The Journal of mHealth Vol 1 Issue 6 (Dec 2014) by The Journal of mHealth

WHATâ&#x20AC;&#x2122;S INSIDE

NEWS, REVIEWS, CLINICAL DATA, mHEALTH APPLICATIONS

The

Journal of mHealth The Global Voice of mHealth

December 2014 | Volume 1 Issue 6

Announcing the Global Digital Health 100

REPORT

ARTICLE

EVENT

Diabetes: Going Digital

Building an Ecosystem for mHealth adoption

mHealth Summit 2014

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

Global Digital Health 100 The most innovative companies in the field of digital health Please see the full list on page 4.

Editor's Comments

Welcome As we come to the final issue of the year, we reflect upon what has been an amazing first year for us here at The Journal of mHealth. From the launch of the inaugural issue in February to the announcement of our Global Digital Health 100 Award List in early December the year has been one of many firsts. This is a perfect time to thank all of our subscribers and readers who have joined us during the course of the year. We really appreciate your support and we hope that you have found our publication to be useful and informative. As we go into 2015 we will be looking to continue to bring you full coverage of the complete connected health industry, with news, research, event reporting, insight and articles from around the world. 2014 has been an eventful year for connected healthcare with some amazing breakthroughs in innovation, and, from what we have seen, a significant uptake in the deployment and adoption of digital and mobile solutions in healthcare environments around the globe. We hear more and more from actual healthcare professionals, rather than ‘technologists’ about the merits of digital solutions, and the practical benefits which are already being delivered. Although we will look to the New Year to provide additional clarification on the regulatory landscape surrounding mHealth, many of the announcements made during 2014 have helped to clarify some of the issues in this developing sector. We also expect the practicalities around reimbursement, interoperability, privacy & security, and methods of deploying solutions at scale to continue to be major development priorities for the industry, in 2015. We were delighted to be able to announce our Global Digital Health 100 Award List, earlier this month, at this year’s mHealth Summit, and in this issue we officially publish the full 2014 list. The list is the result of extensive research and evaluation by our editorial team, which we undertook with the aim of trying to identify and recognise some of the most innovative companies working in the mobile and digital health industry, from around the world. We have received an amazing response to the Award announcement, so much so that we have already begun to prepare for next year’s list. For 2015, we will be supplementing the selection methodology by introducing a submission process, which will begin early in the New Year. So if you are interested in being considered, please do get in touch. I would also like to take this opportunity to thank all of our advertisers, partners, and sponsors who have helped make all of this possible. The Journal of mHealth is dedicated to providing open access, and we rely upon industry support to allow us to continue to be the international voice of the mobile and digital health community. We look forward to developing these relationships through 2015 and hope to have the opportunity to work with more exciting and innovative organisations in the future. Finally, let us wish all of our readers a very Happy Christmas and all the best for the New Year!

Matthew Driver Editor

Published by Simedics Limited www.simedics.org Editor: Matthew Driver Design: Jennifer Edwards For editorial, research and paper submissions, and advertising opportunities please contact: Matthew Driver matthew@simedics.org +44 (0) 1756 709605 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. 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 exercise 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. ISSN 2055-270X © 2014 Simedics Limited

The Journal of mHealth

Table of Contents

In This Issue 4

Announcing the Global Digital Health 100 We are pleased to announce the 2014 Global Digital Health 100, recognising the 100 most innovative mobile and digital healthcare companies in the World today.

Building an Ecosystem for mHealth Adoption Victoria Betton, Programme Director at the mHealthHabitat discusses how the Leeds (UK) based mHealthHabitat has been set up with the purpose of developing a unique ecosystem designed to solve some of the issues surrounding digital adoption.

Digital Health Community Comes Together for mHealth Summit 2014 The Journal of mHealth was in attendance for this yearâ&#x20AC;&#x2122;s HIMSS mHealth Summit in Washington D.C. For anyone who was unable to attend the event or who missed parts of the packed schedule, we have compiled a round-up of some of the key highlights from the event.

December 2014

Table of Contents

Industry News 8

Bionic Arm Restores Sense of Feeling

UK Research Highlights Public Demand for Health Technology to Combat Obesity Epidemic

New Wrist-mounted Medical Monitor Boasts Two-year Battery Life

SUPPLEMENT

REPORT

39 Diabetes: Going

Digital

The role of technology in the prevention, treatment, and management of diabetes

New Method of Vibration for Energy Generation

BIRâ&#x20AC;&#x2122;s First App Launches with Mission to Transform Learning for Doctors

A Tiny Ultrasound-Powered Chip to Serve as Medical Device

Fall Detector for the Elderly Speeds Up Emergency Alerts

Tunstall Expands Global Mobile Health Portfolio

Orange and USAID Join Forces to Boost mHealth Innovations across Africa

International Digital Health Experts to Attend UK Innovation Conference

Tackling the Myths about Patient Data and Use of Technology with mHealth

Philips and Breast Cancer Care Partner to Launch FullyInteractive Breast-Check Application

Could Robotic Nurses Help in the Fight Against Ebola?

Canadian Researchers Create 'Black Box' for Use in Operating Rooms

Upcoming Events

Advertisers Index

Prototype Paper Test can Detect Ebola Strains

Tablet-based Ultrasound Trial Shows Lifesaving Potential in Emergency Services

IBM Launches Humanitarian Initiatives to Help Contain Ebola Outbreak in Africa

Where Policy is Right & Wrong on Digital Health

Empowering Patients: How the mHealth Vision has become a Reality

The Journal of mHealth

Announcing the Global Digital Health 100

Recognising Innovation in Digital and Mobile Healthcare We were delighted to be able to announce our Global Digital Health 100 Award List earlier this month at the mHealth Summit in Washington, DC. The Award, which has received fantastic industry recognition following the public announcement, has been developed to be a comprehensive assessment of the most innovative companies working in the digital and mobile healthcare sector today. Reflecting the evolving importance of mobile technologies and digital solutions in the healthcare sector, the Global Digital Health 100 acknowledges the significant work being carried out, in this field, by pioneering organisations from around the globe. There are so many great companies producing really innovative and amazing products that are set to revolutionise healthcare delivery. This meant we had a very difficult time narrowing the pool in order to select the final 100. What we do know is that all the 2014 honourees are likely to grow to become an amazing selection of companies that are sure to make an impact on modern healthcare. The Award represents 6 months of research by the editorial team at The Journal, who considered the offerings and innovations from over 1,500 different mobile and digital health companies worldwide, before selecting the final 100. Using 10 different quantitative and qualitative evaluation criteria including,

