while the wearer slept, to avoid them having to take it off at night. It also suggested one possible way of presenting the data would be to offer a "wellness score" as a simple percentage read-out that would indicate the extent to which the wristband's owner was taking care of themself. Other details revealed at Samsung's event included a plan to include wi-fi and Bluetooth connectivity in the Simband device.

SAMSUNG DIGITAL HEALTH CHALLENGE To support its Digital Health Initiative, Samsung also announced the Samsung Digital Health Challenge, a $50 million investment fund dedicated to innovative start-ups and technologies in the connected health area. The goal of the fund is to stimulate creative new approaches to digital health and Samsung's open platforms. Additional information about the announcements and the Samsung Digital Health Challenge may be found at www.samsung. com/ssic n

AbedGraham leads US IT Expansion towards the NHS AbedGraham, the London based clinical and corporate strategy consultancy, has recently secured multiple engagements with leading US healthcare IT corporates vying for market leadership in the complex NHS market. Following significant reforms and the allocation of nearly £1bn to fund hospital technology, the UK has become a top-tier commercial target for global providers of software solutions. AbedGraham's clinical expertise and domain knowledge of the com-

plexities of the system have been used to support the introduction of a range of solutions ranging from clinical documentation and workflow to information management and data analytics. Recent clients include the speech recognition giant Nuance Communications and Imprivata, the global market leading provider of single sign on and clinical workflow solutions. Dr Abed, Founding Partner at AbedGraham, comments,

"The UK presents complexities at so many levels for international providers. Whether it's understanding frontline clinical workflow or budget allocation and reimbursement we're seeing a great uptick in interest for our services in order to drive effective sales, marketing and clinical engagement strategies by US providers." For more information please visit www.abedgraham.com n

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Industry News

Innovative Timepiece for the Blind and Visually-Impaired Created in collaboration with product designers, engineers, and people with vision loss, the Bradley Timepiece introduces a stylish innovative design to help the blind and visually-impaired. Marketed as a timepiece for all, and not just for those with a sight-impairment, The Bradley is named after Lt. Brad Snyder who lost his vision from a bomb attack in Afghanistan and then went on to win two Gold medals and one Silver at the London Paralympics in 2012. Powered by a Swiss quartz movement, the watch has a ball bearing riding the circumference of the watch that shows the hour and one on the face that points to the minute. The Bradley was designed by Hyungsoo Kim of Eone Timepieces and was originally funded using Kickstarter, where the project raised considerably more than its target goal. n

FDA Approval of First Mobile Platform for Real-Time Estimation of Surgical Blood Loss Gauss Surgical has announced that the Triton Fluid Management System™, the world’s first and only mobile platform for real-time estimation of surgical blood loss on surgical sponges, has received U.S. Food and Drug Administration (FDA) approval. Triton provides physicians a first of its kind device to accurately estimate intraoperative blood loss through the use of sophisticated cloud-based computer vision algorithms to estimate blood loss and hemoglobin mass on surgical sponges. Current methods of estimating blood loss during surgery based on visual estimation are known to be inaccurate. Clinical studies indicate that the use of blood products beyond a level deemed medically necessary can increase complication rates, ICU days, and overall length of hospitalisation[1,2]. Overuse can also substantially increase the cost of care. The cost of a single unit of red blood cells averages as much as $1,100 when administration and supply costs are included[3]. A recent study by Premier, a health-

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care performance improvement alliance of approximately 2,900 U.S. community hospitals and 100,000 alternate sites, looked at 464 member hospitals and concluded that blood utilisation represents the eighth highest savings opportunity for hospitals – a savings of $1.06 million per hospital, per year.[4] “Blood loss in surgery has always been estimated and in situations of large blood loss, erroneous,” said Aryeh Shander, M.D., FCCM, FCCP, Chief, Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine and Pain Management, Englewood Hospital and Medical Center, Englewood, NJ. “Over or under estimation of blood loss may lead to wrong clinical decisions. This new technology avails us the ability to more accurately account for blood loss with the potential to not only improve patient outcomes but also conserve healthcare resources.” “FDA approval marks a significant milestone for the company and brings a truly novel product into the surgical environment,” said Milton B. McColl, M.D.,

Chief Executive Officer of Gauss Surgical. “The Triton Fluid Management System has the potential to improve the quality of patient care and drive significant savings to hospitals through better utilisation of blood products and reduced length of stay.” At its core Triton uses standard off the shelf mobile computing technology in combination with cloud storage. Using the iPad camera, the system scans surgical sponges that are covered in blood, and sends the images to the cloud where Continued on page 13

Industry News

New Diagnostic Device Aims to Deliver Lab-Quality Results at Patient Bedside standard laboratory cTn-I blood test. The field study demonstrated promising correlation between the finger prick test and the results of the whole blood sample from a venous draw. Moreover, the study indicated that these results can be obtained near the patient in the hands of the care giver.

Philips has completed its first field study for its Minicare handheld cardiac Troponin-I blood test, demonstrating the platform’s potential to produce labequivalent results with finger prick samples within minutes. The Minicare cTn-I system is designed to help physicians, nurses and paramedics identify patients at high risk for acute cardiac events right at the bedside or in pre-hospital settings. The initial results are encouraging as Philips prepares for the Minicare cTn-I system’s clinical trial, scheduled for 2015.

Only about 15 percent of patients presenting in emergency departments with chest pain suffer from acute myocardial infarction (AMI). At the same time, early diagnosis and treatment are critical to improving outcomes around acute cardiac events, and today’s standard lab tests, logistics and reporting can take up to 90 minutes to enable decision-making. With a quick finger prick cTn-I blood test, Philips Minicare is being designed to measure AMI indicators almost immediately, wherever the patient is located. This has the potential to enable doctors to identify high-risk patients earlier, reducing the time from diagnosis to treatment or quickly discharging patients not requiring emergency care.

Waiting on conclusive blood test results can cause anxiety for patients and delay a physicians' decision for treatment. Almost 70% of diagnostic decisions are currently based on information provided by blood assays, but it often takes an hour or more to get the results from a central laboratory. In life threatening conditions like AMI, every minute counts. The Minicare Platform, with a small and easy to use form factor and proprietary Magnotech technology, is being developed to provide blood test results, within minutes, at the point of care, such as critical care treatment centres, ambulances and in the future in GP clinics as well as at home. With heart disease still the leading cause of death and accounting for nearly $500 billion of healthcare spend worldwide, providers are under more pressure than ever to better serve that patient population. Near-patient diagnostics like Minicare have the potential to revolutionise the way clinicians diagnose disease and determine intervention. n

The field study was executed at the Catharina Hospital, a leading cardiology centre in the Netherlands. The Philips prototype blood test, performed at the patient’s bedside using a finger prick blood sample, was run in parallel to the

Digital Health 250 250 Companies Worldwide Leading the Way in Digital Health To suggest a company or to apply to be considered for the list please contact journalofmhealth@simedics.org

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Industry News

New US Study Shows 70% of People Tracking Their Health and Fitness Daily Using Apps A new study released by mobile engagement provider Mobiquity, Inc has found that while 70 percent of people use mobile apps on a daily basis to track calorie intake and monitor physical activities, only 40 percent share data and insights with their doctors. Working with an independent research firm, Mobiquity’s “Get Mobile, Get Healthy: The Appification of Health & Fitness” study reveals the opportunity for healthcare professionals and organisations to leverage mobile solutions to drive positive behaviour change and healthier patient outcomes. In fact, 34 percent of mobile health and fitness app users said they would increase their use of apps if their doctors actively recommended it.

(69 percent), mobile shopping (68 percent), listening to music (60 percent) and making/ receiving phone calls (30 percent).

Mobile drives healthier lifestyles

“Our study shows there’s a huge opportunity for medical professionals, pharmaceutical companies and health organisations to use mobile to drive positive behavior change and, as a result, better patient outcomes,” said Scott Snyder, president and chief strategy officer at Mobiquity. “The gap will be closed by those who design mobile health solutions that are indispensable and laser-focused on users’ goals, and that carefully balance data collection with user control and privacy.”

According to the research, 73 percent of people claim to be healthier by using a smartphone and apps to track their health and fitness. Fifty three percent, in fact, discovered they were eating more calories than they realised. Sixty-three percent intend to continue, and even increase, their mobile health tracking in the next five years. But it doesn’t stop there: 55 percent of today’s mobile health app users also plan to introduce wearable devices like pedometers, wristbands and smartwatches to their health monitoring in coming years.

Smartphone health tracking beats social networking For many, using a smartphone to track their health and fitness is more important to them than using their phone for social networking

But there is room for improvement What’s stopping people from using their health and fitness apps more? Doctor recommendations would be a big motivator, said 34 percent. Privacy was also a concern for 61 percent. But the chief reason people quit using these apps is simply because they forget – something that could and should be addressed by app developers to ensure health apps are less disposable.

Mobiquity commissioned independent research firm Research Now to survey 1,000 consumers who use, or plan to use, health and fitness mobile apps. The study was conducted between March 5-11, 2014.

Summary of results A summary of the results from this survey can be seen in the accompanying infograph. n

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Journal of mHealth The Global Voice of mHealth

Industry News

Global Mobile Subscriptions Reach 7 Billion The mobile industry has scaled dramatically over the last decade. At the end of 2003, there were a little over one billion unique subscribers - one in six people had subscribed to a mobile service. By the end of 2013, according to the GSMA’s annual report, this figure had more than tripled and reached seven billion mobile subscriptions in April 2014.

In the Mobile Economy, 2014, published last month, the GSMA reports that there will be a dramatic rise in the number of mobile connections (including handsets, tablets and machine-to-machine devices), with the number forecast to reach 11 billion by 2020.

works will need to be smarter, responsive, modular, flexible, scalable, adaptable and open. The operator community will need to collaborate on the definition of common processes, guidelines and standards in the network space to meet the challenges and opportunities of the future.

The mobile operator’s association has also identified four key growth areas that present both significant opportunities and benefits for consumers and provide clear opportunities for mobile operators:

According to the report: “Operators should look to avoid fragmentation, guarantee interoperability of services and enable new business opportunities at a regional or global scale. Only through this collaboration will the industry be able to meet increasing demands for capacity and provide the level of service customers will demand as mobile networks play an increasingly important role in their everyday lives.”

These areas are Personal Data, Digital Commerce, Connected Living and a further category, Network 2020.

Continued from page 10

image-processing algorithms estimate the amount of blood contained on that surface and sends it back to the OR in real-time. Triton features an intuitive iPad interface, requires minimal training, and seamlessly integrates into existing surgical workflow. The system is fully HIPAA compliant. “We identified a critical unmet need for a fast and accurate way to estimate blood loss on sponges in the operating room,” said Siddarth Satish, Gauss Founder and Chief Technology Officer. “By leveraging the power of mobile devices in combination with our proprietary software we’re fulfilling that need with the potential to reduce unnecessary transfusions

Network 2020 is shaped by the belief that mobile networks will be at the heart of the all-IP mobile broadband era, connecting devices and acting as the key interface between the physical and digital world. In order to be able to provide connectivity on a cost-effective and sustainable basis, mobile net-

The report maintains that “mobile services will increasingly migrate into the Cloud to deliver on the promise of service access anytime, anywhere through any device; such services will be dependent on the availability of consistent high speed, low latency connections.” This leads to natural opportunities in 4G/LTE and making networks more “self- aware” and dynamically configurable, to cope with the increased traffic demand and also to provide the quality of experience customers expect. n

and the associated costs and complications.”

Ventures with Promus Ventures and Taube Investment Partners participating.

The approval went through the de novo classification process, a regulatory path for some low- to moderate-risk medical devices that are not substantially equivalent to an already marketed device. Under the de novo petition review process the FDA reviewed data from two clinical studies that demonstrated the accuracy of the device.

1. “56 Facts About Blood and Blood Donation” Brookhaven Science and Technology 2. “Saving blood, saving money, saving lives” University of Florida Health Science Center 3. Shander, et al, 2010. Activity based costs of blood transfusions in surgical patients at hospitals. Transfusion 2010;50(4): 753-65 4. Premier Healthcare Alliance Analysis, 2012. “Standardization of blood utilization practices could provide opportunity for improved outcomes, reduced costs.” n

Gauss was an early participant in the StartX Stanford University incubator and has recently relocated its corporate offices to Los Altos. In October, Gauss closed a $6.2 M Series A round of funding. The round was led by LifeForce

The Journal of mHealth

Industry News

$150 Smartphone Spectrometer Can Determine the Number of Calories in Your Food The ability to determine the molecular composition of materials has been available to scientists for many years using expensive lab-based spectrometers, but now a new device offers consumers the same possibilities, at a fraction of the cost. Launched via a Kickstarter campaign, the SciO from Consumer Physics is a $150 handheld device that can determine the molecular fingerprints of a wide range of materials. When the device ships to crowd-funding backers at the end of this year or early 2015, it will come with apps that can report the physical composition of food and pharmaceuticals, says Dror Sharon, Consumer Physics CEO. Sharon says Consumer Physics’ spectroscopic sensor has the potential to divine the chemical composition of a wide range of materials, from gasoline and rubber to cosmetics and gemstones. And once you can determine what something is—on a precise molecular level—you can also extrapolate what it isn’t, inviting new possibilities for product authentication, consumer safety and other applications.

this interaction between the illuminated light and the molecules in the sample.

SCiO is based on the proven near-IR spectroscopy method. The physical basis for this material analysis method is that each type of molecule vibrates in its own unique way, and these vibrations interact with light to create a unique optical signature.

Spectrometers used for near-IR spectroscopy are normally found in scientific laboratories and are very big and expensive. Designed for consumers, SCiO leverages a tiny spectrometer, designed from the ground up to be mass-produced at low cost. Consumer Physics achieved this advancement by reinventing the spectrometer around low-cost optics and advanced signal processing algorithms. SCiO uses technologies developed for cell-phone cameras and optical communications devices to dramatically reduce the cost and size of NIR spectroscopy systems.

SciO includes a light source that illuminates the sample and an optical sensor called a spectrometer that collects the light reflected from the sample. The spectrometer breaks down the light to its spectrum, which includes all the information required to detect the result of

To deliver relevant information in real time, SciO communicates the spectrum of the sample to a smartphone via Bluetooth, which in turn forwards it to a cloud-based service for review. Advanced algorithms utilise an updatable database to analyse the spectrum

June 2014

within milliseconds and deliver information about the analysed sample back to the user’s smartphone in real time. Sharon simplifies the process even further: “It senses the spectrum of the actual molecules, sends it to the cloud, and compares what it finds to a huge database.” The company have targeted food compositions for the initial roll out. The system enables a user to scan an item of food and to determine exactly its molecular composition. Assuming that the database is pre-populated with all the information it needs to identify various fats, carbs and proteins, the system can report back specific data on the food you scan. The key, Sharon says, is for the Consumer Physics database to have molecular profiles of everything we might target. He says that when SCiO ships to

Industry News Kickstarter backers, he expects the database to recognise about 80 percent of all the various foods we eat. Proteins are the hardest to detect, followed by carbs, and then fats are the easiest to profile. But in the end, Sharon says, all these materials are within SCiOâ&#x20AC;&#x2122;s reach. Consumer Physics is focusing on food for its initial roll-out, as the world is obsessed with nutritional data, and calorie tracking presents such an obvious consumer use case. But the sensor technology itself is capable of analysing a wide range of substances.

Future use cases for the device include pharmaceutical authentication, allowing consumers to identify allergens in food, as well as many uses beyond the health and wellbeing market. SCiO has launched with an open API, so third-party developers will be able to extend the list of materials covered by the Consumer Physics database, and also create apps suited to specific use cases. For more information visit: www.consumerphysics.com n

Low-cost Motion Controller Provides a Unique Approach to Physical Therapy Therapy hopes to build games in the future to help patients with arthritis, carpel tunnel syndrome and even multiple sclerosis. The use of motion controllers in physical therapy is nothing new. Ever since the launch of platforms like the Nintendo Wii and Microsoft Kinect, rehabilitation units have been employing motion and gesture control programs and games to improve the way in which patients engage with their physical therapy excercises.

Physical therapy isn't fun. It's a physical and emotional challenge that often consists of dull, repetitive tasks. It's boring, and offers patients almost no short-term rewards for their very real efforts, however, a new breed of application that introduces key gamification concepts offers new ways to engage patient's in their rehabilitation process. A new software platform called Visual Touch Therapy is trying to make physical rehabilitation fun, gamifying repeti-

tive exercises by marrying a Leap Motion controller, a PC and a simple memeinspired video game. The game itself is fairly simple: players perform simple motions over the Leap controller that cause a dog character to run (or fly a jetpack) across the screen, and their performance and improvement can be tracked, quantified and even sent to their physical therapist for review. Currently, the games are focused on helping stroke victims, but Visual Touch

The Leap motion controller, is a unique proposition in this field as it introduces a low-cost easily programmable device that is capable of being incorporated across a diverse range of platforms. The leap controller is being incorporated into a range of health related projects. MotionSavvy is an initiative to use the technology as a means of providing realtime sign language translation. Another innovative project called MACSAir aims to bring touchless capability to manipulating catheters in MRI machines during heart surgery â&#x20AC;&#x201C; reducing the time that patients need to spend under the knife. n

The Journal of mHealth

Industry News

Global mHealth Market Expected to Reach $49 Billion by 2020 The global market for mHealth is expected to reach $49 billion by 2020, according to a new study by Grand View Research, Inc. Monitoring services are expected to remain the dominant and fastest growing market segment, with market revenue of USD 1,227.5 million in 2012, and an estimated CAGR of 49.7% from 2014 to 2020. In addition to the headline growth figures, the report also outlines some of the key economic and social factors which are driving the market. Per capita healthcare expenditures have been increasing, which makes medical services unaffordable for a large percentage of the population. As a result, demand for mobile health is expected to increase considerably over the next six years. In addition to smartphone proliferation, uptake of 3G and 4G networks is expected to increase demand for telemedicine services. Aging population and growing incidences of diseases linked to changing lifestyles have intensified the need for affordable and accessible healthcare. The report also cites concerns among users, regarding the safety and privacy of information, along with the need for secure infrastructure, as some of the key

challenges for market participants, going forward. Key mHealth services analysed and reported in the study include monitoring services, diagnosis services, healthcare systems strengthening and others. Other services primarily comprise wellness and prevention, and are focused on elderly care, drug abuse prevention, healthy living, smoking de-addiction and child care. The European market is expected to be the largest regional segment by the end of the forecast period. Remote monitoring solutions and patient treatment accounted for majority of the overall mobile health deployment in the European region. On account of growing smartphone adoption, the region has also witnessed growth in health and wellness based mobile apps. The UK dominated regional mobile health deployments, with services delivered through channels ranging from SMS to complex apps. Further key findings from the study suggest: »» The global market was valued at USD 1,950 million in 2012, and is expected to grow at a CAGR of 47.6% from 2014 to 2020. »» Chronic disease management was the largest contributor to the monitoring services market, with higher demand from developed markets of North America and Europe. The market for post acute care services accounted for 19.5% of the overall monitoring services revenue in 2012. Diagnosis services are more prevalent in developing markets, and

growing adoption of these services is expected to considerably augment access to healthcare in these regions. »» Mobile operators accounted for 48% of the overall market in 2012, with majority of their revenue originating from monitoring services such as independent aging solutions. The market for healthcare providers is expected to grow slower than the global average, at an estimated CAGR of 45.1% from 2014 to 2020. Quelling credible concerns among users, along with availability of regulatory support is crucial for driving profitability of industry stakeholders. »» North America dominated the global market, accounting for 33.5% of total revenue in 2012. Highest demand originated from monitoring services, with growing incidences of chronic diseases necessitating the need for mobile health solutions among others. High per capita healthcare expenditure in developed markets is expected to be the key driver for regional growth. Driven by the need for accessible healthcare, the Asia Pacific market is expected to be the fastest growing regional market, at an estimated CAGR of 49.1% from 2014 to 2020. »» The market comprises of many stakeholders including mobile operators, device vendors, healthcare providers as well as content players. Companies operating in the market differ on the basis of their offering, and play a key role in overall mHealth adoption. Strategic collaborations and partnerships with healthcare providers, and resolving standardisation and interoperability issues are essential for mass acceptance.

The full report “mHealth Market Analysis And Segment Forecasts To 2020,” can be found at: www.grandviewresearch. com/industry-analysis/mhealth-market n

June 2014

Industry News

App Offers Interesting New Way for Doctors to Learn Clinicians are being given the opportunity to fit specialist learning into their busy lifestyles thanks to a tailor-made medical learning tool devised by Papworth Hospital experts. The Papworth Hospital MCQ Learning App gives health specialists the opportunity to learn on the go. Developed by Dr Alain Vuylsteke, Consultant Intensivist at Papworth Hospital, the App offers dynamic multiple-choice tests to users to provide a quick and effective way of learning about highly specialist medical techniques. It is built so that two tests are never identical, includes comprehensive expla-

nations and will retrieve supplementary information from the internet.

its full potential by including many more learning modules in the near future.”

On completing the test users are presented with a virtual personal certificate with their final score which can be archived, downloaded or emailed for their records.

The MCQ Learning App currently offers a range of multiple choice questions on transoesophageal echocardiography (TOE).

It has already received worldwide interest from clinicians and other professionals. Dr Vuylsteke, who worked with other Papworth Hospital Consultants to create this App, said: “It is great to have built a tool that facilitates the sharing of knowledge accumulated in an institution such as Papworth. We will hopefully gather enough support to realise this concept to

This procedure provides clear ultrasound images of the heart and is used as an alternative to standard echocardiography. It is hoped that the App will be expanded to include a variety of specialist heart and lung subjects, including electrocardiography and radiography. For more information on this application visit: www.papworthhospital.nhs.uk n

New Method for Lowering Blood Pressure Without Side Effects High blood pressure is known to be one of the greatest health risk, worldwide, behind smoking and alcohol consumption. In Germany, around 25 percent of the population suffers from arterial hypertension.

write the information in these fibers with such precision that other bundles of fibers with other functions are not affected. The researchers have named this procedure for individual analysis, selection, and stimulation “BaroLoopTM.”

Microsystems engineers Dr. Dennis Plachta and Prof. Dr. Thomas Stieglitz from the Laboratory of Biomedical Microtechnology at the Department of Microsystems Engineering (IMTEK) of the University of Freiburg have teamed up with the neurosurgeons Dr. Mortimer Gierthmühlen and Prof. Dr. Josef Zentner from the Medical Center - University of Freiburg to develop a new implantable cuff equipped with electrodes that can lower blood pressure without causing side effects.

The scientists tested the device on rats and succeeded in lowering their mean blood pressure by 30 percent, without causing side effects such as a reduced heart rate or a drastic decrease in respiratory rate. The findings of the study have been published in the Journal of Neural Engineering.

Doctors usually prescribe drugs against high blood pressure. In around 35 percent of patients, however, pills do not succeed in reducing blood pressure in the long term. Chronic high blood pressure leads to damage in other organs – the eyes, kidneys, the heart, and the central nervous system, in particular. In order to help patients whose blood pressure cannot be reduced by means of drugs, the Freiburg researchers propose implanting a newly developed cuff with 24 electrodes in the socalled vagal nerve on the neck. The device starts by determining which electrode is closest to the nerve fibers that transmit the blood pressure signal. Then it uses electrostimulation to over-

The idea for the research project originated in 2004 within the context of the establishment of the Peter Osypka Endowed Chair in Neuroelectronic Systems at the Department of Neurosurgery. Now that the scientists have determined that a cuff with electrodes is feasible in principle, they have begun to develop a completely implantable system. As such a device is classed as an active implant that must fulfill the highest level of safety standards according to medical product laws, they do not expect to produce a licensed product for at least ten years. Original Article: Plachta, et al. 2014. Blood pressure control with selective vagal nerve stimulation and minimal side effects. Journal of Neural Engineering 11 036011. n

The Journal of mHealth

Industry News

'Grip Chips' Let Hand Prostheses Think for Themselves Touch Bionics, a manufacturer of highend hand prostheses, has announced a number of new technologies that enhance their i-limb ultra revolution bionic hand. Of particular interest are the companies new Grip Chips. These coin-sized Bluetooth-enabled devices, can be stuck to any object to automatically activate a particular grip of the hand when it comes near. For example, when sitting down in front of the computer, the hand can immediately fold all except one of the fingers to make typing on the keyboard easier. Using the my i-limb app, patients can easily program grip chips with any grip or gesture and place in a desired location. Simply holding an i-limb ultra revolution device within close range to a grip chip will activate the programmed feature. The intuitive solution combined with the dexterity of the prosthetic hand

enables users to perform a variety of activities with ease and precision. The limbs can be currently controlled using a smartphone interface that allows the user to select pre-defined grip positions for their prosthesis. The novel Bluetooth-enabled devices mean that these pre-defined grips can be more quickly accessed in relation to the users environment, allowing the correct grip to be assumed at the necessary time of operation. Other examples of how this can be practically incorporated into a patient's everyday life would be for activities like picking up a cup, or operating door handles. By automating the grip process the prosthesis becomes much more intuitive to the user's individual requirements.

grammed via the mobile app. To make that process easier, the new i-limb skin active TS prosthetic hand surface works with touchscreen devices and all i-limb devices will be made compatible with the Android OS. For more information visit Touch Bionics online at: www.touchbionics.com n

The grip chips add to the range of control options for users of the companies i-limb prosthetic limbs. In total there are 36 different grip options that can be pro-

Proteus Raises $120M to Scale Smart Pills Proteus Digital Health has raised $120 million from new, undisclosed investors. The company will use the funding to continue its plans to commercialise its ingestible sensor system at scale, as well as to continue demonstrating the value of the technology on health outcomes and costs. The Proteus digital medicine platform is a medication management and adherence system that includes unique measurement tools, like sensor-enabled pills, a peel-and-stick biometric sensor patch worn on the body, and companion smartphone apps. The patch records when a pill is ingested and also tracks other things like sleep patterns and physical activity levels. The ingestible sensor component secured FDA clearance in July 2012, while the company’s sensor-laden patch got FDA clearance in 2010. “We are entering the commercial era of the Internet of Things (IoT) – your car, your clothes and increasingly your personal care products are going to be connected,” President and CEO Andrew Thompson said in a statement. “Our focus is on partnering with major health systems to deliver solutions that enable consumers and their families to switch on their

June 2014

own healthcare, creating critical information that can be used to ensure they and their doctors make positive decisions about use of medicines and personal health choices. A key part of our success will be to ensure that we have the support of investors as we build this market. The financing we closed is an important demonstration of investor confidence in the growth potential created by IoT companies.” Proteus announced this past March that it would open its first international manufacturing plant for its digital medicine system in the UK, in partnership with parts of the UK’s National Health Service. The company expects to employ 200 at the facility. “Proteus Digital Health has created a remarkable leadership position in the digital health care market by enabling medicines to communicate with the internet,” Symonds said in a statement. “This technology has the potential to enable Proteus Digital Health and its partners to re-engineer the existing commercial assets of the pharmaceutical industry in order to create high value proprietary products that leverage the drugs they already sell using the mobile phone in every consumer’s pocket.” n

The Value of Video in Modern Health and Social Care

The Value of Video in Modern Health and Social Care Embedding video within health and social care provision has been shown to produce significant health economic and quality benefits. This report considers the implications of incorporating video in order to underpin communication in modern clinical work flows. The use of video in healthcare is nothing new, in fact the concept for teleconsultations has been around for decades. Despite this, it is only really in recent years that the use of video has become more widely accepted among healthcare professionals and providers as a viable operational tool. As part of our consideration, in this issue, of the barriers and challenges that can affect adoption of digital and mobile health solutions, we have partnered with UK based healthcare video provider v-connect to consider the deployment, use, benefits, and barriers to adoption of video within modern health and social care clinical work flows. Using deployment case-studies and user experiences, we analyse how this type of system can be best employed in order to integrate effectively within everyday use scenarios. Video is an extremely compelling medium for healthcare, as it can provide the means to remotely administer care whilst maintaining the critical aspects of human interaction, that foster trust and rapport between patient and carer, something that can often be lost when using technology. In fact by increasing the ability to connect with care providers in a wider range of circumstances, often facilitating the interaction, video can actually be used to underpin communication in care situations.

The Technology The v-connect solution, developed by UK based Red Embedded Systems, is a dedicated secure and proven video communication service linking professionals together to improve the quality of care. Developed in partnership with the UK National Health Service and local

June 2014

authorities the system meets the highest levels of security whilst delivering seamless communication. The service has been deployed throughout the UK to meet the needs of a number of different health and social care priorities. By partnering with care organisations to enable the delivery of services that focus on outcomes, the system is creating new possibilities for accessing health and social care and associated services from the home, and other remote locations. â&#x20AC;&#x2DC;v-connectâ&#x20AC;&#x2122; provides a service led solution that incorporates a set-top box connected to a recipients television. The hardware and system requirements are easily installed resulting in an unobtrusive, secure, encrypted, teleconferencing system. Recipients have access to a tailored carousel-style menu interface that incorporates all of the relevant services for their particular care requirements. This allows care providers to deliver multiple services at a single point of access. As well as live video features, it is also possible to upload learning or rehabilitation content specific to an individual recipient that can be easily accessed when required. Access can also be monitored to help maintain adherence with care plans, and the system easily integrates with other condition monitoring services to link live video with real-time bio-telemetry. With a small number of users the system works with a simple person-to-person approach. As the number of users increases and the need to integrate multiple services develops v-connect offer communications hubs. These are simple to use call-management panels enabling care providers to easily manage, triage, filter, and re-route all calls to ensure that they all receive the attention they require. The system has interfaces across all major IT platforms,

which means that video calls can easily be re-routed to the PC, smartphone or tablet of relevant consultants, doctors, or carers. The use of a dedicated video solution delivers healthcare providers and the end user patient with significant benefits over other communication applications, such as domestic consumer services like Skype, and VoIP which is predominantly business orientated, and therefore inappropriate for use in care situations. By developing the system with direct input from the NHS, the technical elements of the service have been designed to ensure that they integrate with existing IT provisions, meaning that care providers can access the system easily from behind corporate firewalls, ensuring that video can be effectively integrated into everyday work flow.