December 2014

disruptive impact, proof of concept, technology innovation, social value, execution of strategy, and industry integration, The Journal of mHealth editorial team has selected the 100 companies that demonstrate true innovation and the opportunity to disrupt the delivery of healthcare at scale. The selection criteria meant that we were able to truly consider companies based upon innovation, comparing start-up offerings alongside established and larger organisations. Companies recognised by the Award offer technologies across a range of categories including, clinical solutions, wearable technologies, healthcare applications, medical devices, and data analytics, providing solutions and services that all have the potential to transform and disrupt the way in which healthcare is delivered. This yearâ&#x20AC;&#x2122;s list reveals some interesting insights into the distribution and adoption of mobile and digital technologies in different health markets around the globe. 63% of honouree companies are based in North America, 30% in Europe, and 7% came from other regions around the

world, which seems to reflect the relative levels of maturity of these technologies and services in those respective markets. As this was the first year for the Global Digital Health 100 the selection process was entirely based upon the research and assessment of the editorial team at The Journal of mHealth, but future years will incorporate a submission process that we believe will allow us to ensure we remain updated on all potential innovators for the Award. We will begin accepting submissions for the 2015 Award list in January. Anyone interested in making a submission can register their interest now by emailing journalofmhealth@simedics.org. We will be including follow-up interviews with CEOâ&#x20AC;&#x2122;s and representatives of some of the final 100 companies in forthcoming issues, which will provide additional insight and perspective into the digital health market. n

Announcing the Global Digital Health 100

The 2014 Global Digital Health 100 List Company Name

Location

Medopad

Clariture

USA

Tiatros

USA

TedCas

Spain

Neurotrack

USA

Infield Health

USA

Ayogo Health

Canada

Portable Medical Technology (ONCOassist) Ireland Proteus Digital Health

USA

MediSafe

Israel

Equicare Health

Canada

WalkJoy

USA

Caremerge

USA

Shimmer

Ireland

dacadoo

Switzerland

Exco InTouch

MIRA REHAB

Visible Health

USA

LifeWIRE Corp

Canada

Medweb

USA

Philips

Netherlands

Qardio

USA

DiabetesTools

Sweden

Propeller Health

USA

Gauss Surgical

USA

Scriptpad

USA

Facts & Figures »» 1,500 companies reviewed »» 10 different assessment criteria »» From 16 different countries »» 8 categories

Categories »» »» »» »» »» »» »» »»

Healthcare Applications Clinical Solutions Wearable Technologies Medical Devices Hardware Assistive Technologies Telehealth/Telecare Data Analytics

By Region 63 North America 30 Europe 7 Rest of the World

By Country

58 United States 17 United Kingdom 5 Canada 3 Ireland 3 Switzerland 2 Spain 2 Israel 2 Netherlands 1 Sweden 1 Finland 1 Austria 1 South Korea 1 Greece 1 Australia 1 Belgium 1 New Zealand

The Journal of mHealth

Announcing the Global Digital Health 100

The 2014 Global Digital Health 100 List

Company Name

Location

Company Name

Location

Cara Health

USA

NeuMitra

USA

Epion Health

USA

Motion Computing

Global

Gecko Cap

USA

tribogenics

USA

Medixine

Finland

WellDoc

USA

DrDoctor

Samsung

South Korea

Patient Source

BioSensics

USA

CareSpan

USA

Sensiotec

USA

Aseptika - Active8rlives

Tactio Health Group

Canada

babylon

Ginger.io

USA

mySugr

Austria/USA

AdhereTech

USA

healthbank

Switzerland

Validic

USA

uMotif

VIDAVO

Greece

NurseBuddy

Ireland

v-connect

Sitekit

LGTmedical

Canada

IMS Health

USA

Big White Wall

Soma Analytics

Peek Vision

SwipeSense

USA

Kit Check

USA

Yosko

USA

Tonic Health

USA

eClinic Healthcare

USA

Mersey Burns

etect

USA

Global Kinetics Corporation

Australia

AgileMD

USA

DICOM Grid

USA

Omada Health

USA

Aura Healthcare

Cellscope

USA

Oxitone Medical

Israel

Docphin

USA

doccom (Careflow Connect)

drchrono

USA

Mint Solutions

Netherlands

nephosity

USA

BioBeats

USA

December 2014

Announcing the Global Digital Health 100

The 2014 Global Digital Health 100 List Company Name

Location

Company Name

Location

Touch Surgery

Second Sight

Switzerland

Wearable Intelligence

USA

Zynx Health

USA

Voxiva

USA

e-Telmed

USA

AirStrip

USA

GeaCom (Phrazer)

USA

QxMD

USA

MobileSmith

USA

AliveCor

USA

InsightMedi

Spain

MC10

USA

IMEC

Belgium

MediMobile

USA

Nexus6

New Zealand

Cureatr

USA

eClinicalWorks

USA

iRythym

USA

Telcare

USA

LifeNexus (iChip)

USA

Glooko

USA

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The Journal of mHealth

INDUSTRY NEWS News and Information for Digital Health Professionals

Bionic Arm Restores Sense of Feeling Advances in bionic hands have restored a sense of touch to two patients for more than a year, report US scientists.

Mr Spetic can tell, while blindfolded, whether he

years. A team at Case Western Reserve University attached sensors to the bionic hand and in surgery fitted "cuffs" around the remaining nerves, which were capable of delivering electronic stimulation. This allowed the team to send different patterns of electronic stimulation to the nerves using a computer, which were then interpreted in the brain as different sensations. The team "mapped" these sensations to 19 different locations on the hand, from the palm to the tip of the thumb, and matched the sensors to the different electronic patterns of stimulation. One of the beneficiaries of the American work was Igor Spetic, who lost his right hand in an accident four years ago. He was fitted with a bionic replacement, but it was incapable of feeling the world around him. He had to carefully watch what he was doing and judge by eye whether he was squeezing too hard. With the help of the new technology Spetic is now able to perform extremely delicate tasks, like removing the stalks from cherries.

The team have also refined the technology to enable identification of different pressure and textures. For example,

December 2014

is handling different materials such as Velcro or sandpaper. He has been using the sensing hand for two-and-a-half years. Another patient has been using the system for one and a half

Mr Spetic said: "I would love to feel my wife's hand, just to hold hands would be the ultimate." Lead researcher Prof Dustin Tyler said "They can do really fine delicate tasks now. We believe within five to ten years we will have a system that is completely implanted. So that a person would have the procedure to put electrodes on each nerve and a device for their pocket, so that when they turn it on they can feel their hands." In both patients the modified hand had the added bonus of eliminating "phantom limb pain", in which patients still feel pain from the hand that is no longer there. Meanwhile another recent trial has seen scientists at Chalmers University of Technology in Sweden implant the first boneanchored bionic arm. The technique known as "osseointegration" involved connecting the arm directly to the bone, nerves and muscles in the residual stump of the patient's arm. Dr Max Ortiz Catalan who led the research said: "We have used

Industry News osseointegration to create a long-term stable fusion between man and machine, where we have integrated them at different levels. The artificial arm is directly attached to the skeleton, thus providing mechanical stability. Then the human's biological control system, that is nerves and muscles, is also interfaced to the

machine's control system. "Reliable communication between the prosthesis and the body has been the missing link for clinical implementation of neural control and sensory feedback, and this is now in place." n

UK Research Highlights Public Demand for Health Technology to Combat Obesity Epidemic Findings from the first AXA PPP Health Tech & You State of the Nation survey have revealed the attitudes of the UK public towards health technology and how obesity is the number one public health concern that needs to be tackled using health technologies during the next 12 months. During a keynote speech at the AXA PPP Health Tech & You Forum at the Design Museum in London, George Freeman MP, Life Sciences Minister, highlighted that even though cancer and heart disease cause the most deaths in the UK each year, obesity, by far, is the health condition people surveyed online are most looking to technology to address and solve during the next 12 months. The survey showed that 57 per cent of respondents were most concerned with tackling obesity as compared to Diabetes (15 per cent), Cancer (9 per cent) and Heart Disease (8 per cent). George Freeman MP, commented: “These findings are a wakeup call about the importance of digital health tech in combating the rising burden of chronic disease through earlier diagnosis, better treatment and reduced hospital stays. With today’s patients hungry for additional support via apps, monitoring devices and other health technology solutions, we need to ensure that the NHS is working together with patients to accelerate access to modern health technology.” The survey also revealed that 43 per cent of people believe that the NHS should provide health technology free of charge to help people improve their overall health. The report surveyed over 2,000 individuals to gain their views towards the health technology revolution and how the country believes the impact that apps, devices and gadgets have on our nation’s health. Additional key findings include: »» 44 per cent of respondents think that health technologies could help them manage a long term health condition »» Nearly half of respondents (48%) live in a household that contains someone with a long term health condition »» Over the next five years respondents feel the most commonly used health technologies will be pedometers (23 per cent), wristband/watch (22 per cent) and fitness related smartphone apps (18 per cent)

The age group most open to health technology are aged between 18 and 44. 42 per cent of 18-44 year olds agreed that health technology would positively impact their health if they used it regularly. This is in comparison to those aged 45-54 (30 per cent) and 55+ (23 per cent) AXA PPP Health Tech & You is a joint initiative of AXA PPP Healthcare, 2020Health and the Design Museum, in an attempt to put the health technology revolution into a wider context for the benefit of patients and consumers: to look at how it can change lives and society, from the detail of wearable health technology to the treatment of long-term conditions. James Freeston, Marketing Director, AXA PPP healthcare, states, “Nothing could be more personal than your own health. We and our Health Tech & You partners believe personal health technology is the new age, giving more control to consumers to live healthier and more active lives. This new research clearly demonstrates the public demand for health technology to help combat conditions like obesity. Health technology, and the public's desire to use it, has now reached a stage where existing public health campaigns focussing solely on advertising, posters and leaflets have to be questioned.” For more information visit: www.healthtechandyou.com n

The Journal of mHealth

Industry News

New Wrist-Mounted Medical Monitor Boasts Two-Year Battery Life A smart band, the Assure, designed for remote medical monitoring has been showcased for the first time at the Innovate UK 2014 event held in London during November. The most noteworthy feature of the new device, developed by Cambridge-based Acticheck, is a battery life that provides power for two years without recharging. This challenges a key drawback of existing wearable devices which typically require daily or weekly recharging. Acticheck founder and general manager Karl Gibbs explains: 'The biggest problem with smart wearable devices is that they need recharging regularly. 'By minimising processes within the wristband, and without compromising on quality, style or function, we have managed to create a device with a battery life of two years - that is unparalleled in this market.' Acticheck is currently moving to secure patents for its battery management technology. The device is intended for use in remote monitoring of the elderly, patients with serious long-term medical conditions or lone workers. It continuously analyses a series of physiological data, including body temperature and pulse, with its on-board sensors. It will send an automatic notification via an in-home base station or smartphone to care providers when these move

beyond accepted parameters. This represents an improvement on existing systems that typically require the wearer to actively press a button. Gibbs adds: 'Assure negates the need for bulky, unattractive pendant alarms and gives wearers the confidence to celebrate their independence both inside and outside of their home.' The device is set for commercial release in the spring of 2015. Acticheck has committed that it will sell for less than ÂŁ200 [â&#x201A;Ź253] for its first two years on the market. n

New Method of Vibration for Energy Generation Scientists at the VTT Technical Research Centre in Finland have devised a new way of generating energy using mechanical vibrations. They have found a way to harvest the vibrational energy which occurs naturally when two surfaces with different work functions are connected via electrodes. Itâ&#x20AC;&#x2122;s a potential power source for wearables and other lowpower electronics. Work function is the amount of energy needed to remove an electron from a solid and it determines, for example, the photoelectric effect. When

December 2014

two conducting bodies with different work functions are connected to each other electrically, they accumulate opposite charges. Moving of these bodies with respect to each other generates energy because of the attractive electrostatic force between the opposite charges. In VTT's experiment the energy generated by this motion was converted into useful electrical power by connecting the bodies to an external circuit. This new energy conversion technique also works with semiconductors, say the researchers. To date, the bulk of research into small

energy harvesters that turn mechanical vibration into electricity has focused on piezoelectric and electrostatic devices. Unlike these devices, VTT's technique does not require an integrated battery, electrets or piezo materials. VTT estimates that the new electricity generation technology could be introduced on an industrial scale within three to six years. The research was published in the journal Scientific Reports. n

Industry News

BIR’s First App Launches with Mission to Transform Learning for Doctors An ambitious new mobile app has been launched by the British Institute of Radiology (BIR) to transform how doctors study for their professional qualifications. This is the BIR's first ever app as the historic organisation seeks to respond to the rapid rise in smartphone and tablet use among young doctors. It is compatible with iPhones, iPads and the iPod touch, as well as a variety of Android smartphones and tablets. Imaging Single Best Answer was developed by Apadmi, the UK's leading mobile app developer, which saw off bids from approximately 15 other companies in an open tender over the summer to secure the right to work with the BIR. The BIR, which can trace its roots back to 1897, is the oldest radiological society in the world. Today, it is a globally recognised membership organisation for healthcare professionals working with imaging science and radiation technologies such as X-rays, magnetic resonance imaging (MRI) and ultrasound.