Health and social care deployment Alasdair Morrison, Service Manager of STAY (Sandwell Telecare Assisting You) at Sandwell Metropolitan Borough Council in the UK has been working with v-connect for a number of years to provide video for a range of different health and social care deployments. He describes how Sandwell have been an early adopter of the technology, and how through their experience of using the system they have recognised the potential that video services can deliver, particularly when used across, multiple agencies, organisations and departments involved with health and social care delivery. In one deployment, which highlights the significance of using video in social care situations, Sandwell Council was able to

The Value of Video in Modern Health and Social Care For Alasdair Morrison of STAY the critical element of using video and other complimentary digital solutions is that it necessitates the re-engineering of services, thus adding not only the value of video interactions, but actually making the underlying services themselves more efficient.

save nearly half a million pounds in costs (in the first year of use). By analysing high-cost learning disability care packages, provided by the Council, Morrison and his team were able to identify particular cases where care and assistance could be better provided using telecare and virtual visits as a means of providing targeted, assistive, at-home, care to people with learning disabilities, whilst also supporting those people to become more independent. The use of the system gave the Council the ability to create a dedicated video service that was present in each recipients home. The system was then networked across a range of services that combined to improve the assisted living solution. This meant recipients could network with each other across secure video and audio links, they also had access to a 24-hour alarm service, should emergency care or advice be required. The integrated nature of the solution additionally meant that contact with care stakeholders, family, and other support channels could be provided via the same solution. The potential though is even greater. Sandwell have identified other preventative and social care services that can all be provided via the system at the single point of access, for example housing management, tenancy support and community services. This means that a range of services can be accessed by the user, and multiple agencies can collaborate and use the system to administer services, which in turn reduces the unit cost of having the hardware located in a property.

The aim for Sandwell is to develop an inclusive system that deploys across access points located both in residential homes, and at various convenient community locations like libraries, leisure centres, and council offices, etc. They also intend to integrate the system across all community health and social prevention teams, through the establishment of a Multi-Agency Prevention Platform. With video at the heart of the interaction this solution will combine existing services to provide a streamlined point of reference for interactive access to health and social care. Delivering a package of services via a single system not only reduces costs, but also strengthens the effectiveness of each component offering, as well as fostering cross-discipline and multi-agency cooperation. This prevents duplication of resource commitment and better overall strategic management. Other councils in the UK are equally recognising the benefits that can be derived from initiating this type of preventative, in-community and in-home care, and are beginning to explore these across an interesting range of care circumstances. Calderdale Council recently trialed the v-connect system as a means of providing relational care to out-ofarea residents and found the system to be extremely useful in building relationships between their care providers and the care recipients. The Council is now exploring other cases that may benefit from this type of interaction.

This sentiment is echoed in primary and secondary healthcare. Dr Richard Pope of Airedale NHS Foundation Trust UK describes the motivation for video and digital solutions as not being led by a desire to negate or necessarily reduce admissions but instead it is about delivering clinical efficiencies by ensuring that care is provided in timely, relevant situations. Airedale have, over the past 9 years, successfully delivered a digital strategy built upon video services. Their initial work involving the provision of clinical video consultations to prison offenders, has significantly grown to encompass a range of remote care and consultation services, across a number of different medical disciplines. All care situations involve multiple stakeholders. One of the critical elements to deploying a successful digital health solution is being able to offer a system that is sufficiently flexible enough to meet the different demands of these stakeholders. This is particularly critical where video is being used to manage patient care and provide remote consultations. It is important that the systems are available at the right time, in the right place, and via a method that fits with the needs of the user. One way to look at these interactions is to break down the relevant connections involved in the care continuum into component relationships: Professional to professional communication; professionals to a person at home or in a care home; and, where people are supported by family or carers. Each of these relationship will require slightly different operating work flows, and it is therefore imperative to establish protocols along with service level agreements to ensure successful operation. As part of Airedale's Right Care strategy they are introducing a raft of services that enable patients to access the right care, in the right place, and at the right Continued on page 24

The Journal of mHealth

Connecting care professionals

colleague

Connecting care and treatment in the home

Connecting people together in the community

Solutions that improve outcomes We can work with you to implement a network of care that enables personalisation for the cared for and integration between care providers.

v-connect provides a complete solution to implementing video communication in the remote delivery of care.

Connecting Care, Connecting Carers Connecting Care

Video connects people to each of their services giving them a single point of access to care in their home.

Connecting Carers

Using video to communicate between care providers allows better communication between carers.

v-connect.co.uk

01274 287 787

info@v-connect.co.uk

Colleague, Care and Companion are three different aspects of the v-connect service. By using the same infrastructure to deliver all three aspects, the service ensures maximum return on any investment. This simple one stop approach tackles some of the key issues facing health and social care:

- With the ever increasing financial impact of multiple morbidities and the ageing population, integration of services becomes essential to ensure the person is treated both effectively and economically.

Colleague is proven to deliver this.

- A simple, single point of access to care in the home, provides immediate support and treatment, reducing acute attendance at the emergency department and number of bed days in hospital.

Care is proven to deliver this.

- Connecting family members and other carers in a simple, visual way builds confidence, reassurance and trust.

Companion is proven to deliver this.

Talk to us today to see how v-connect can connect your services to your people to improve your care and reduce your costs. v-connect.co.uk

01274 287 787

info@v-connect.co.uk

The Value of Video in Modern Health and Social Care Continued from page 21

time. Video is seen as one of the key enablers to this policy, and the Trust has developed a range of services to deliver care via video and other digital channels. For Dr Richard Pope of Airedale NHS Trust this is all about individuals taking ownership of their conditions and allowing them patient-centred care that can be easily accessed. At present the various Airedale services operate as a centralised digital triage, where highly-skilled nurses are available for video consults with managed patients. They then have access to manage the care pathway by which that patient either moves into the secondary care system, or remains under primary care in their own home. In terms of work-flows this delivers immediacy, in that a patient can be assessed via video immediately to determine whether they need hospital admission, additional primary care assistance or simply selfadminstered help. “Often simply the reassurance of knowing that the system is available is sufficient to reduce many hospital admissions, particularly those related to anxiety” states Dr Pope. The longer-term aim of the Airedale solution is to deliver connected care that will allow patients to easily conference with consultants or specialists, from all over the UK and ultimately around the world in order to gain the best possible care package for the patient, without the

need for extensive referral or relocation between care organisations.

Integration For care providers often one of the biggest challenges when adopting a videoled service network is the difficulties of deploying the system so that it integrates with their current service packages. This means that in order to be successful it is vital for video solution providers to create, design and deploy a full service, to ensure that there are agreements in place so that there is someone to call should problems arise, leaving the care providers free to deliver care, and not manage IT systems. Allowing care providers to develop strategic plans for the implementation of video across a range of services without worrying about crossservice network problems. Alasdair Morrison, of STAY, describes how their experience of deploying video across health and social care services has been relatively easy in terms of the technical elements of the provision. “Because v-connect initially developed the system with the help and advice of the NHS, it meant that any deployments in primary or secondary healthcare, where IT systems used the same NHS standards, were relatively simple to deploy as they easily integrated within the current network architecture.” Many solutions that are available to pro-

vide video services in healthcare work in such a way that they can compromise the integrity of the network security. By requiring open connections or disabling elements of a firewall, native systems can be left vulnerable to intrusion, or suffer from connection and reliability issues. Knowing that the NHS and other public organisations represent such a large part of the care provision network in the UK it is imperative to offer a service that can be effectively integrated without compromising the network integrity of the end user, whilst still delivering secure deployment and fully encrypted video and audio. Airedale NHS Foundation Trust worked extensively with Redembedded to help deploy secure, stable and reliable services. Rebecca Malin, Deputy Director of Strategy and Business Development at the Trust believes that it is essential for developers and systems providers to use internationally accepted network and IT standards, in order to ensure that systems can be easily adopted. These standards become even more vital when organisations begin to demand and implement a multi-system solution, and require those solutions to inter-connect. Dr Shahid Ali, a GP and Professor of Digital Health, and Director at Dynamic Health Systems has collaborated with v-connect to integrate video into the Vitrucare patient management solution offered by the company. VitruCare is an internet delivered ‘self-care’ service that allows patients, with the continued support of the GP, to make decisions, using data from their electronic health record to change their lifestyle to improve their overall health. Dr Ali believes that the integration of different mobile and digital health solutions is a vital aspect of ensuring greater adoption throughout the sector. The collaboration between these two solution providers demonstrates that integration is possible, provided that industry partners are willing to cooperate on the development and interoperability of solutions. “Technology itself is not the barrier!” states Dr Ali. “Providing the technology works in the manner it is designed, then the technology itself is not necessarily the problem. Integration is the barrier!

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The Value of Video in Modern Health and Social Care Solutions need to be able to talk to one another, system-to-system”.

Changing the culture of care provision A long term proponent of digital and mobile health solutions, Dr Ali has spent nearly a decade advocating the need for institutional change in order to encourage the greater adoption and widescale deployment of digital and mobile health systems. He believes that there are a variety of barriers influencing the wider adoption of these technologies in the UK, but also that we are finally approaching a tipping point whereby the wider medical industry is beginning to understand that change must happen and that digital connected solutions are a critical component in this equation for change. “In terms of where the push or pull for greater use of digital and mobile health solutions is coming from, it is not from one individual source, but instead we are beginning to see a multi-faceted push towards the wider adoption of these solutions. This is coming from: Demand from patients – for these types of services; from industry providers; from doctors and care providers; and from government policy” states Dr Ali. Technology in the health sector can often be contentious, as it is perceived differently by various stakeholders. Developers and manufacturers of healthcare technology often view the solutions that they develop from a technical perspective that doesn't always translate into clinical benefit. One of the reasons for this is that technology is often grouped within the context of IT, something requiring extra training or knowledge aquisition in order to be used effectively. Because of this it is often viewed as a hindrance to care provision rather than as an enabler. Providers must therefore demonstrate the clinical compatibility of their solutions in order for them to be more widely accepted. ‘v-connect’ recognised the need to clearly define their product within a clinical context, and have taken significant steps to undertake 'cultural shift' within the way that they, as technologists, communicate the potential for their integrated video solution to healthcare professionals.

Cultural change is a major obstacle and one which cannot be changed quickly or without full cooperation between all parts of the care-supply continuum. Resistance to change comes from the uncertainty that these solutions can have upon working practices, the impact on workloads, and the changes to the care provider - patient relationship are all concerns that need to be addressed in order to encourage clinicians and care commissioners to adopt digital health into primary methods of working. Resistance from staff was initially an issue for Sandwell Council. This reticence, however, was very quickly overcome when staff realised the capabilities of the technology to support and empower care recipients in new ways, which freed up human resources for more serious or difficult cases. Airedale NHS Trust also witnessed similar early sceptism from staff, particularly among clinicians, in relation to data security and compliance. Rebecca Malin from the Trust states that, “Once we had demonstrated to clinicians that we had implemented effective rules of governance, security and encryption,

then the concerns were quickly overcome. Clinicians quickly recognised that these type of solutions deliver positive outcomes to their patients, and therefore represent an effective method of administering care. “Interestingly there was little or no reluctance from patients in terms of security, and in fact the adoption among patients has been extremely straight-forward.” “We did have initial concerns that by offering 24/7 access to care providers, that we would be flooded with incoming requests, which is why we started the service small. However, this has not been the case at all, instead patients seem content with the knowledge that the access is there should they need it”. Upstream cultural change in organisations is more problematic. The methods in place to commission services, and the tariff structures necessary to fiance them, are often poorly designed to cope with the commissioning of digital and technological solutions. In fact the way in which the current system operates in the UK, means that NHS managers are often Continued on page 26

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The Value of Video in Modern Health and Social Care Continued from page 25

ill-equipped to implement these services within the current structure. The need to re-engineer the way in which services are delivered and change the way in which payments for care are administered is often seen as too much of a risk to an organisation. The need for a body of evidence that demonstrates the cost-efficiencies and the improvements in care, particularly for patients with long-term or multimorbidity conditions, becomes the colloquial 'chicken and egg' situation. For the industry at large the need for cultural change within the UK NHS has in many cases prevented technology providers from gaining significant traction within the market. According to Dr Ali, this is slowly beginning to change, as UK Clinical Commissioning Groups, which are still in their relatively infancy, are beginning to understand that changes in the way that care is delivered need to be made. So that it is necessary to embrace technology in order to empower the individual to take greater responsibility for their own medical needs and as a means of controlling flows of information.

The need for a clinical perspective Adam Hoare Managing Director at v-connect describes first-hand some of the barriers that have arisen in bringing a health care video solution to market, and the need to brand and convey the message of the solution effectively to healthcare providers, in order for them to make informed decisions on the effectivness and likely return on investment from commissioning video services. We have been deploying video to support care delivery for five years. In that time we have come to understand how to lower some of the barriers to adoption. The original decision to provide a service was developed out of our early experience. The service we have developed addresses barriers to adoption such as: 1. There is no one-size-fits-all approach. The video service we deploy underpins many different care services across primary, secondary and social care. Each engagement is unique and requires close collabora-

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tion with the customer to design and develop the network of connections. This leads into the second point. 2. In different deployments the user interfaces need to support different workflows. Implementing virtual waiting rooms, call transfers, mobile devices, touch sensitive triage panels and the set top box facilitate the use of video communication with different stakeholders. The ability to develop these interfaces and work with customers leads to the next point. 3. In order to have video underpin care delivery there needs to be a clear understanding of how the technology interacts with practice. This means working with practitioners to appreciate their needs. This bottom up approach is slower as we are working with very busy people. However, it is very necessary to understand how video can help without presenting another barrier to getting things done. These requirements cannot be met by a transactional, top-down approach where the technology and its implementation follow a template. Lowering the barriers takes time but all the evidence we are generating suggests that embedding the video in care produces health economic and quality benefits with many outcomes being emergent from the usage. These emergent behaviours often come when the network crosses traditional barriers or siloes. A further barrier to the adoption of video in care has been the idea that off-the-shelf or simple video approaches such as Skype can be used and that practice will assemble around them. We have worked on ensuring that our solution can cross secure networks such as N3 and that of Local Authorities so that the embedded video can enable these cross silo deployments. Many simple solutions cannot do this as they present a security threat to these networks. In fact we have developed our service approach to have minimum impact on internal IT systems so that deployment does not become an IT headache for care organisations. This serves to lower another barrier to adoption. The approach described is best navigated

by a small enterprise that can be flexible in terms of technology development and collaborate with partners to develop the video in a way that underpins care delivery. Whilst developing this understanding we were very technology focussed in the way we initially discussed the service. We were lucky enough to deploy the service with Manorlands Hospice in Keighley. Here we met Steve Davison who was managing the hospice. He was impressed by what the video could do for the residents and has subsequently worked with us as a clinical consultant. With his background in nursing he was able to help us reshape the message to be about outcomes. We are currently launching our new brand for the service v-connect. When discussing the v-connect service we focus on three groups of stakeholders: »» Care – looks out outcomes related to connecting practitioners to people at home or in residential care. »» Companion – looks at outcomes related to connecting family members to people being cared for. »» Colleague – looks at the benefits to practitioners of being able to use the video to communicate between themselves. It is much easier to explain how care can become person-centred and better coordinated between care organisations using this new approach. We still have a lot to learn. Where we deploy the video it is disrupting current pathways and opening up new ways of delivering care effectively and efficiently. ‘v-connect’ will be presenting a number of papers at this years King’s Fund International Digital Health and Care Congress held in London in September that will give a flavour of how v-connect is impacting on care delivery and bringing new combined opportunities through interoperability. The topics that will be considered will include: The integration of cardiac monitoring with video to enable service transformation; promoting patient empowerment and sustainability in kidney care using telemedicine; and, technologies supporting integration and person-centred care. n

Social Networking 'Transforms' How Healthcare Teams Work

Social Networking and Alerts Technology ‘Transforms’ How Healthcare Teams Work New technology which gives instant alerts about patients to healthcare staff and allows them to communicate on a secure social network has “transformed” how teams work and “significantly improves patient care”, according to a leading clinician. Dr Michael Bedford, a renal research registrar, hailed the success of a trial which gives medical staff at East Kent Hospitals University NHS Trust mobile alerts in real time about acute kidney injury patients. Once alerted, the medical team, often spread across multiple sites, can discuss the next steps via a secure social media style system of messaging and responding. The first four months of the pilot with DocCom’s Notify and Careflow software have shown faster decision making, enhanced patient care and improved overall efficiency within East Kent’s renal department. The team are hoping to see a further impact in terms of realising the subsequent cost savings over the coming months. Dr Bedford said: “This technology really does have the ability to completely transform how we work and ultimately, improve patient care significantly.” The team was frustrated that their existing system of emails, text messaging and paging, combined with face-to-face meetings was causing delays for patients and healthcare teams alike. Dr Chris Farmer, Associate Medical Director for IT at EKHUFT, said: “In the past, we have seen cases where a patient has arrived at A&E and there has been an unavoidable delay before they are seen by a specialist in charge of their care. With the DocCom systems in place, the right people have been informed of their arrival immediately, and they have been with the patient within an hour.” The EKHUFT team found the DocCom systems easy to set up and use, and said this significantly contributed to the trial’s success. Dr Farmer added: “It’s the easiest IT system I have

ever implemented. No training was required, it was completely intuitive. The benefits are immediate and obvious, and people like using it. The beauty lies in its simplicity. They haven’t tried to be clever and only kept in what is needed.” Whilst the clinical teams have seen first-hand how the systems can transform their day-to-day practice, the Trust’s Medical Director, Dr Paul Stevens said there has been an improvement in overall efficiency. “The system provides an easy way to get everyone together to make a quick decision. And importantly for me, this has fantastic potential for improving patient safety and ensuring the correct accountability,” he said. Dr Stevens urged other Trusts to come and witness what can be achieved with this technology. “For Trusts that are willing to adopt and embrace social technology, I believe the possibilities are endless. We could see major improvements in communication between primary and secondary care for the explicit benefit of patients. With the DocCom systems developed, all Trusts need to do is invest in the infrastructure to make these improvements a reality.” DocCom estimates that with results such as those in East Kent, significant cost savings can be made. For example, a 20% reduction in an AKI patient’s length of stay would translate to savings for the hospital of up to £7.7m a year. Dr Jon Shaw, DocCom’s Managing Director and Founding Partner, said: “We are delighted with how the renal team at East Kent – and most importantly their patients – have been able to benefit from the technology. Thanks to the success of the pilot, we are now working with EKHUFT to roll out the use of the technology to benefit other departments across the Trust.” n

The Journal of mHealth

CONFERENCE NEWS ATA Plans to Launch Telehealth Accreditation Program In his speech to the annual ATA (American Telemedicine Association) conference in Baltimore, Edward Brown, President of the Association, outlined plans to introduce an accreditation scheme for the telehealth industry. The aim of the accreditation program, which is detailed in a draft consultation paper, aims to clarify the relationship between the industry and consumers. The American Telemedicine Association is working toward an autumn launch of the accreditation program for primary care and urgent care. Brown, who also heads up the Ontario Telemedicine Network, has said the program is needed to help consumers make good choices and to reassure patients that online medical

consultations are convenient and safe. It published a draft document earlier this month and is seeking public comment. While the ATA has developed Core Guidelines for Telemedicine Operations that provide overarching, broad guidance, the purpose of these draft guidelines is to provide specific recommendations on the use of real-time, two-way videoconferencing (VTC), and telephonic communications between providers and patients (i.e. direct-topatient) in the delivery of primary and urgent care. The guidelines address clinical, technical, and administrative specifications, and establish baseline practice expectations for remote consultations, promote quality outcomes, and support

a more informed patient population. The guidelines address the use and application of telehealth services suggesting that telemedicine in primary care settings should treat uncomplicated conditions or be used for simple or routine followup for patients with underlying chronic conditions, and for the management of patients with medical conditions such as allergies and asthma, influenza, low back pain, and upper respiratory infections. The draft consultation document can be read online in full at: www.americantelemed.org/docs/default-source/standards/ ata-primary-urgent-care-guidelines-draft-publiccomment-final-(2).pdf n

Medical Devices Summit West 2014

Today most medical devices are part of a larger system and they no longer work as stand-alone items. Information platforms are built into medical systems, wireless tools are rapidly evolving, and connectivity and interoperability have increasingly become an integral part of health systems. Join industry professionals for this year's Medical Devices Summit West in Fremont California! The only way to push the envelope of innovation is by sharing new ideas, promoting novel technologies, and working together on strategies for foster-

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ing development. Join us for discussions on the most cutting edge software and devices on the market, and most importantlylearn how they got there, and what they're doing to stay ahead! Attendees will be given the opportunity to work closely with thought leaders to share ideas, experiences and strategies- while working towards a common goal of truly revolutionizing the medical devices industry. For more information visit: www.opalevents.org/trk/mdswc1411.html n

Conference News

Wearable Technologies Conference 2014 – San Francisco

Wearable technologies are all around us now. But what is in it for you? Is your current strategy the right one? Do you know the right people? Technologies worn close to the body, on or even in the body still leave a lot of open questions. Meet new people, grow your ideas, and find the right partners at the world’s most profound gathering for Wearable Technologies – the Wearable Technologies Conference 2014 I USA taking place on July 8 and 9 in San Francisco. For the 12th time Wearable Technologies will be gathering its entire ecosystem from chip vendors, integrators, test houses via network providers, product and service solution providers to distribution. Expect to meet representatives from companies of

all sizes but also creative thinkers, artists, designers and media. You will see product launches of the hottest new wearables, hear discussions about tricky areas in this business, learn about the most innovative enabling technologies and meet invaluable new contacts. At the WT Innovation Show you will be able to test products and see demos live at the venue. We are very proud that we can deliver the deepest insights to you as well as we are able to guide you with our expertise. For more information please visit: www.wearable-technologies.com/ events/wearable-technologies-conference-2014-usa/ n

Healthcare Revolutions: Big Data and Smart Analytics Healthcare and insurance have always shared a symbiotic relationship. Changes in the delivery of healthcare through digital intervention, big data collection, and intelligent analytics, all have a subsequent impact upon the way insurers perceive and value different aspects of health. As we recognised in the April issue of The Journal of mHealth, in our interview with Peter Ohnemus at Dacadoo the age of personalised insurance based upon our own individual health is already here. The question now is how will technology in the 'healthcare revolution' change the life and health underwriting landscape? If we are at the edge of a data-driven paradigm shift in healthcare, the effects on aggregate health and therefore on insurance models, will be considerable. Healthcare Revolutions: Big Data and Smart Analytics, an event organised by the Swiss Re Centre for Global Dialogue, brought together a formidable panel of presenters to consider some

of the topics relevant to this issue. In this article we bring you a number of pertinent speaker abstracts.

From diagnosis to personalised prognosis: Will better information lead to better decisions? (Karin Frick, Head of Think Tank, and Member of the Executive Board, GDI Gottlieb Duttweiler Institute)

Prediction was once the realm of priests and magicians. In today's society it is increasingly a tool for planning. Where once we had post-illness diagnosis of a condition, the future promises preillness prognosis. Our increasing faith in prediction is

based on technology. A body of datadriven tools is capable of discovering and analysing patterns so that past correlations can be used to forecast likely future outcomes. Predictive technologies, which include data mining, neural networks, and system modelling and simulation, have been applied to the study of weather systems, traffic patterns, stock markets, epidemiology, consumer behaviour, terrorist activity, and many other areas of study where there can be a significant number of variables. Technology and our ability to record data is expanding exponentially; and healthcare is seen as one of the primary beneficiaries. Entrepreneurs are creating apps that can run on smart phones claiming to be capable of predicting conditions from depression to sport injury. These metrics not only benefit the individual, but also the wider healthcare industry. With the data gleaned from these devices, insurContinued on page 30

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Conference News Continued from page 29

ance companies, employers and healthcare providers can view a comprehensive picture of an individual and a population's health – one that is more accurate and trustworthy than a first-person narrative. This increase in predictive ability should be a force for good, but human reactions may be unpredictable. Prognosis could provoke change, equally it could provoke over- or underestimation of the risk, or – if the prognosis is not positive – to ignore it altogether. We already know that humans have a tendency to drift towards hyperbolic discounting. The risk of a terrorist attack, which statistics tell us is highly unlikely, is seen by most respondents as being far higher than diabetes – which statistics suggest is a much likelier fate. Moreover, most people have an inability to imagine how they will age and how their preferences and personalities will change. The most effective way for humans to take on and realise information is through feedback loops. The first stage is evidence, the actual data; then comes the prognosis based on the data; the relevance of the prognosis has to be realised in its social and physical context; the consequences of the prognosis are understood; and the individual finally acts according to the previous four steps. The circle is started again. These stages can be identified within the use of fitness armbands that record physical movement. Evidence (steps) leads to prognosis (expected gains in fitness); leads to relevance (frequently in a gaming context, which encourages participation); leads to consequences (feel better, weight loss); and finally action (take more steps in a day). This does not mean there are not questions about predictive technology. Human happiness is not a universally defined quantity. Some may feel uncomfortable in the knowledge that our future is already defined. Moreover, it is difficult to know what to do with prognoses that may not be beneficial; such as a predisposition to criminal behaviour or a degenerative condition. Predictions can be self-fulfilling. As W.I. Thomas and D.S. Thomas suggested in 1928, “If

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men define their situations as real, they are real in their consequence.”

Reducing the burden of chronic disease through remote monitoring and management (Laurence Jacobs, Senior Research Scientist, University of Zurich Medical School)

The traditional approach to the management of chronic diseases is not optimal from a medical perspective, and it is extremely expensive. Moreover, the worldwide growth in cases of chronic disease continues to increase at a very fast pace. Reasonable cost estimates place the total financial burden caused by chronic disease in the several hundreds of billions of dollars annually. This situation is untenable in the long run. Left unattended, this problem is such that in the not too distant future, no society will be able to afford the cost of caring for its ailing population. The traditional approach to this problem simply does not scale well. Fortunately, there are alternatives to the traditional approach. These alternatives, at present mostly in the development or testing phases, are not only much cheaper, but they have the potential of being better for the patient from a medical perspective. The current opportunity was born not only of necessity, though that has played an important role, but also from the confluence of the general population's interest in health. Companies have developed small, accurate and inexpensive biosensors. These have led to a growing availability of good quality data that can be used to derive accurate models that can generate alerts, or even trigger devices to react to critical changes in the one or more parameters being monitored. Diabetes is a prominent example. As far as growth, it is estimated that there will be around 250 million sufferers worldwide by 2030, more than double the amount estimated in 2005. A key component of the process of managing dia-

betes is to measure the level of glucose in the blood several times a day. With the technology of a few years ago, this process is painful , expensive and cumbersome, requiring the extraction of blood and the use of portable meters. However, current technology already allows for a reasonably practical way to measure glucose continuously using a sensor that is implanted subcutaneously. Even better, several start-ups are announcing systems to measure glucose continuously without the need to extract any blood at all. These sensors, several using light, or estimating the levels of blood glucose by analysing tears or saliva, will soon become commercially viable. These systems will not only be simpler and cheaper, but they will also lead to better methods of treatment. There are currently many clinical trials underway that aim to test integrated platforms, running smartphones, that measure, analyse, and report on multiple continuous measurements of a potentially large number of important biometrics that promise to optimise the treatment of several chronic diseases. Patients and their doctors can be informed in real time on effective treatment change, and alert on critical risk factors. This would have been impossible only a few years ago, and it will eventually revolutionise the management of chronic disease.

Using common data to make uncommon predictions (Ben Reis, Director of the Predictive Medicine Group at Harvard Medical School and the Children's Hospital Informatics Program)

We are living in the age of many unknowns. In two major respects, we are entering new territory for human evolution. One of those is age. Evolution has focused on keeping us healthy through reproduction and child-rearing years, but many people now live well beyond this stage. Those extra years bring co-morbidities and chronic conditions. Another novelty is urban living. There have been town dwellers for thousands of years; but never have we had more city dwellers than rural farmers. That implies different environments and different patterns of physical activity. The more we know about the effects of these new trends in human existence, the more we can seek to positively influence our health.

Conference News Previous healthcare revolutions have not proved to be quite as revolutionary as initially hoped. Although decoding the genome was a ground-breaking achievement, rather than providing a clear blueprint of our genetic selves, it revealed how much we did not know about the interaction of genes in determining human traits and the existence of epigenetics, the interaction of genes with their environment. Similarly, whether the potential treasure trove of data that accompanies the smartphone revolution will enhance our capacity to predict health status remains to be seen. We already have, however, rich sources of data available to us. One source is claims submitted from the providers to insurers to cover medical costs. This data provides information on the frequency of individual visits to the doctor, the conditions the individual suffers from, the geographic placement of claimants, the prescriptions or treatments undertaken by the doctors, and the effectiveness of these treatments as registered by the need of the individual to return to the doctor subsequently. On the whole, insurance claims have produced some remarkable insights: »» Behavioural models: Health records provided a surprisingly accurate prediction as to those individuals who might be more susceptible to being victims of domestic violence. »» Epidemiological models: Insurance claims have proved a good proxy in the identification of disease clusters and outbreaks.

»» Predictive drug affects: The safety of drugs is generally measured in comparison to a reference drug. Using network models, adverse drug effects can be detected and even predicted years in advance. There are other rich sources of existing public data. One of these is search engine query data. One study suggests an inverse relationship between the availability of abortion services in a particular US state, and Google searches for abortion services. This may suggest that demand for abortion is relatively constant across different states, it is the supply side that accounts for different abortion search rates.

The wireless future of medicine: How the digital revolution will create better healthcare (Adrian Ionescu, Professor of Nanoelectronics, Ecole Polytechnique Federale de Lausanne (EPFL), and Chair, Guardian Angels Initiative)

Mobile health is not just an interface between individual and device. It will soon become part of a much more expansive and wider Internet-of-Things (IoT). This Internet-of-Things will not only capture health data; it will capture pollutant data; will monitor the way we drive and we live; will measure stress levels, with the final goal of proposing personalised safe and secure services for

a better quality of life. Eventually it will allow the creation of smart cities and of a smarter society. The foundation of the IoT will be trillions of tiny wireless devices. Not only will it allow for smart care, it will allow for smart energy use and smart interaction. It will form part of our strategy to tackle problems caused by population ageing; the spread of chronic disease; and the associated healthcare costs. Creating an Internet-of-Things represents a major logistical challenge. Smartphone handsets will eventually come to be seen as cumbersome relics. The IoT relies on multi-parameter sensing technology being tiny and power free. Guardian Angels are future zero-power smart autonomous systems with sensing, computation, communication, and energy harvesting features. Over three years the Guardian Angels research partnership aims to reduce current energy device consumption by a factor of 100; over a ten year period, the partnership wants to reduce device energy consumption by a factor of a thousand. This can be done through combinations of advances in biochemical technology; through the application of stacked nanowire sensors; through the use of emerging 1D and 2D nanomaterials; through nanoelectronics and nanomechanics; enabling single molecule-sensing and novel functions in forgettable devices. These sensors will be able to function by use and storage of energy from adjacent energy sources, e.g. solar, thermal or vibration. All these technologies must be able to broadcast signals to some form of receptor and ultimately processor. n

Health Datapalooza Review Health Datapalooza is a national conference focused on liberating health data, and bringing together the companies, startups, academics, government agencies, and individuals with the newest and most innovative and effective uses of health data to improve patient outcomes.

vices; Francis Collins, MD, PhD, Director, National Institutes of Health; and, Adriana Lukas, Founder & Organiser, London Quantified Self. Conference attendees also heard about the launch of OpenFDA, a new initiative from the FDA’s Office of Informatics and Technology Innovation (OITI).