The app helps trainee radiologists prepare for the Royal College of Radiologists' Final FRCR (Part A) Exam. It features a total of 450 questions across each of the six exam modules: cardiothoracic and vascular; musculoskeletal and trauma; gastro-intestinal; genito-urinary, adrenal, obstetrics and gynaecology and breast; paediatric; and central nervous system and head and neck. It has two different modes of assessment. The 'test' function presents users with a number of multiple choice questions in which they are given the summary findings from a scan and invited to select the best diagnosis. They will then be shown the single best answer along with a detailed explanation of why this is the case. Meanwhile, the 'exam' function enables students to sit the same questions under timed exam conditions before reviewing their answers and detailed explanations at the end. The app records all of the user's scores, giving them the opportunity to see how much they have improved over time. In addition, all data is pre-loaded into the app so that it can operate offline. This means it is suitable for use in areas with poor internet access such as during the daily commute, on the tube or in rural areas. Nick Black, co-founder and director of Apadmi, said: "It has been a real privilege for our team to create the British Institute of Radiology's first ever app.” "Every doctor needs to embrace continuing professional development in order to improve their knowledge and skills over time, but many healthcare organisations have yet to take advantage of the huge benefits that apps can bring to the learning process. Imaging Single Best Answer is a great example of how apps can help

the healthcare sector." Sophia Anderton, head of publishing at the British Institute of Radiology, said: "We're really happy with the Imaging Single Best Answer app.” "Following a highly competitive pitching process, we decided to work with Apadmi because the team came across extremely professionally and had clearly researched the British Institute of Radiology and our requirements in detail. This is our first ever app so we had a lot to learn about the creative process, but Apadmi's team were great at answering our questions and coming up with sensible suggestions to guide us through. What's more, the app was completed on time and on budget, and both the iOS and Android versions are very intuitive and easy to use. "We're confident that the Imaging Single Best Answer app will transform how doctors revise for their exams by enabling them to learn at a time and place that suits them. By helping doctors develop their skills in a more modern way, this app will hopefully improve patient outcomes and ultimately save lives." The Imaging Single Best Answer app is available to download on the App Store and Google Play. For more information, please visit www.apadmi.com. n

The Journal of mHealth

Industry News

A Tiny Ultrasound-Powered Chip to Serve as Medical Device Stanford engineers are developing a way to send power, safely and wirelessly, to “smart chips” in the body that are programmed to perform medical tasks and report back the results. The idea is to get rid of wires and batteries, which would make the implant too big or clumsy. Their approach involves directing ultrasound at a tiny device inside the body designed to do three things: convert the incoming sound waves into electricity; process and execute medical commands; and report the completed activity via a tiny built-in radio antenna. “We think this will enable researchers to develop a new generation of tiny implants designed for a wide array of medical applications,” said Amin Arbabian, an assistant professor of electrical engineering at Stanford. Arbabian’s team recently presented a working prototype of this wireless medical implant system at the IEEE Custom Integrated Circuits Conference in San Jose. The researchers chose ultrasound to deliver wireless power to their medical implants because it has been safely used in many applications, such as foetal imaging, and can provide precision and sufficient power to implants a millimetre or less in size. Arbabian and his colleagues are collaborating with other researchers to develop sound-powered implants for a variety of medical applications, from studying the nervous system to treating the symptoms of Parkinson’s disease. The Stanford medical implant chip is powered by piezoelectricity (pressure on a material generates an electric voltage). The

Stanford team created pressure by aiming ultrasound waves at a tiny piece of piezoelectric material mounted on the device. In the future, the team plans to extend the capabilities of the implant chip to perform medical tasks, such as powering sensors or delivering therapeutic jolts of electricity right where a patient feels pain. The “smart chip” also contains an RF antenna to beam back sensor readings or signal the completion of its therapeutic task. The current prototype is the size of the head of a ballpoint pen. The team hope to design a next-generation implant onetenth that size to interface with brain cells, using arrays of micro implants across the entire 3D structure of the brain, and for other uses. n

Fall Detector for the Elderly Speeds Up Emergency Alerts A wearable device that sets off an alert when it detects a fall has been developed to give elderly people reassurance that emergency services will be contacted instantaneously if they suffer an accident. Called FATE, or FAll DeTector for the Elderly, the device uses technology similar to airbags in cars which are triggered when sudden acceleration is detected.

FATE is a three-year European

December 2014

project that brings together a consortium of technology and delivery partners. The ultimate goal of the FATE project is to widely validate an innovative and efficient ICT-based solution focused on improving elderly quality of life by providing an accurate detection of falls in ageing people, both at home and outdoors. This is done by implementing a portable and usable fall detector that runs a complex and specific algorithm to

accurately detect falls, and a robust and reliable telecommunications layer based in ZigBee and Bluetooth technologies, capable of sending alarms when the user is both inside and outside the home. The system is complemented by a number of secondary elements such as a bed presence sensor and a device called the i-Walker (an intelligent walker designed to detect fall risk for older people with significant gait difficulties). The idea is

Industry News that the entire system can help ensure successful prevention and detection of falls across many different circumstances.

The system is being tested and validated in three pilot studies involving real living scenarios, one in each of three different EU countries (Spain, Italy and Ireland), in close collaboration with the relevant

public authorities. A great majority of falls in ageing people result from a combination of factors. The ageing process itself is one of these factors. Other contributing factors include chronic health problems (diseases of heart, problems in eyes, poor vision, muscle weakness, dementia, arthritis, etc), physical and functional impairments (lower extremity weakness, balance disorders), medications and alcohol abuse, and hazards and obstacles in the home (poor lighting, lack of bathroom safety equipment, loose carpets). The hope is that FATE can deliver a complete system that will improve the prevention of falls in affected ageing people by addressing and solving a number of relevant issues. These include: »» The automatic detection of a fall (with very low error rate) »» The localisation of where the fall occurred, thus facilitating the inter-

vention »» The improvement of the fear of falling (FOF) effect »» The use of the i-Walker when necessary for mobility improvement and eventual contribution to rehabilitation »» The definitive improvement of the "long-lie" syndrome »» The precise detection of falls for people with low cognitive problems like memory loss is a critical factor in prescribing a rehabilitation program The FATE system and the devices that have been developed have all been designed within a specific care model focused on strengthening public and private collaboration to reach a reliable service. It is hoped that it will provide a sustainable model of care that can be delivered to elderly populations across Europe. For more information visit: www.fate.upc. edu n

Tunstall Expands Global Mobile Health Portfolio Tunstall Healthcare, in an exclusive partnership with Tactio Health Group, has launched a new app based solution to improve shared decision making in health and social care. Adding mobile solutions to its digital health portfolio, Tunstall’s apps will enable professionals to re-define the care experience and expand the number of care facilities including the patient’s location of choice. The traditional, passive approach to healthcare, initiated by the patient visit to the GP, is becoming increasingly unaffordable. Active health management is needed so that health and care professionals can cost effectively manage a wider spectrum of patients and conditions, with full confidence in the data and reports generated for the individual. Tunstall’s solution includes tools that allow data and reports to be appended to the patient record, and there are plans to make these solutions interoperable with GP systems and EPRs.

Self-management through apps is not unique but “Supported Self-Management” is; it allows health and care professionals to encourage patients to participate in managing their own health as they work to achieve their individual goals. The mPro app has been designed for care professionals to support patients who download the mTrax app onto their own smart phone or tablet, keeping track of mood, sleep, nutrition, pregnancy, weight, body fat, steps, physical activity, blood pressure, SpO2, cholesterol, glucose, body temperature and diabetes (Type 1, Type 2 & Gestational). Tunstall Active Health Management offers programmes that can be adapted to the needs of the individual as their circumstances change. These range from supported self-management to the more traditional clinically monitored telehealth solutions, when additional support is needed. Programmes designed by health and care professionals and supported by Tunstall’s extensive experience in telehealth

care, can help people stay healthy for longer and make choices about how to manage or improve their health and wellness. Cecilia Bufton, Group Product Management Director at Tunstall said, “We have been evaluating the use of apps and other similar ‘light touch’ approaches to telehealth care for a number of years and have not found anything that meets our customers’ requirements. The majority have limitations such as relying on SMS text only, with no safe audit trail of messaging however I’m pleased to say that our partnership with Tactio gives us a comprehensive solution.” Working on both Android and Apple, including the new Apple HealthKit on iOS 8, the flexibility of the system allows you to see real-time key health and fitness indicators together, in an easy, flexible format. This is about improving lives and putting people in control of their own care and Active Health ManContinued on page 14

The Journal of mHealth

Industry News Continued from page 13

agement. It is about creating a shift from reactive care to cost-effective active care. Michel Nadeau, P.Eng, President, CEO and Founder of Tactio Health Group, added “I wanted to work in partnership with a global leader and expand our offering into new territories. Tunstall has decades of expertise in telehealth in global care markets and our integrated product and service offering enables us to address new preventive healthcare market segments, by meeting the needs of the empowered patient and ultimately changing lives for millions of people. This element of democratising healthcare worldwide is at the very foundation of Tactio.” Tactio Health Group is a world leader in mobile health systems with millions using its mobile health applications on iOS and Android, enjoying the personal and family benefits of being supported to live a more active, healthier lifestyle. The exclusive partnership will cover 11 of Tunstall’s main markets with the UK being first to launch. A number of Tunstall’s customers have already expressed

keen interest in using a professional app based service and the first customer pro-

grammes will be available from December 2014, with more planned for 2015. n

Orange and USAID Join Forces to Boost mHealth Innovations across Africa The U.S. Agency for International Development (USAID) and global telecommunications operator Orange used the December Global mHealth Forum in Washington, DC to announce a new alliance aimed at developing innovations in mobile health. These mHealth innovations will help treat and care for individuals in developing countries across Africa. “Together with USAID, we are creating innovative mHealth platforms that open up the opportunities for remote patient monitoring or healthcare workers to make better-informed decisions and facilitate quality care for all citizens.” “With the increasing use and decreasing cost of mobile devices, leveraging

December 2014

mobile phone technology to accelerate access to health information and services is a game changer,” said Dr. Ariel PablosMéndez, USAID’s Assistant Administrator for Global Health. “USAID’s partnerships with private companies, such as Orange, enable us to have a larger impact in a cost-effective manner.” The first phase of these health systemstrengthening programs will leverage the expertise, technology and local resources of both organisations to improve quality of care and ensure that health services are readily accessible to the public at large. Niger and other countries are currently under exploration. Future services will use integrated

mHealth platforms and Orange mobile networks to communicate alerts and share resources around family planning and maternal health. Healthcare workers will be able to use the technology to share medical expertise, collaborate with specialists regardless of location, and improve patient care. In addition, the public will be able to access health information via the mHealth platforms. Orange’s global footprint, with mobile and fixed networks in 20 countries in Africa and the Middle East, will provide seamless and reliable access to these services. A maternal mHealth solution will provide medical practitioners access to the latest tools and medical information allowing them to monitor a mother’s

Industry News pregnancy from a distance. This is particularly useful in some parts of Africa where much of the population lives in rural areas without easy access to healthcare or readily available means of transport. By using mHealth solutions, medical professionals would be able to flag potential problems early and provide the necessary care that reduces risks to mother and child. “There is a tremendous amount of good that mobile technology and digital innovations can bring to improve the quality of healthcare to those less

fortunate,” said Thierry Zylberberg, Director, Orange Healthcare. “Together with USAID, we are creating innovative mHealth platforms that open up the opportunities for remote patient monitoring or healthcare workers to make better-informed decisions and facilitate quality care for all citizens.” The goal of the USAID/Orange alliance is to create a framework for easily replicating these important mobile services in a number of African countries throughout the region. In West Africa, USAID and Orange are starting to develop a

regional platform with a menu of mobile applications that ministries of health, donors and NGOs could use for consumer education, health worker tools, mobile money, and data collection. Orange’s expertise in interoperability and scalability will ensure that such platforms adhere to local regulatory and structural organisations. Orange has been at the forefront of realising Africa’s digital transformation, connecting people, entrepreneurs, towns and cities, and delivering innovative services such as mobile payment. n