This year’s event, held in Washington DC, had over 2000 attendees, over three days of keynotes, sessions, and events.

There were a wealth of digital solutions and health applications on show with live demonstrations from ActualMeds Corp, Purple Binder, and Maxwell Health. Developers were also invited to participate in the Code-a-Palooza challenge, which was won by Lyfechannel. n

Among the keynote addresses were speeches from: Kathleen Sebelius, Secretary, Department of Health and Human Ser-

The Journal of mHealth

Conference News

mHealth + Telehealth World 2014

mHealth + Telehealth World 2014 taking place July 22 – 24, 2014 in Boston, MA brings together hospitals, health systems, health plans, and innovators to share successes and failures of existing programs and discover new technologies and strategies for expansion of programs. Network with experts in mHealth and Telehealth as you learn valuable strategies to bring success

to your organization. We are happy to extend a $300 registration discount to you when you mention promo code MHJOU. For more information or to register, please visit www.worldcongress.com/mhealth or call 800.767.9499 n

International Digital Health and Care Congress: Improving Health Through the Use of Technology

For those interested in the design and application of new technologies that support improvements in health care, The King’s Fund is hosting its annual three-day digital health and care congress in September.

concerning health care technology. This is a standalone event for those involved in the research and evaluation of digital health and care programmes who may not wish to attend the full congress.

Following on from last year’s success, this highly-acclaimed event brings together international researchers, policy makers, practitioners and innovators to share experiences and showcase new designs in digital health, mobile health, telehealth and telecare.

During Thursday 11 and Friday 12 September, there will be plenary sessions and breakouts focusing on the advancements and benefits of digital health and care. These will be aimed at UK and international health and social care professionals, technology providers and commercial and third sector health and social care.

The organisers have received an unprecedented response to their call for papers and are expecting to showcase an exciting range of projects during the event. Topics will include: »» »» »» »» »»

sustaining independence as people age preventing and managing chronic illness effectively supporting people with mental health issues digitally enabling service transformation new innovations in health care technology

The congress also offers the chance to attend a pre-congress seminar on Wednesday 10 September, where attendees will explore the latest research and evaluation methodologies

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In previous years the congress has sold out far in advance so the organisers recommend that you register soon to guarantee your place. To find out more about the congress, the sponsorship opportunities and to register, visit www.kingsfund.org.uk/digital2014 The King's Fund is an independent charity working to improve health and health care in England. They help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate. They’re vision is that the best possible care is available to all. n

eHealth: Accelerating Towards a Healthy Future

eHealth: Accelerating Towards a Healthy Future Article written by Neelie Kroes Vice-President of the European Commission, responsible for the Digital Agenda population ages, the 'silver economy' is emerging as a highly promising market.

Over recent years the European Commission has been working hard to shape a new vision that puts people in control of their health and wellbeing. At the wheel are the patients, on the road towards efficient and effective healthcare. The benefits are a triple win: putting the patient in control, saving on costs and efficiency, and creating huge opportunities for innovative services and start-ups. This is the ethos behind our European Innovation Partnership for Active and Healthy Ageing. I attended the eHealth Forum in Athens on 12-14 May (2014), which put this vision on the public stage at a time of substantial market opportunities. One of the key issues we discussed was the emergence of mobile health, or mHealth, defined as the use of mobile phones, tablets and other wireless devices in healthcare. These are smart devices for disease self-management and remote monitoring, leading to prevention rather than cure, and more independent living; tools offering fitness and dietary tips as well as lifestyle and wellbeing apps. These new technologies can all help healthcare professionals treat patients more efficiently, get citizens more involved in managing their health and diseases and help Member States deal with tight budgetary and human resources, while facing an ageing population. One example of an mHealth service is the EU-funded REACTION project

which developed a mobile system that helps doctors and nurses within the hospital to treat patients with diabetes. Via sensors, the system monitors vital signals such as blood glucose levels and administered drugs and gives therapy advice; the data stored on a server is shared via tablet-computer used by the medical staff. This has significantly reduced the workload, increased the autonomy of nurses and improved the quality of care of diabetes patients. BOOMING BUSINESS The mHealth market is rapidly developing: Around 100,000 health and wellbeing apps are already available across Apple’s AppStore, Google Play and on other global platforms. So far, more than 200 million individuals have downloaded sports, fitness and health apps. The rise of mHealth is unstoppable and we want to ensure mHealth reaches its full economic and social potential and contributes to high-quality healthcare. This will create huge opportunities for innovative services, start-ups and the app economy. Beyond mHealth, the market for digital health and wellbeing technologies is also growing rapidly. The global market for telemedicine alone is set to grow from €7.2 billion in 2010 to € 19.3 billion by 2016. At the same time, the convergence between wireless communication technologies and healthcare devices and between health and social care is creating innovative new businesses. And as our

OVERCOMING BARRIERS On the 9th April 2014, the European Commission published a consultation on mHealth to ask what should be done to increase user trust and patient safety in order to boost mHealth’s contribution to high quality healthcare. We want to know whether this should be done regionally, nationally or at an EU level. We want feedback on issues related to ensuring that health apps meet citizens' demands for quality and transparency. mHealth services must adhere to strict data protection rules, and we should be intelligent about how we use the data: we could prevent an epidemic in the future. For all eHealth systems to work seamlessly across national borders, the many different systems used by hospitals and other healthcare providers need to be able to communicate with each other. While projects such as epSOS have taken great strides forward, this is not a widespread reality. On top of that, both patients and professionals need to learn to use these new systems. But perhaps the biggest challenge is the required change in mind-set: Getting used to managing our health and care in a different way, from emailing your doctor to using devices to track your daily activities and levels of fitness. CONNECTED CONTINENT In order to benefit from the great advantages which eHealth offers us, we of course need fast, reliable broadband networks, as well as a quality guarantee for high-quality connections end-to-end, the connections that new healthcare innovations may depend on. Our proposed safeguards for the open internet mean providers cannot just decide to block or throttle any content, application or services, including new health apps or services. And the successful vote of the Connected Continent regulation in the European Parliament recently is a huge step forward in achieving this guarantee. n

The Journal of mHealth

Can We Really Deploy mHealth at Scale?

Can We Really Deploy mHealth at Scale? By Keith Nurcombe Keith Nurcombe has worked in healthcare for over twenty years spending the last few years working with businesses in the health and technology space, most recently building O2 Health where he was Managing Director until the end of 2012, since then he has been providing consultancy services to businesses. This is a question that gets asked a lot and asked of most companies either delivering in the mhealth space or looking to provide services for consumers, patients or healthcare professionals. I don’t believe it is the right question, I think there are far more pertinent ones for investors or those who procure these services for their patients to be asking. Such as talk to me about the quality of your products and the systems you have in place, show me how they work for my patients and users or what is it that you are developing that could help me change the way I work and deliver care to my patients. I think the answer to the question is a very firm YES and YES in both cases. It is delivering and there are good examples of where and how that delivery is changing the way care is delivered. One of the best examples is the Whole System Demonstrator in the UK, which delivered really significant results in hospital admissions and mortality rates for patients. Can it be deployed and be effective at scale, there are good examples of where

this has happened and the US Department of Veterans Affairs is the best example currently of scaled deployment in the USA which has delivered excellent results. Are there issues that we as an industry face – yes and some of these are harder to get past than others. Technological issues – sometimes we struggle to get the technology to do what we want it to reliably and certainly we have to make sure that the users and the procurers of the service really understand what we are providing and equally what the technology can't do! Regulatory issues – the differences between the US (FDA) and the European Bodies (EMA and the EU) are creating obvious strains for organisations that want to provide services in both markets. We need to get uniformity of agreement on what is a medical device, what software is a medical device and equally importantly which isn’t analysing and therefore doesn’t need to be classed as a medical device. Currently that interpretation is mainly made by organisations and developers themselves

and that will lead to procurers becoming confused and concerned about potential safety. Acceptance and uptake – is very mixed in the market currently with a number of countries making steady progress forward with the adoption of technology and solutions but this is very varied across Europe and within the US as well. For me the positive acceptance seems to be in two key areas: 1. Strong uptake and understanding of managing patients at home, remotely and using technology to provide this solution. 2. Using technology that the patient already has – ie their own mobile phone or tablet rather then expensive pieces of equipment which need to be purchased by the payor. Overall, the market is moving, people are seeing the benefits of mhealth and decision makers are starting to include the industry and the services it provides in changing healthcare delivery for the future. n

EXECUTIVE HEALTHCARE CONSULTING Nurcombe Consulting delivers interim senior management support, strategic business analysis, change management as well as development of plans and capability for entry into the healthcare market in the UK and globally. Experience at end to end business reviews and then implementing required changes to deliver strategic goals and change of direction for businesses. Management support at senior level within organisations to deliver change as well as day to day management of the running of the business. Support in delivering new business opportunities into new markets in the healthcare space with considerable experience in: • • • • • • •

Pharmaceuticals OTC and Consumer brands Healthcare delivery to patients in their home Tele-health and tele-care provision Provision of staff and care for patients in their home and also in NHS and private care settings Development of private healthcare opportunities working with the NHS and other state providers Digital Health and the use and deployment of technology to support patient and health outcomes

With over twenty years experience in healthcare locally, regionally and globally this consultancy has the experience to deliver value to your business. For more information please visit www.nurcombeconsulting.com or email nurcombeconsulting@gmail.com

June 2014

Engaging Patients Using mHealth

Engaging Patients Using mHealth Thought leadership article by Mark Brincat of Exco InTouch When it comes to developing effective mHealth solutions, it is essential to incorporate a range of proactive methods that engage with patients, and help to integrate the solution in to their accepted treatment process. Maintaining this level of engagement, is the only real way to ensure that a solution can help to deliver positive outcomes. In a series of discussions Mark Brincat of Exco InTouch considers a variety of methods that can help solutions achieve successful and sustained patient engagement.

ADAPTABILITY There are no hard and fast rules as to how mHealth adaptability is defined, but I would suggest there are a number of levels that help us understand the extent to which a product might respond to individual patient needs. Perhaps the highest level to start with is personalisation. This is where a patient can put their own mark on a product and make it feel like something that is unique to them, perhaps including some elements of look and feel, or methods of interaction. Next, a patient could configure a product around their own specific needs, the product might have been already configured with a patient’s clinical specifics by a health care professional, but patients could additionally configure to their own needs and priorities. Once the patient is up and running, the product would be designed to respond to a series of patient inputs and events, some adhoc and some scheduled. It is here that products are really going to differentiate themselves. These pathways are numerous and complex and a product must be flexible enough to respond to different patient profiles, requirements and progressions. Multi-level solutions might include assessment, medications management, lifestyle management and informational content, all of which need to work and adapt in sync with each other. For example, if assessment and medication tracking show a change in condition, then there is a likely need to reflect changes in lifestyle management

and informational support. Add on top of this a patient’s state of behaviour acceptance and you have a variable set of parameters that a product needs to interpret and respond to correctly. Looking at the technology involved, this would require a rules engine to manage a dynamic set of interactions. At its simplest level, we can think of a rules engine as software which uses rules that can be applied to data to produce outcomes. It is important that rules are only defined where events and outcomes are sufficiently understood. In the future, expert systems will take findings from the system and dynamically build them back into the rules engine, so that a solution learns and improves interventions based on real world data. For now, we will learn from anonymised patient data findings and refine or build new rules and interventions into the system. Companies will need to develop skills around the analysis of ‘big data’, identifying signals and patterns. This will be an exciting period in advancing our understanding of patient populations and disease anthropology. When patients stop taking medication or stop proactively managing their condition generally, their change of mind did not happen that morning, it started weeks or months ago with a series of smaller issues slowly stacking up. mHealth solutions need to focus on the multitude of issues and support patients with a range of interactions that work in sync with each other and respond to an individual patient’s real world experience. As this level of mHealth product takes hold in the market, it will be remarkable how quickly we can advance disease management.

BUILDING BEHAVIOUR CHANGE INTO MHEALTH SOLUTIONS We have seen the successful application of behavioural change theories in patient services such that there is now good recognition of the ability of such methods to encourage patients to proactively manage their healthcare conditions. There are a number of behaviour change

models applied in the area of healthcare, examples include: Health Belief/Health Action Model. This model suggests that a patient’s belief in a personal threat together with their belief in the effectiveness of behaviour will predict the likelihood of that behaviour. For example, a cardiovascular patient may have certain beliefs about whether it is safe for them to exercise with such a condition. The Health Action Process Approach. This is a framework of motivation and volition constructs that are assumed to explain and predict individual changes in health behaviours such as quitting smoking, improving physical activity levels or dietary behaviours. This approach suggests that the adoption, initiation, and maintenance of health behaviours should be conceived of as a structured process including a motivation phase and a volition phase. I-Change Model. This model assumes at least three phases in the behavioural change process, these being; awareness, motivation and action. ‘Awareness’ is the result of accurate knowledge and risk perceptions of the patient about their behaviour. ‘Motivation’ to change behaviour is dependent on a patient's attitude, social influence beliefs and self-efficacy expectations. While ‘Action’ focuses on self-efficacy, action planning and goal setting. I do not profess to be an expert in the area of behavioural theory but I have and continue to work with teams to apply these behavioural models into patient solutions and services, and they really work. Linking back to the need to build adaptive patient solutions, incorporating a behavioural layer into these solutions is another dimension of a solution’s ability to understand and respond to individual patient needs. A solution needs to be able to incorporate elements of a behavioural model, be it methods of data capture, behavioural logic or patient messages. There are more than enough sources of expertise in the market from Continued on page 36

The Journal of mHealth

Engaging Patients Using mHealth Continued from page 35

which a suitable approach for specific diseases or populations can be identified. When developing an mHealth solution for a specific disease population, in addition to understanding aspects of patient segmentation like age, disease stage and medication, we need to remember that that patients will also be at different behavioural stages. We therefore need to respond differently to a patient who is in denial of their condition, than to a patient who has accepted their condition and is trying to learn how to better manage themselves. We also need to bear in mind that once we get patients to progress from one behavioural stage to the next, they may revert back to a previous behavioural stage. For some, trying to also incorporate behavioural change into mHealth solutions might feel like a bridge too far. Perhaps this is seen as a level of complexity too difficult to incorporate on top of everything else. However, when broken down to its constituent parts, behavioural change can be incorporated into an adaptive platform.

INCENTIVES At Exco InTouch we have been working to incorporate incentivisation into a patient’s goal and lifestyle management. Patients can either work towards predefined goal programmes, which might be specific to their condition or more generally around diet and exercise, or they can define their own personalised goals. Patients can then work towards these goals individually or collaboratively. In terms of patient collaboration, the universal growth of social media, software apps and gaming has made the concept and acceptance of collaborative engagement common place. This can either take the form of co-operative engagement, which might include patients working together towards a common goal, or patients working individually or in teams in competition with others. How then, do we plug incentivisation into goal and lifestyle management? For those patients starting out,

June 2014

they could view other existing patient’s socially shared activities, these patients would perhaps then display their own individual goals and achievements within the social environment. Patients looking to get started could then find others dealing with similar personal challenges and this acts as a powerful behavioural nudging mechanism to show what can be achieved. For those patients not wanting to engage within a patient community, they can still do their own thing and could still gain tremendous benefit from seeing other patient’s approaches and achievements.

patients the right kind of support and encouragement to work towards important healthy targets is fundamental to patient engagement. We can then build on this and explore new and appropriate ways to remunerative and financial incentive. This could take the form of a reward points or voucher based system that patients can spend in specified areas. With any incentive system with monetary value, it will be important to build checks into the system to prevent fraudulent activities. This could simply be a case of linking achievement to clinical outcome, for example a reduction in BMI, possibly requiring health care professional verification. Although the mechanics of a reward system can be universal, a product might need to connect into different reward programmes in different territories. I believe there is a real opportunity here for the pharmaceutical industry to consider a completely new approach to drug pricing. mHealth programmes like these can provide pharma companies anonymous real world data on patient adherence to their medication and self-management. This provides the opportunity to link reward to drug price by offering discounts to patients who achieve longer term adherence and agreed clinical and health improvements. This discount could go directly to patients who pay for their drug products in some countries or feed through to health insurance premiums in other countries.