Prototype Paper Test can Detect Ebola Strains In a case of true health-tech mobility researchers have developed a simple paper test that uses DNA-programmed blotting paper to give doctors a simple disease test that will reveal an infection in 30 minutes for just a few pence. Researchers have proved the technique works by developing a prototype Ebola test in just 12 hours, and using just $20 of materials. The diagnostic uses a soup of biological ingredients including the genetic material RNA, which the researchers are able to freeze-dry and preserve on ordinary paper. Team leader Jim Collins, who has joint appointments at Boston and Harvard Universities, says the biological powder can be reactivated by simply adding water, like living powdered soup. "Once they're rehydrated, these biological circuits function in these small paper disks as if they were inside a living cell." Jim Collins is a leading pioneer in the field of synthetic biology, well known for his 2000 paper showing genetic circuits could be created in the same way as electronic circuits can be programmed, helped launch the discipline. Since then, synthetic biology has become a powerful tool in fundamental biology, with researchers hacking the genetic programmes of microbes to study their life processes, or

give them the power to compute using logic like a digital processor. Collins' group has previously reprogrammed bacteria to become cellular data recorders, collecting information as they pass through an animal's bowels. But the discipline has required specialist skills, so that few laboratories can take advantage of the techniques. The researchers' avowed intention in the new work, described in the journal Cell, is to make synthetic biology widely available.

They've definitely succeeded, says Professor Lingchong You, an expert in cellular reprogramming at Duke University. "This paper-based approach is incredibly attractive. It feels like you could use it in your garage! It'll give scientists a synthetic-biology playground for a very low cost." The materials in the powdered biochemical soup include simple enzymes that bacteria need, molecules to power Continued on page 16

The Journal of mHealth

Industry News Continued from page 15

the chemical reactions, amino acids which are the bricks of cell biology, and importantly ribosomes, giant molecular machines that read genetic material and use it to assemble the bricks into functioning proteins. In liquid form, these cell extracts are routinely used in biology labs. Linchong You gives credit to Collins for having the imagination to freeze dry them with synthetic genes. "With hindsight, it's obvious it should work. But most of us don't think in this direction - there was a real leap of faith. But the fact you can leave these freezedried systems for a year, and they'll still work - that's quite remarkable." Alongside the paper-based biochemistry, Jim Collins' team - in collaboration with Peng Yin, also at Harvard University's Wyss Institute - has also introduced a new way of programming RNA, the molecular cousin of DNA which ribosome machines read. Their method makes the gene-circuits far more flexible

than previous approaches. The new type of RNA can be programmed to react and respond to any particular biochemical input, and then switch on the rest of the genetic machinery. "This gives us a programmable sensor that can be readily and rapidly designed," Collins explains. The Ebola test they experimented with is a proof of principle showing how flexible the programming step is. "In a period of just 12 hours, two of my team managed to develop 24 sensors that would detect different regions of the Ebola genome, and discriminate between the Sudan and the Zaire strains."

ger, variants of the test could be used to reveal antibiotic resistance genes in bacterial infections or biomarkers of other disease conditions. Their Ebola test is not suitable for use in the epidemic areas at the moment, Collins emphasises, but it would be simple to devise one that is. The arrays of programmed paper dots would be easy to mass produce. Lingchong You envisions an "entire fabrication process carried out by computeraided circuit design, robotics-mediated assembly of circuits, and printing onto paper."

In contrast, conventional antibody tests take months and cost thousands of pounds to devise, the researchers argue.

And price is not the only consideration. Collins points out the freeze-dried circuits are stable at room temperature. In large parts of the world where electricity is unreliable, or there are no refrigerators, this would be a particular advantage.

The genetic test kit gives a simple colour output, turning the paper from yellow to purple, with the change visible within half an hour. By changing the input trig-

"We are very excited about this," he added. "In terms of significance, I rank this alongside all the other breakthroughs I've been involved in." n

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Industry News

Tablet-based Ultrasound Trial Shows Lifesaving Potential in Emergency Services Samsung Electronics America has recently announced the preliminary results of a groundbreaking trial into the use of tablet-based ultrasound in emergency services vehicles. A total of six emergency services vehicles at Bedford, Hurst and DFW Airport Fire Departments in the Dallas-Fort Worth area have been equipped with Samsung’s PT60A ultrasound as part of an ongoing trial. Since the trial began in July of 2014, ultrasound has been employed in 91 callouts to support diagnosis in cases involving trauma, internal bleeding, acute abdominal pain and cardiac arrest. In cases where specialist opinion is required, ultrasound images are transmitted wirelessly from the on-board device to doctors at JPS Health Network through Trice Imaging’s mobile encryption and image management system. The system also allows physicians to collaborate in real-time in order to prepare for the patient’s arrival at the emergency room. The first phase of the trial has revealed a number of key findings. In several instances, the transmission of ultrasound images has enabled medics and/ or doctors at the hospital to positively identify internal bleeding/fluids, resulting in faster treatment upon the patients’ arrival at the emergency room. Early diagnosis has also enabled the hospital to ensure relevant specialists are on hand upon the patient’s arrival. Medics at DFW Airport’s Fire Department have utilised ultrasound on cardiac patients presenting no pulse. While the existing protocol has been to contact their medical director to determine whether to cease resuscitation efforts, in several instances ultrasound has detected heart movement and medics have continued treatment, resulting in return of spontaneous circulation and eventual patient discharge. More than 50 medics have been success-

fully trained on the use of Samsung’s PT60A ultrasound system, receiving certification from the Chief of Trauma. In the field, medics have been able to rapidly access the tablet-based ultrasound to conduct scans while the patient is in transit. Wireless image transmission to the medical director has taken as little as 30 seconds. “This trial has demonstrated the significant potential for expanded use of point-of-care ultrasound by emergency services medics,” said Dr. Roy Yamada, EMS Medical Director for the Dallas/Fort Worth area. “By transmitting images from the Samsung PT60 in the ambulance to specialists at the hospital in real time, we are able to make critical decisions that can save precious minutes and have a tangible impact on outcomes for trauma and cardiac patients.” The Samsung PT60A, Samsung’s first tablet-based ultrasound system, is designed specifically for point-of-care applications. Using the one-touch measurement features of the ultra-portable and compact device, exam results are delivered with maximum efficiency. The system’s Auto IMT™ and quick diagno-

sis report can help providers make critical decisions and enable timely treatment for the patient. “Time to the operating theatre is critical in determining the survival of trauma patients,” added Dr. Raj Gandhi, Trauma Medical Director, John Peter Smith Hospital, Fort Worth. “By receiving ultrasound images from the emergency services personnel while the patient is en route, I can make a more accurate determination if surgery is required and have the patient transported directly to the operating room. This trial points to a significant opportunity to improve our emergency services protocols that has the potential to save many lives.” Doug Ryan, Group Vice President, Health & Medical Equipment, commented: “Samsung has made a longterm commitment to leveraging its technology to bring new innovations to healthcare. The Samsung PT60A was developed to provide quick, accurate diagnosis at the point-of-care and it is exciting to see its lifesaving potential demonstrated through this groundbreaking emergency services trial together with Trice Imaging.” n

The Journal of mHealth

Industry News

IBM Launches Humanitarian Initiatives to Help Contain Ebola Outbreak in Africa

Following our Special Report in the last issue of The Journal of mHealth that looked at the role technology is having in the fight against Ebola we have recently heard the details of a number of initiatives from IBM aimed at helping to curb the spread of Ebola in West Africa. They include a citizen engagement and analytics system in Sierra Leone that enables communities affected by Ebola to communicate their issues and concerns directly to the government; a donation of IBM Connections technology in Nigeria to strengthen the Lagos State government’s preparedness for future disease outbreaks; and a global platform for sharing Ebola-related open data. The efforts combine expertise from IBM’s global network of research labs with the company’s years of experience in humanitarian disaster response by applying mobile technology, data analytics and cloud computing to help governments and relief agencies as they seek to contain the deadly disease. The work benefits from contributions from a number of partners including Sierra Leone’s Open Government Initiative, Cambridge University’s Africa’s Voices project, Airtel and Kenya’s Echo Mobile. Citizen Engagement in Sierra Leone IBM’s new Africa research lab, in collaboration with Sierra Leone’s Open Government Initiative, has developed a system that enables citizens to report Ebola-related issues and concerns via SMS or voice calls. It provides actionable insight to the government about the day-to-day experiences of communities

December 2014

directly affected by Ebola to help improve its strategy for containing the disease. “For us to tackle Ebola, it is crucial to maintain an open dialogue between the government and the people of Sierra Leone,” said Khadija Sesay Director of Sierra Leone’s Open Government Initiative. “IBM has enhanced our work on citizen engagement through the use of innovative technology and opened up an effective communication channel with the general public so that we can learn from their input and create actionable policies in the fight against Ebola.” Tapping supercomputing power and analytics capabilities via the cloud, the system is able to rapidly identify correlations and highlight emerging issues across the entire data set of messages. As the SMS and voice data are location specific, IBM is able to create opinion-based heat-maps which correlate public sentiment to location information. For example, it has already brought to light specific regions with growing numbers of suspected Ebola cases which require urgent supplies like soap and electricity, as well as faster response times for body collection and burials. The system has also highlighted issues with the diagnosis of Ebola empowering the government to approach the international community to request more testing facilities and equipment. “As Africa’s first technology research lab, we are uniquely positioned to use innovation to help tackle some of the continent’s biggest challenges,” said Dr. Uyi Stewart, Chief Scientist, IBM Research – Africa. “We saw the need to quickly develop a sys-

Industry News tem to enable communities directly affected by Ebola to provide valuable insight about how to fight it. Using mobile technology, we have given them a voice and a channel to communicate their experiences directly to the government.” The system uses radio broadcasts to encourage people to get in touch and express their opinions. Cambridge University’s Africa's Voices project has helped to develop a radio engagement model, incorporating questions into public service announcements to elicit feedback from citizens in both English and Krio – one of Sierra Leone's most widely spoken languages. “Radio is a powerful medium in Africa but its potential to gather and analyse audience feedback has not been fully seized,” said Dr. Sharath Srinivasan, Director of Cambridge University’s Centre of Governance and Human Rights. “We are working with IBM to offer people across Sierra Leone a channel to voice their opinions and, crucially, to ensure that the data is rapidly analysed and turned into valuable insight about the effectiveness of public service announcements and possible public misconceptions about Ebola.” Telco operator Airtel has set up the toll-free number via which citizens are able to send SMS messages. “Mobile technology is Africa’s most powerful communications platform providing an important channel for reaching large numbers of the population,” said Sudipto Chowdhury, Managing Director, Airtel, Sierra Leone. “As one of Africa's leading mobile operators, we will do everything we can to ensure that mobile technology contributes to tackling the spread of Ebola and we are partnering with IBM to ensure the effective flow of information between the government and the citizens of Sierra Leone.” The SMS data is anonymised by Kenyan start-up Echo mobile which specialises in leveraging basic mobile phones to give voice to underserved communities. “We're working to make sure that the stream of messages from patients, health workers and the general public can be used to augment the response effort and provide a direct and near realtime view of the situation on the ground," said Jeremy Gordon, Product Director, Echo Mobile. IBM is currently looking to extend the work to analyse mobile phone signal data in order to monitor and track population movement enabling scientists to map and predict the spread of disease. Technology That Facilitates Coordination Nigeria has taken a leadership position in the fight against Ebola and has recently been declared free of the disease. To support the country’s preparedness for future outbreaks, IBM has donated its Connections technology to Nigeria’s Lagos State Government. Nigeria’s Lagos State Government hosts an Ebola Operations Centre that coordinates disease containment efforts on behalf of the Nigerian government and other organisations. IBM’s technology donation will help strengthen the coordination of public health emergency response teams and ensure that the Lagos State Government is able to manage and respond to