...providing patients the right kind of support and encouragement to work towards important healthy targets is fundamental to patient engagement

Patients interested in joining the community, could join existing groups and activities or create their own. For example, individual patient step count activity targets could contribute to a group of patients working together to walk the equivalent of Paris to Rome (titled ‘The Paris to Rome Challenge’), a distance of approximately 1,400 kilometres or 1,750,000 steps. Twenty-four patients working together and walking 2,500 steps per day could achieve this target in a month. This kind of social engagement could take any form, be it exercise or diet. These challenges can also be turned into competitive events, with teams perhaps competing against each other to achieve different targets, for example, first team to arrive, single longest activity in a day and more. We hear a lot about gamification and this is too often associated with on screen computer games. However, this approach to social engagement offers the ability to build collaborative events amongst patients and provides a very effective form of gaming challenge, in fact this is a growing sector within the traditional gaming market. You may have noticed that I have spoken about the activities and challenges, but not once mentioned reward. It is important to recognise that providing

The challenges facing healthcare are enormous and as well as joining up concepts, we have to think about bigger changes if we are to respond quickly enough to this crisis. This need is driving a real desire for change with all stakeholders and in my experience presenting innovative and revolutionary approaches is well received by regulators, healthcare providers and payers alike. n

mHealth Interventions Wheel

Assessment Set up any form of information capture

Clinician

Patient Data

Providing required level of support & integration to healthcare providers

Capture data directly from medical & healthcare devices

Caregiver

Alerts

Helping carers to support & monitor relatives

Intelligent monitoring for patients, carers & HCPs

Treatment Management

Careplan Patientâ&#x20AC;&#x2122;s summarized view of their key data & progress

Helping manage treatments, clinical visits, tests & vaccinations

Content

Goals Management

The right information & educational content delivered in the right way & time

Setting and managing pre-defined & personalized goals

Reward Acknowledging patient progress & achievement

Exco InTouchâ&#x20AC;&#x2122;s health solutions are patient centric self-care models that allow patients, carers and healthcare professionals to interact, support and be involved in patient care remotely. The system is built on a modular platform of functionality that can be combined with individual workflows, rules and content to create a highly specialized therapeutic product. These functions, part of a larger library, are built as generic modules that can be configured and adapted to deliver specific programs, as well as being presented with a look and feel that reflects patient and customer needs. These programs and platforms are built on the background of systems that have supported hundreds of thousands of patients in clinical trials.

Understanding Stress and Post-traumatic Growth

Understanding Stress and Post-traumatic Growth A course for returning veterans on Tiatros-Research, a flexible HIPAA-Compliant collaboration platform for clinical research Authors: K.P Norman, M. Dallman, K. Cerrone, S. Norman, D. Altobello, J. Homchowdhury

BACKGROUND Young people serving in the armed forces are given extensive periods of military training at entry to prepare them for service life. During training, they are provided with concepts and constructs of the military culture to ensure they are physically, mentally and emotionally fit for the tasks ahead. By contrast, preparation for return from the military to civilian life, jobs and family is given far less time and attention, even though this is an equally great change from their recent lives, experiences and the personal growth that occurred while they were in the military culture. There remains stigma associated with reporting mental difficulties that may accompany the transition from military to civilian life and because of this, there is some distrust in seeking answers to these openly[1, 2]. Moreover, sleep disturbances[3], risky behaviours[4, 5], family problems[5] and homelessness[6], are common in returning veterans even in those without diagnoses of mental difficulties. With the goal of helping those in, or leaving the military to resolve some of these issues both conveniently and in private, the Young Adult and Family Center (YAFC) in the Department of Psychiatry at the University of California, San Francisco has teamed up with Tiatros Inc. to leverage its scalable, cloud-based, socialnetwork styled software platform that enables collaborative, individual-centric services. Using the HIPAA compliant Tiatros solution, we have designed an initial course that enhances understanding of their experiences by the Veterans. The first course emplaced within Tiatros. 'Next Mission: Stress Resilience

June 2014

and Personal Growth', is an exploration of the neurophysiology, biology and narrative process of the military experience to help service members tell their own stories and better understand their own journey into, through and out of the military. The course is intended also to develop the connections and sense of community that are so important to transitioning veterans. The course is given over sixteen 2-hour classes. Each class is comprised of 3 parts: The narrative portion is based on the 6 stages in Joseph Campbell's Hero with a Thousand Faces[7] and is illustrated with clips from movies and readings; A neuroscience portion deals with the common changes that occur in the brain after stress and trauma; The third portion is comprised of mindfulness and writing exercises. There are two sets of writing assignments for each class: Journal writing for twenty minutes a day which is entirely private to the individual student, and writing in response to questions based on the narrative content and neuroscience portions of the course which can be viewed by course moderators and other students within the Tiatros solution. Additionally, in the final sessions the students present to the others in the class group their course projects that are to be related to some aspect of the monomyth as it relates to their personal journey. Course administrators post an individual invitation to each student to sign up for the course using Tiatros' secure messaging function. The platform supports secure communications (to one or to many) through various contemporary social networking methods including: Posts; audio and video blogging; Video chats; SMS; and, multi-party video conferencing, while allowing simultaneous

but separate communication threads among various subsets of students and instructors in the class. Tiatros uses a number of proprietary technical strategies to preset and enforce access rights that ensure the privacy of communications. Easy-to-use and redundant methods assure that instructors can exercise complete and instant control over which communications are available to everyone and which are available to only a subset of the class community. The course administrators have access through Tiatros to the site of each student who is taking the course to ensure the safety of all participants. Students individually control the degree of interstudent interaction. Because Tiatros' proprietary content management and delivery engine handles content files of any size, and content files that are created in virtually any underlying application, including all common document , image, audio and video formats, all of the course classes and content are contained entirely within Tiatros. Fidelity of the content files is fully preserved and the viewing experience is identical to that experienced while watching a movie downloaded from a premium online service to a laptop. Content is streamed directly to mobile phones, and tablets as well as to laptop computers. Importantly, this capability in reverse permits flexibility in the format of student to the required homework; the student is allowed to choose from the most personally appropriate medium: video, uploaded photographs, written and/or and hand-drawn pictorial responses. Assignments and course content are stored within the course Library on Tiatros. The course administrators can easily pre-set an automatic delivery schedule

Understanding Stress and Post-traumatic Growth ÂŽ

Ready for the most innovative ideas in healthcare

when specific content files are distributed to students. There is a common blog site for students and instructors to discuss their responses to the course content, which is carefully monitored by course administrators. They are able to remove inappropriate comments at anytime (together with explanatory interaction with the poster) in order to maintain the positive tone of the interactions and to encourage individual growth and understanding of experiences. Evaluation of the student's progress is simple, in that each time an individual enters Tiatros, it is accompanied by a time-stamped record, and completed assignments are also noted. This allows the instructors to automatically prompt individual students to access and complete assignments and keep up with the course, as well as to spontaneously interact with the individual if they seem to be particularly troubled. For troubled students who want more individual help, there is a list of sites to which they can go for that help, in addition to private conversations with the psychiatrists involved in the course. Efficacy of the course for students can be evaluated formally through pre- and post-course questionnaires, once institu-

â&#x201E;˘"

tional approval for this is gained. Privacy is ensured through the transformation of student names into numbers. Tiatros supports technology-assisted, direct engagement of students that provides a unique and highly effective channel to collect information in real-time through a variety of validated means, such as questionnaires about symptoms of PTSD, substance abuse, personality, growth relationships and other relevant information. Additionally, written course assignments by individuals can be automatically evaluated for changes in word usage and hopefulness in story telling that qualitatively estimates changes in outlook of the individual throughout the course. Tiatros support the capability of downloading the responses directly into a number of programs that can evaluate them for significance. Figure 1: Schematic showing the TiatrosResearch product as it supports the Next Mission offering: Two versions of Next Mission have been given in person in classes taught at City College San Francisco. The response of the Veteran students who took the course was positive with respect to aid from each of the narrative, neuroscience and writing portions. The course given through the Tiatros platform will

be beta-tested at several military sites in 2014. Beyond the current course, future courses tailored toward the specific problems experienced by female veterans, and the families of returning veterans are now being developed.

REFERENCES

1. Kim P. Y. Et al. 2010. Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat. Psychiatric Services 61:582, 2010. 2. Hoge C.W. Et al. 2004. Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. New England Journal of Medicine 351: 13. 2004. 3. Seelig A. D. Et al. 2010. Sleep Patterns Before, During and After Deployment in Iraq and Afghanistan. Sleep 33: 1615. 2010. 4. Hoglund M. D, Schwartz R. M. 2014. Mental Health in Deployed and Nondeployed Veteran Men and Women in Comparison with their Civilian Counterparts. Mil Med 179(1):19. 2014. 5. Blow A. J. Et al. 2013. Hazardous Drinking and Family Functioning in National Guard Veterans and Spouses. Journal of Family Psychology 27:303. 2013. 6. Fargo J. Et al. 2012. Prevalence and Risk of Homelessness Amoung US Veterans. Prev Chronic Dis 2012:9:E45. 7. Campbell, Joseph. 1949. The Hero with a Thousand Faces. 1St Ed Bollingen Foundation. n

The Journal of mHealth

A Clinician's Guide: How to Enhance Adoption and Diffusion...

A Clinician’s Guide: How to Enhance Adoption and Diffusion of Technology in Healthcare By Dr Alexander Graham Healthcare provision across the world faces unprecedented challenges in the modern day, with spiralling costs, aging populations and political pressures impacting on the quality and quantity of care given. As a result, front-line staff are consistently being asked to do more with less. Having practiced as a doctor in the UK, I have seen the relationship first hand between healthcare professionals and technology. My anecdotal view, in the years I spent as a student and doctor, is that the vast majority of technology hinders rather than helps clinicians in their day-to-day work. But we have the technology to put a man on the moon so why can’t we reliably improve workflow, communication and outcomes in hospitals and clinics? Why is healthcare as a system so reticent to accept new technologies that could improve workers’ conditions and improve patients’ lives? The answer is unfortunately a complex one with many precipitating factors but if technology companies can understand some of the main barriers to adoption and diffusion then they can mitigate them with a bespoke approach. It is possible to write whole books on this topic but I shall concentrate on what I feel are the three main barriers: culture, workflow and staff heterogeneity.

CULTURE

Healthcare professionals are frequently bombarded with sales pitches from a range of salespeople, from drug reps to device manufacturers to IT professionals, often with a hard-selling, non-userfocused manner. The default setting amongst an increasing majority of clinicians as a result of this is scepticism and disenchantment (sometimes referred to as ‘innovation fatigue’) such that when the next painkiller, hip replacement or software innovation comes along, sellers will often start very much on

June 2014

the back foot, even if the product or service is of high quality. This means that the ‘pre-sales’ process for technology is critical. Sellers need to make a conscious and sustained effort to develop personal relationships with the people who will not only be their end users but should become their clinical champions in terms of driving forward procurement and then adoption and diffusion. Senior clinicians will often sit on the board of directors in hospitals and assist in procurement of new technologies so this is a remarkably important step.

WORKFLOW

The representation of the day-to-day lives of doctors, nurses and other healthcare professionals in the media and by the general public is unfortunately often far from the truth. It is impossible to explain the workflow patterns of clinicians if you have not worked in a hospital or at least spent an extended amount of time in clinical care before. Technology will never be diffused within a healthcare system if it is not intuitive, easy to use and at least contributes to making the day-to-day lives of professionals easier. To give you an idea of the scale of some of the pressures that workers can be put under, consider how a hospital operates over a weekend. It is regularly expected that 2-4 doctors will be looking after somewhere in the region of 400 patients, with the number of daily tasks (blood result checking, ordering scans, reviewing patients) in the hundreds. If you have a device or software platform that requires excessive time to use or creates superfluous data, it is unlikely to last much past the first trial. By walking the walk of your target market, you will find numerous reflection points and nuances in the system that you must use in either developing or refining your product or service. By overcoming these mini-hurdles, end-user engagement will be that much greater.

STAFF HETEROGENEITY

Analysing the workflow patterns of your target market will hopefully help assist in the realisation that you cannot group all doctors or all nurses in one homogenous group. The work of an emergency consultant compared to an orthopaedic surgeon or the work of a ward nurse to a nurse consultant will be virtually incomparable with different working patterns, environments and stakeholder interactions present. As a result it is imperative to build in flexibility to your product or service such that individuals’ concerns, ideas and differences can be allowed for. One of the most successful companies I have seen recently has a fully bespoke software application for patient data gathering so each department or professional can tailor the interface to their exact requirements rather than having a top-down implementation. Flexibility in your product will generate a much larger potential user base.

CONCLUSION

If you do not have a bridge between the technology that is being produced and the end-users on the front line, then your products and services will never reach their potential. Fully understanding the environments in which your target markets operate is crucial to any commercial success and imperative for companies to understand. Dr Alex Graham is a medical doctor by background, having trained in London before entering the business world. He is currently a founding partner at AbedGraham, a research and strategy consultancy which assists global IT corporates to navigate the clinical, organisational and commercial complexities of the UK’s National Health Service (NHS). n

Lab Quality Testing in the Palm of Your Hand

Lab Quality Testing in the Palm of Your Hand New portable, mobile, point-of-care handheld testing devices, that can undertake a wide range of advanced laboratory procedures, have the potential to radically change care processes, by providing rapid pre-hospital, bedside and at-home diagnostic testing. Laboratory testing for accurate disease diagnosis is an essential and extremely effective everyday facet in the provision of medical care, however, traditional laboratory facilities are not always suited to every care situation. Often the time taken between the extraction of a sample at the point-of-care and the return of conclusive results can delay diagnosis and in turn impede the required treatment. Whilst laboratory testing is taken for granted in parts of the world, as a normal part of diagnostic care, in many regions there simply isn't the technology or infrastructure in place to allow sophisticated and sometimes even basic laboratory testing. From a patient's perspective the ability to relocate the testing environment from the doctors surgery or hospital to their home is a promising development that can significantly change the way in which a medical condition is monitored and treated. Basic bedside laboratory tests are nothing new, however, a new breed of portable devices are starting to deliver the opportunity for advanced testing procedures to be undertaken directly at the point-of-care with results being placed instantly in the hands of the attending physician. The possibilities of this type of technology spell cogent changes to the manner and particularly the rate at which diagnostic tests can be undertaken, and subsequent treatment prescribed. It also provides opportunities to conduct tests, that would previously have only been undertaken in a hospital or traditional care environment, remotely, wherever, and whenever they are required.

plished through the use of transportable, portable, and handheld instruments (e.g., blood glucose meter, nerve conduction study device). The goal of these devices is to collect the specimen, test, and obtain test results rapidly at or near the location of the patient so that the treatment plan can be adjusted as necessary. Smaller, easier to use, faster, smarter, and connected devices are increasing the use of point-of-care-testing because it is now cost-effective for diagnosis and management of many diseases, such as diabetes, carpal tunnel syndrome, and acute coronary syndrome, while with the patient.[1] In diabetes care, continuous glucose monitoring systems are in routine use. These subcutaneous devices monitor glucose in real time and communicate with an insulin pump wirelessly. Insulin dose is then adjusted based on pre-programmed patient specific algorithms. These devices also enable seamless, real-time capture of patient data not only for immediate patient assessment and treatment but also for data collation, analysis, and evaluation to determine new approaches to improving patient safety (reduction in medical errors) and improved patient outcomes. A number of examples of this type of device are currently in advanced stages of development, and as a result we are beginning to see a growing number of different technologies available across a wide range of disease and condition types.

All of these devices deliver rapid results using mobile technology to capture, store and relay disease specific information. By coupling the testing device with smartphone applications, it also means that manufacturers are able to reduce costs to deliver complex, yet affordable, solutions. Providing a patient with quantitative information, through selftesting and enabling this information to be shared with both care stakeholders, and software applications that can analyse the results, means that the user is given an increased role in the management of their own condition. The mobile aspect then provides connectivity to allow the transfer and sharing of this information with care providers, doctors, specialists, as well as enabling data capture in electronic medical records and other condition management solutions. Many lab-on-a -chip (LOAC) and nano-technologies are in the feasibility stages of development, and these devices use a variety of analytical methods for measurement of a specific analyte such as a routine chemistry, biomarker (protein or peptide), DNA/RNA, or a pathogen. Point-of-care-testing is accom-

UK manufacturer QuantuMDx is one company at the forefront of handheld laboratory testing devices. They have developed a molecular diagnostic platform called Q-POCâ&#x201E;˘, which is capable of extracting DNA from a variety of biological samples, and analysing them for specific disease characteristics. The universal device is a small handheld unit that can fit into a lab coat pocket. It incorporates an intuitive graphical user interface operated by a touchscreen and accepts cartridges that contain all the reagents and sensors required to process a whole sample such as blood, tissue (fresh and FFPE), thinned sputum, swabs, etc and to provide a molecular diagnosis in 10-15 minutes. Continued on page 42

The Journal of mHealth

Lab Quality Testing in the Palm of Your Hand Continued from page 41

The system operates using cartridges pre-loaded with reagents and probes specific to a disease, such that the operator can insert different cartridges for different conditions into Q-POC™ allowing the device to be used to test for many different diseases. The operation is equally as simple: input the sample into the cartridge, insert the cartridge into the device and press go. In 10-15 minutes a result will be presented on-screen. The company uses their proprietary Q-FILTER™ technology to capture cellular debris in a lysed sample, allowing the DNA to continue flowing through the fluidic channel in solution. This simple methodology rapidly purifies DNA for amplification. Lyophilised reagents, stored on-chip, are rehydrated by the sample as it passes through the fluidic channel. These heat and time stable reagents provide the disposable test cartridge with a shelf life of 18 months. On-board reagents also allow fully automated sample to result testing, with no further hands on involvement. The Device then employs a nanowire biosensor microarray to detect 10's to 1000's of features. Thousands of uniform, reproducible nanowires are arrayed on a mass producible, low cost computer chip. The nanowires are printed with DNA probes associated with disease or drug resistance. When the amplified DNA flows over the biosensor, target sequences hybridize to the probes. As DNA is naturally negatively charged, this causes a change in charge density at the surface of the nanowire, which in turn causes a change in resistance in the nanowires. The nanowires are individually calibrated and monitored in realtime with the signal processed by an on-board application specific integrated circuit (ASIC) and analysed by algorithms to give a diagnostic result. QuantuMDx are currently working on a number of projects to deploy their technology as a means of tackling disease around the world. The company is in the process of developing Q-TB™, a rapid and cheap test that will analyse sputum samples at the patient's side and diagnose multi-drug resistant TB (MDR-TB) within 15 minutes enabling immediate personalised prescription of the most effective TB drug treatment. The three year £2m project will integrate QuantuMDx's state of the art DNA analysis device with a novel sputum disruption technology and a comprehensive TB biomarker panel developed by St George's, University of London. The project is particularly strong as it also embraces the expertise of various global academic TB Groups and several TB focused charities and NGOs who are currently working in the field to help eradicate the disease and who understand, first hand, what is needed for a rapid TB diagnostic.

Advanced portable point-of-care laboratory devices are also being developed for bedside testing in hospital environments. Philips Healthcare recently announced the completion of its first field study for its Minicare handheld cardiac Troponin-I blood test, demonstrating the platform’s potential to produce lab-equivalent results with finger prick samples within minutes. The Minicare cTn-I system is designed to help physicians, nurses and paramedics identify patients at high risk for acute cardiac events right at the bedside or in pre-hospital settings. Only about 15 percent of patients presenting in emergency departments with chest pain suffer from acute myocardial infarction (AMI). At the same time, early diagnosis and treatment are critical to improving outcomes around acute cardiac events, and today’s standard lab tests, logistics and reporting can take up to 90 minutes to enable decision-making. With a quick finger prick cTn-I blood test, Philips Minicare is being designed to measure AMI indicators almost immediately, wherever the patient is located. This has the potential to enable doctors to identify high-risk patients earlier, reducing the time from diagnosis to treatment or quickly discharging patients not requiring emergency care. Waiting on conclusive blood test results can cause anxiety for patients and delay a physicians' decision for treatment. Almost 70% of diagnostic decisions are currently based on information provided by blood assays, but it often takes an hour or more to get the results from a central laboratory. In life threatening conditions like AMI, every minute counts. The Minicare Platform is being developed to provide blood test results, within minutes, at the point of care, such as critical care treatment centres, ambulances and in the future in GP clinics as well as at home.

The state of the art device will enable doctors, nurses and health professionals alike to perform complex testing that will guide prescription of targeted drug treatments.

Disease specific testing devices are starting to emerge across a whole range of treatment pathways, allowing patients to conduct testing in their own homes without the need to travel to doctors surgeries or hospital. These devices are generally connected, allowing data to be easily shared across the whole spectrum of care stakeholders. Proving patients with accurate bedside testing also allows them to more easily manage their own condition.

In a similar deployment the company is also working on a malaria diagnostic to allow health workers to tackle drug resistance. With no need for clean water or stable electricity, QuantuMDx's handheld lab will offer a technology leap to developing nations, giving even the most rural communities access to life saving diagnostics.

One particular innovation that has been designed with a consumer focus on point-of-care-testing comes from US company CUE. Their POC mobile connected testing platform has been specifically targeted at the consumer health-tracking audience, allowing health conscious consumers to go beyond simply activity and vital sign monitoring, to tracking health at the molecular level.

June 2014

Lab Quality Testing in the Palm of Your Hand The CUE system works in a similar manner to Q-POC™ using different cartridges to test biological samples for different bodily responses. The company sees its product as an adjunct to the currently available health trackers by providing consumers with intelligent, actionable, data on five key aspects of their health. At present the modular system has been designed as an at-home lab test, which, using a sample of blood, saliva, or mucus can conduct at home versions of five laboratory tests: Influenza,; Testosterone, Vitamin D, Inflammation, and Fertility. Information from each test is sent via Bluetooth to the user’s iOS or Android smartphone, providing a platform for analysis. According to founder and CEO Ayub Khattak, Cue picked five tests which people already pay for in large numbers, despite the relative inconvenience and expense of getting a laboratory test done. Testosterone levels are something athletes often want to know about, as well as older men. People are interested in Vitamin D because of its effect on mood — according Khattak over 70 million Vitamin D tests are ordered each year. Inflammation is both a predictor of heart disease and a counter-indicator for intense workouts — if people detect that they’re inflamed, it might be a hint to back off from exercise for a little while. Those three tests, as well as the fertility test, are designed to be done regularly, more like a tracking device than a one-time test. The influenza test on the other hand, which was the original concept behind the company, is designed to be used by parents or other individuals to check for flu at home, in order to reduce unnecessary doctor visits, especially during an epidemic or a heavy flu season. “We’re not intending to replace the doctor, that’s not what we want to do,” said Khattak. “We want people to have more informed conversations with physicians. A mother, for example, who’s worried her child has flu. She’s able to get the piece of mind she wants by taking that test as soon as the child is sick. And then she can call the physician and have a more informed conversation. And then that doctor can make better decisions based on that information.” Cue hopes to expand to other lab tests as time goes on. Khattak said he wasn’t allowed to make specific claims about accuracy prior to FDA clearance, but he thinks that the tests have the potential to actually be more accurate than their laboratory counterparts, simply because so much more of the process is automated.

Cue’s technology is not yet FDA cleared. Like several recent technologies, the company plans to use an investigational device exception to sell some advance copies of the device prior to securing clearance, and then use information from those units for the usability testing required by FDA. The company hopes to ship the pre-sold units by spring 2015. Cue is just one of many start-up and research projects that are in the process of developing this type of consumer-facing, athome, testing solution. Matrilyzer is a company developing a mobile application and device that attaches to existing iPhones, iPods or iPads. It is designed for patients to monitor an enzyme called collagenase, which is released by existing tumour cells allowing them to spread to new parts of the body by breaking down the matrix that holds healthy cells together. Matrilyzer will enable patients to monitor their collagenase with one drop of blood. When the amount of collagenase increases in the body, it suggests to doctors that new cancer cells might be growing in other parts in the body. Collagenase has been studied for a long time in cancer patients, and suggests that cancer cells are leaving the primary site, invading distant healthy tissue, and forming new tumours. The solution which is still in the early stages of development is intended to help patients easily measure collagenase from their home. That data can then be used as more information for doctors to potentially run scans, consultations or prescribe treatments.

Barriers to Acceptance The key issue of alignment and concordance of point-of-care with central laboratory methods cannot be overlooked by laboratories, regulators, and the industry. Lack of alignment with definitive methods remains a potential barrier to further acceptance and the subsequent growth of point-of-care devices. Manufacturers must demonstrate accurate correspondence of their devices to definitive laboratory tests, or properly aligned reference methods.

Microfluidics A major innovation that is paving the way for the increasing number of lab-on-a-chip devices is microfluidics. When a test is relatively simple, then lateral flow tests can work perfectly well without fluid management technology, however, as the complexity of the test increases then it becomes necessary to incorporate microfluidic management systems. Microfluidics is therefore seen as an enabling technology allowing for the miniaturisation and integration of laboratory protocols into portable devices. Such is the promise of microfluidics in the healthcare sector that a recent report from Yole Developpment suggests that point of care testing based on the technology is expected to grow sharply, from $1.6B in 2013 to $5.6B in 2019.[2] The report also estimates that the wider point of care market’s contribution Continued on page 44

The Journal of mHealth

Lab Quality Testing in the Palm of Your Hand Continued from page 43

to in vitro diagnostic is poised to increase from 13% to 17% over the next five years, leading to a market of around $30B in 2019. The application of these types of portable mobile testing devices covers a range of scenarios, including: Emergency testing; Home tests; Doctorâ&#x20AC;&#x2122;s office screening; Decentralised hospital tests; Environmental testing; Forensic and military; Thirdworld infections; and, Agro-food. Medical Device applications in microfluidics are being enhanced by electric field manipulation, novel ligand sequestration, photometrics, spectroscopy, florescence, and a whole host of adjunct technologies. The potential applications in the medical space are nearly limitless and with advancements in micro fabrication, have become very cost effective. There are several advantages to the lab-on-a-chip approach, beyond the convenience of being able to test in the field. The test sample required is much smaller because of the sensitivity of the chip, which is useful if you need to measure the very earliest stages of a disease when the chemical markers in the blood are low in number and would probably be missed by standard tests.

New Financing Options Driving Development Another interesting factor driving forward the adoption of some

of these types of testing device, (particularly consumer targeted products) are the use of crowd-funded financing options to help develop devices specific to certain disease types. Crowd-funding investment platforms, allow developers and innovative start-ups to go directly to their end consumer (patients) prior to fully developing a device. By gaining support and financial backing, often through pre-orders, companies reduce their risk of going to market, by ensuring that at the very least prototyping funds can be secured. The initial sales of the product can help deliver information on efficacy and the capabilities of a solution, which can in turn assist in gaining additional market approval. By undertaking this type of route to market companies are also creating communities of potential users, that have a vested interest in the successful development of the product. This significantly helps to gain traction in the marketplace, test products, secure early sales, and demonstrate a demand that can then be used as evidence to secure further future development funding from more traditional financing sources, and help ensure the long-term viability of the solution. 1. 2.

Dubois, J A., 2013. "The Role of Point-of-Care-Testing and Rapid Testing." Medical Laboratory Observer Yole Developpment Report 2014. â&#x20AC;&#x153;Point of Care Testing 2014: Applications for Microfluidic Technologies.â&#x20AC;? n

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The Changing Face of Healthcare: Quality in Medical Applications

The Changing Face Of Healthcare: Quality in Medical Applications A thought leadership article by Dieter Speidel For generations, innovations that created direct impact and value were personified by lone geniuses, the likes of Thomas Edison and Steve Jobs toiling away in their laboratories. Today's reality, however, paints a different picture; the confluence of Political, Economic, Social, and Technological forces forge a diverse, and often complex ecosystem that shapes, fosters and demands innovation. The medical technology field, especially in the developed economies, long profited from the convergence of forces that spurred innovations, such as prosthetic limbs, hearing aids, imaging technologies and less-invasive cardiovascular procedures, which have reduced recovery times and greatly improved healthcare outcomes. However, according to PwC’s report titled, “Operating performance in the Medtech industry: Trends and imperatives”, Research and Development (R&D) activities are not generating as much value and growth as they historically did. PwC's study of 56 global medical technology companies revealed that the impact of R&D on revenue growth declined at an average annual rate of 10% between 2005 and 2011. These companies compensated for this decline through cost cutting measures and by increasing operational efficiencies. The most significant challenge faced by the medical device industry is that the fundamental nature of innovation has changed dramatically. It was a world built on incremental innovations with hardware focus. The notion that the players could demand price premiums for these innovations is slowly disintegrating. This phenomenon is accelerated by the emergence of modular systems that complement hardware ubiquitously available among healthcare stakeholders and by shift to software-centricity. The adoption of mobile technology at breakneck speed has also transformed the Healthcare industry, creating an area of innovation - Mobile Healthcare

(mHealth), fueled by numerous mobile applications developed and released by companies and developers alike for general use by lifestyle consumers, patients and healthcare professionals’. In 2012, the number of medical application users reached 247 million and the global revenue from mHealth apps grew to USD 1.3 billion, and continues to grow on an upward trending curve.

Surveys reveal that mobile applications have become increasingly important to both, patients and doctors alike. Research conducted by Dutch physicians showed that over 60% of doctors use medical apps on their mobile devices. 83% of them use mobile apps to find information; 47% utilise them for reference purposes, and about 40% use them for support during consultations.

With mobile applications, regular smartphones could be easily converted into an effective healthcare platform that patients come to rely on.

However, another study published by the Department of Neurology in the Academic Medical Centre, University of Amsterdam also discusses the dangers, lack of regulation, and proposes quality assurance guidelines for mobile healthcare apps. The authors of the study agree that medical apps have tremendous potential, but also underline the alarming lack of knowledge about risks these apps pose. Regulation and guidance are urgently required.

Disease symptoms and medication side effects can be easily and progressively tracked, logged and electronically shared with healthcare practitioners. Gathering diagnostic data, such as blood pressure, heartbeat rate, and even much more complex and kinds of diagnostics such as e.g. for antibiotic resistance and eye diseases can be automated. Appointments with healthcare specialists can be scheduled with a single click and these meetings improve in quality as patients could systematically record and share their concerns with these experts before a physical visit. In case of physical discomfort, sickness or diseases, patients could browse through a comprehensive FAQ database through a mobile device to see available medications and options before physically consulting a practitioner. In extreme scenarios, as in cancer, patients could gain access to a community of patients, where they could discuss their problems, ask questions, derive inspiration from success stories, participate in information exchanges, gain moral support and stay positive, knowing that they are not alone in their battle for cure. Healthcare organisations could curate knowledge from diverse information sources and provide structured access to healthcare consumers where and when they need it. Pharmaceutical companies could use mobile channels to disseminate information, organise webinars, work directly with patients, and so on. The possibilities are boundless.

Furthermore, medical apps should be peer-reviewed by healthcare experts and quality control measures should be streamlined to safeguard the quality of care. Because doctors and patients rely on the information and tools around cure, ensuring quality and safety are of paramount importance in gaining their trust in medical apps. Awareness among medical professionals is absolutely required, so that they can make informed choices about the apps they use in clinical care knowing that some apps may contain unreliable, non-peer-reviewed content. Hence, it's easy to recognise that mHealth is a very complex and diverse ecosystem; mHealth applications require the highest degree of accuracy from both, device and software. The medical app frontier is an entirely new development for established regulatory bodies like the US Food and Drug Administration (FDA). In July 2011 in its “Draft Guidance for Industry and Food and Drug Administration Staff: Mobile Medical Applications”, Continued on page 46

The Journal of mHealth

The Changing Face of Healthcare: Quality in Medical Applications Continued from page 45

the FDA proposed that certain types of mobile apps targeted for medical use be considered medical devices and placed under its scrutiny before they can be released for public use. However, the FDA clearance processes for medical apps do not require comprehensive clinical testing to ensure safety and quality as the processes for drugs and medications. With the increasing complexity of software systems, the possibility of failure through software defects increases exponentially, reinforcing the need for stringent quality assurance measures. Even though FDA's guidelines on medical apps has been finalised, it only addresses a subset of the entire medical app space. According to a study, “Medical apps for smartphones: lack of evidence undermines quality and safety”, although no harm caused by medical apps has been reported, without app quality assurance and safety standards, it's only a matter of time before some medical errors happen and unintended harm to patient occurs. To ensure quality of medical apps, authors of the study suggest: 1. Official certification marks that guarantee quality 2. Peer review system implemented by physicians’ associations or patient organisations 3. Making high quality apps more findable by adding them to hospital or library collections Presently, the feedback and ranking mechanism in place at app stores, while good for games and less critical apps, is highly inadequate for medical apps. The medical community, app store operators, regulatory bodies, auditors, patients, and other stakeholders need to get more involved in evaluating medical apps, at least on the following aspects: 1. Validation and certification of software quality that endorses apps' fitness for purpose and use 2. Peer reviews by diverse stakeholders – physicians, medical associations, patients, regulatory agencies, subject matter experts, etc. 3. Continuous monitoring of user feedbacks, complaints through establishment of vigilance systems The responsibility of addressing

June 2014

the aforementioned requirements falls on the medical app development companies; they are required to validate the apps they develop – a responsibility requiring a spectrum of expertise and experience. Many medical app development companies have neither the bandwidth nor the resources to handle comprehensive quality assurance and validation. Though several journals now include app reviews by doctors and healthcare practitioners, evaluating the apps from a 360-degree perspective requires cross-functional skills and knowledge. For example, medical app design is an area of paramount importance when developing mobile medical apps. Medical apps are intricate tools placed in the hands of doctors and patients, which can significantly influence healthcare outcomes. Hence, these apps must be designed and developed with usability in mind and addresses human factors, including user errors that result from unintuitive design. In an article titled, “Developing a Mobile Medical App? Don’t Forget Human Factors!”, medical app developers should consider at least the following human factors: 1. Preliminary analyses (such as hazard analyses, contextual inquiries, task analyses, heuristic analyses, and human factors expert reviews) 2. Exploratory human factors research 3. Formative human factors usability testing 4. Human factors validation testing The FDA guidance also recommends app manufacturers to follow the human factors guidelines, even when their apps are not subject to regulation. This strategy is perceived to be the best way to both, mitigate risks and encourage adoption, while simultaneously avoiding high costs associated with unnecessary redesigns and product recalls. From a software engineering perspective, even small changes in software could dramatically change the way a mobile medical app works. These changes may stem from requirement changes, design modifications, or amendments required by regulatory agencies. Ensuring the continued quality, accuracy and safety of mobile medical apps requires that any software modifications undergo a life cycle of software quality assurance and validation process. Regression test-

ing should be as comprehensive as possible to demonstrate that the changes were implemented correctly and, did not adversely impact other parts of the product. FDA's final guidance addresses these perspectives required of mHealth apps and states that regulating mobile medical apps will be a high priority from 2013. The ramifications of this decision implies that medical app development companies are forced to implement rigorous testing procedures to ensure compliance – a development that's perceived to be associated with high costs, complexity, and scope. Raising the bars might improve the overall healthcare outcomes, but may simultaneously deter aspiring developers and entrepreneurs from developing Healthcare IT solutions. Complex challenges such as these often spur innovative, creative and simple solutions, but in the case of mHealth apps these challenges can be thoroughly addressed using the help of professional communities and users, in other words through crowdsourcing testing and evaluation. Crowdtesting, a variant of outsourced software testing, undertaken with a community comprising of subject matter experts, professional testers, legal consultants, software engineers, healthcare professionals, patients, usability experts, etc. easily scales the scope and support required by a medical app development company to ensure that their solutions have been evaluated at all angles and comprehensively tested. The concept of crowdtesting, traditionally used to ensure quality of general purpose web- and mobile apps, subjects the medical app to an exhaustive battery of tests performed under real-world conditions on a variety of devices with a group of professionals plus an identified target users group, before the medical app is released to the marketplace. Crowdtesting encompasses the rigor of traditional, formal software testing methods and complements these formal methodologies by emulating realworld conditions - a development that many medical app companies haven't had access to before. The fundamental concept of crowdtesting is the idea of distributing a specific quality assurance problem among a community of experts, specifically curated to

US and UK Working to Strengthen Use of Health IT for Better Patient Care solve the task. These experts are inherently motivated to solve the challenges for, either monetary or non-monetary rewards. Medical app development companies could avail crowdtesting services ranging from fully managed testing services offering to a self-service concept, where the company only seeks access to the testing platform and the expert community when needed. In addition, the company could save on associated overheads, such as hardware and software costs because the community already owns various combinations of different device types, operating system and language versions – a situation that's almost impossible to simulate in an

internal lab. Crowdtesting opens a large pool of software testers and domain experts to medical app companies, so selection of target groups could be achieved at different levels of granularity. As the crowdtesting process is fast and flexible by design, it could easily be integrated into existing software release cycles and delivery models, so that the shortcomings could be identified and corrected immediately before the software is released. Crowdtesting also permits testing at different stages of software development - from the prototype evaluation to a final check at the end of the beta stage. The ability to leverage real medical app users and devices

helps achieve a substantial cost reduction during development and maintenance phases of the medical app lifecycle. Furthermore, human factors enumerated by FDA could be progressively validated through the various stages of software development through post-deployment and maintenance. As a result, the software quality increases exponentially while simultaneously relieving the app development company of important domain considerations beyond their area of expertise and freeing up their internal resources to focus on core operations. Dieter Speidel is the Founder & CEO of PASS Group, a leading Swiss provider of software and system testing services. n

US and UK Working to Strengthen Use of Health IT for Better Patient Care As the use of health information technology grows in both the United States and the United Kingdom, HHS Secretary Kathleen Sebelius and U.K. Secretary of State for Health Jeremy Hunt have recently signed a bi-lateral agreement for the use and sharing of health IT information and tools. The agreement strengthens efforts to cultivate and increase the use of health IT tools and information designed to help improve the quality and efficiency of the delivery of health care in both countries. The two Secretaries signed the agreement at the Annual Meeting of the HHS Office of the National Coordinator for Health Information Technology. “While we have very different health care delivery systems and payment models, we both face similar challenges posed by aging populations, increased levels of co-morbid chronic disease, and escalating complexity of care delivery and costs,” Secretary Sebelius said. “By working together, we can more effectively take on these challenges, improve the health IT economy, and the health of the American and British populations.” The agreement signals a formal commitment by both countries to collaborate to advance the applications of data and technology to improve health. “This is a ground-breaking agreement that will help both of our countries use information and technology more effectively to improve care, safety and give people more control over their health, which is now even more important as we transcend care boundaries,” said Secretary Hunt. “By bringing knowledge together this will not only offer insight into tackling common problems across health IT, but through innovation, it will help small to medium enterprises play an effective role in our health-

care market. I would like to thank all involved in making this agreement happen and look forward to collaborating across our health IT economies.” Originally identified at the June 5, 2013, bilateral summit meeting between the United States and United Kingdom, the collaboration focuses on four key areas for health IT and innovation. Sharing Quality Indicators – The collaboration reviewed existing quality indicators and selected Depression symptom screening and knee/hip quality indicators, and is now identifying alignments across existing British and American repositories to identify best practices in the design and use of quality indicators. Future work will include mutually leveraging technical experts and data, and working on a standardised approach to quality indicator development. Liberating Data and Putting It to Work – HHS and the National Continued on page 49

The Journal of mHealth

China: A Market for mHealth?

China: A Market for mHealth? The China-British Business Council recently published this article, looking into the opportunities for mHealth in China. The Chinese healthcare market represents huge potential opportunities for digital health and mhealth service providers, but there are still significant barriers to widespread adoption. Following the theme of this issue the article illustrates the global appeal that mHealth and Digital Health services have, and the options that they can potentially provide centralised governments to meet the needs of rising populations by providing effective care solutions.

Mobile health (mHealth), referring to the use of mobile devices (or more generally wireless technology) in healthcare delivery, is still in its early stages of development but is attracting increasing attention from healthcare providers and payers in both developed and emerging markets worldwide. By improving communications between healthcare providers, payers and patients, enabling the remote monitoring of symptoms and allowing patients to take greater control of their own treatment, mHealth is already demonstrating that it can be highly effective for delivering better and more cost-effective patient outcomes. mHealth has a particularly strong potential in China to address the country’s rapidly ageing population. With few children to support their parents and an exploding middle class that views healthcare as a luxury good they can consume, there is also a shortage of hospitals, clinics, physicians and nurses to meet these demographic and economic demands. With its unique market characteristics and rapidly developing healthcare system, the country is facing particular challenges to provide basic primary healthcare equitably and universally, whilst also providing quality, medically advanced and patient-centric clinical care for those who are able and willing to pay for premium services. China has the largest and fastest growing ageing population in the world (with one fifth of the world’s elderly population), and the one-child policy means that two ageing parents have only one child to care for them in their later years[1]. The Chinese middle class is larger than the population of the United States and already makes up more than half of the urban population. With their growing disposable incomes

June 2014

and generally more advanced education levels, the Chinese urban middle class increasingly prefers international-style medical services. While the Chinese government has aggressive plans to reform the healthcare system in China, as illustrated by the healthcare reform goals in the 12th Five-Year Plan (2011-2015), it will require the adoption of transformative technologies and medical practices to meet these demands. Innovative yet practical mobile health solutions could potentially fill many healthcare gaps in China, where consumers are willing to pay out of pocket for services from both public and private medical service providers. It would also enable providers to overcome difficulties in generating these offerings within existing budget constraints. Pilots of mHealth services are underway or already completed in a number of provinces, and are delivering both real benefits to consumers and potentially attractive returns to investors. For example, the “12580” hospital booking and reminder system in Guangdong,

Nei Menggu, Tianjin and Zhejiang supported by China Mobile has helped to reduce the cost of healthcare delivery and at the same time improve patients’ access to doctors and medical facilities. Shanghai Jiaotong University has set up a remote service centre to serve patients equipped with mobile-enabled medical devices provided by hospitals to monitor and diagnose their conditions. Experience from these pilots will help to shed light on how to address the problems of uneven distribution of medical personnel and facilities across rural and urban areas. The pervasiveness of technology is enabling the emergence of a new, more patient-centric healthcare value chain. For technology vendors, service providers and investors(1), mHealth offers many opportunities. The mHealth survey projects that by 2017, China will be the second largest mobile health market after the United States, with an estimated US$2.5 billion in revenues[2]. Development of this market will be further facilitated by the establishment of elec-

China: A Market for mHealth? tronic health records, with the Chinese government aiming to cover 75 per cent of the population by 2015[3]. There will be a range of commercial opportunities relating to the sale and integration of the devices, as well as the processes and associated IT platforms required to deliver mHealth solutions. There will also be opportunities for investments and joint ventures with companies specialising in this area. Overall, stakeholders should revisit their business models so that mHealth is conceived, positioned and developed as a critical component of an integrated, efficient care system and not as a standalone solution. Inspiration may be found in other industries, such as media, retail and travel/tourism, that provide value-added online services – free of charge – in order to generate a

competitive advantage. Overall, mHealth presents excellent opportunities for both Chinese and foreign companies to work with healthcare providers and payers to bring better, faster and more cost-effective treatment to patients globally. Mobile technology holds the potential to address some of the long-standing issues in healthcare provision, as current trends dictate. By acting promptly, stakeholders can ensure they are active players in this exciting and inevitable new future for medical care. 1. Kaneda, T. ‘China’s Concern Over Population Ageing and Health.’ Population Reference Bureau, June 2006. An ageing population is defined as those

Continued from page 47

Health Service will discuss and find areas of collaboration around: »» Open data and safe and secure data transparency of secondary stored data, with the consent of patients to allow for the two countries to further assess the quality of preventive interventions and health care delivery »» Interoperability standards for improvement of data sharing and clinical care respectively, with a focus on consumer/patients accessing and sharing their data Adopting Digital Health Record Systems – Both organisations will work to maximise successful adoption of digital records

who are aged 65 and above. It is estimated that there are approximately 102 million elderly people in China. 2. Emerging mHealth: Paths for Growth, Economist Intelligence Unit, 2012 (www.pwc.com/mhealth). 3. China healthcare reform goals in the 12th Five-Year Plan for National Economic and Social Development of the People’s Republic of China (2011-2015) This article was taken from China-Britain Business FOCUS, a monthly magazine published by the China-Britain Business Council for its members. The China-Britain Business Council helps companies of all sizes from all sectors to do business with China. Find out more at www.cbbc.org n

across the health care spectrum and support the development of a robust health IT workforce; and Priming the Health IT Market – Both organisations will work to support the Health IT Marketplace by identifying barriers to innovation, sharing individual certification approaches for patients and clinician-facing applications, and strategies to support small and medium enterprises/start-ups. The full text of the memorandum of understanding can be found at www.healthit.gov/policy-researchers-implementers/health-information-technology-use-united-states-and-united-kingdom n

We can publish your educational white papers, case studies, and research reports in The Journal of mHealth We can work with you to develop engaging, creative, and informative content that will help educate and promote the results of your work, to a targeted audience of industry professionals. Our readers appreciate thought-provoking white papers that educate and inform in order to expedite their decision-making process. Publishing credible, quality white papers in The Journal of mHealth will ensure that your potential clients will refer to them frequently as valued resources. Our publishing programs all include an integrated marketing plan to ensure your content gets high exposure. Contact us for more information on our Content Publishing Programs

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The

Journal of mHealth The Global Voice of mHealth