any new reported cases of Ebola or future epidemics. IBM’s Connections technology has a proven track record in humanitarian disaster response situations. It provides health workers and administrators with a reliable and secure digital platform to work together virtually and in person, enabling them to securely share documents, identify experts, exchange video, chat and audio messages, provide updates, tap into information via mobile devices and hold virtual meetings. Storing information securely and conveniently in the digital cloud means that vital information can be accessed by authorised users anywhere. IBM has previously provided similar technology in other crisis situations around the world to support collaboration and coordination amongst response agencies. In 2010, SmartCloud supported a post-Haiti quake effort called Colleagues in Care, which helped doctors in Haiti learn from doctors in the US and elsewhere. The Chilean Red Cross used the platform to establish a disaster command centre following the 2010 Chile earthquake. The platform was also used by agencies in the US following Hurricane Sandy in 2012 and for flooding recovery activities in Colorado in 2013. IBM is broadly offering access to its IBM Connections cloudbased platform to all government agencies and non-governmental organisations working to stem the spread of Ebola. Ebola Open Data Repository Globally, IBM volunteers are leading a community effort to help identify, inventory and classify all open data sources related to the Ebola outbreak and are calling on organisations worldwide to contribute data. The goal is to create a cloud-based Ebola Open Data Repository which will provide governments, aid agencies and researchers with free and open access to valuable open data related to Ebola. To support the work, IBM volunteers helped organise a recent Ebola Open Data brainstorming session in New York where members of the local tech community met with health experts and aid organizations to develop Open Data solutions to help tackle Ebola. "Data can be a powerful resource for managing and mitigating epidemics,” said Jeanne Holm, Evangelist for Data.Gov. “Governments and other organizations have valuable open data that could help in relief efforts - about roads, airports, schools, medical facilities and populations. Such information can help to drive data-driven decisions during times of uncertainty. IBM is playing a key role in this initiative by helping to identify and gather more open data sources that might inform decisions around Ebola." Around the world, cities, states and nations are publishing open data and creating new data supply chains and ecosystems to help tackle national and global challenges. Many African governments such as Sierra Leone, Liberia, Ghana, South Africa, Malawi and Tanzania have joined the Open Government Partnership to take advantage of published open data to drive innovation and support better collaboration. To learn more about IBM in Africa, visit: http://ibm. co/1evaCes n

The Journal of mHealth

Where Policy is Right & Wrong on Digital Health

Where Policy is Right & Wrong on Digital Health By Dr Alexander Graham 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). He is also medical director of EMEA for Imprivata. Given this is the last article of the year; I thought it would be interesting to review some of the year-end publications and reviews that have been released in the UK from central bodies. The Five Year Forward View and Personalised Health and Care 2020 were two generally wellreceived papers from the NHS that detailed, amongst other areas, the role of technology in the NHS for the next half decade. The Five Year Forward View had a limited look at technology but the ideas of interoperable electronic health records, the collaboration of research data and smartphone ubiquity are certainly admirable. A focus on apps however, without any mention of developing a platform or a portal around them and no mention of interoperability was less welcome. It remains my strong belief that isolated medical apps will do little to improve healthcare if they cannot be built into existing and future infrastructures. The Personalised Health and Care 2020 paper, the first publication of the new National Information Board, delved a little more deeply into the specific areas of technology creation and adoption. However, as with the majority of government issued literature, it remained very much high level in scope. Again, welcome initiatives espoused included giving healthcare professionals access to real-time data (wireless monitoring here is a key element of this – companies such as Sotera Wireless in the US are making big steps in wireless physiology monitoring) and expansion of the patient care record and data sharing and mining, on which analytics platforms will drive further efficiencies. The most interesting part of the document however, in my opinion,

December 2014

was the drive to empower care professionals regarding data and technology. More power is set to be put in the hands of chief clinical informatics officers (CCIOs) which is a welcome development. For too long, the UK has lagged behind the USA (who have had widespread ‘physician executives’ for some time) in bridging the gap between information technology and front-line workers. The rise of the CCIO in the UK is certainly a good start, but I do believe we need to pay far more attention to the adoption and diffusion of technology than the technology itself which sounds like an odd statement, but is backed up by theory and personal experience. A paper released in 2008 called All Change Please detailed the spend, of the NHS, on new ideas (not limited to technology). £2.4 billion was spent on the creation of new ideas, but only £0.15 billion on the spread and implementation of these ideas. I believe there needs to be central and local mandates to address this gap. My oft-repeated phrase I use in my consulting work is that the technology works 99.9% of the time, so why isn’t it being diffused in 99.9% of institutions? As with the majority of inventions, leadership is always the key factor. An IT colleague of mine at a prominent London NHS Trust, recently visited Boston Children’s Hospital, where every decision, protocol and management plan is developed through constantly revised data which is generated at every step of the patient pathway. As a result, patient care plans are altered and augmented almost by the week, as analytics platforms throw up better ways to improve patient flows and devise treatments. Of course, this is not an easy state to reach quickly, it requires strong leadership but

also buy-in and engagement at all institutional levels from the consultants down to the porters, not to mention appropriate incentivisation (consultants are part paid to engage in the IT programmes specifically). This is where I would love to see a sea change in how we view technology as a whole in the healthcare context. Specific funds and schemes for technology procurement are undoubtedly welcome, but central funds allocated to, and local institutions concentrating on, implementations rather than just procurements would help to optimally realise the benefits of technologies, reduce clinical disaffection with technology and actually save huge amounts of time and money in the process. A co-ordinated effort between vendors, hospitals and central bodies would ensure technology becomes the foremost driver in healthcare improvement, which we all know it can be. n

We want to hear from you The thoughts and ideas of our readers and subscribers are essential to us at The Journal of mHealth. We want to hear your opinions on the mHealth industry. Contact us at journalofmhealth@ simedics.org The

Journal of mHealth The Global Voice of mHealth

Building an Ecosystem for mHealth Adoption

Building an Ecosystem for mHealth Adoption Demand for digital and mobile health solutions from all sources is rising. Developing an ecosystem around digital can, however, be problematic. Organisations like the UK’s NHS have recognised that digital solutions and technology-led services can help deliver new and innovative methods of care delivery, but they are often ill-equipped to bring together all the necessary stakeholders and suppliers to develop effective projects. In this article Victoria Betton, Programme Director at the mHealthHabitat discusses how the Leeds (UK) based mHealthHabitat has been set up with the purpose of developing a unique ecosystem designed to solve some of the issues surrounding digital adoption. The mHealthHabitat programme was established in Leeds at the beginning of 2014 to support digital innovation for improved patient experience and outcomes and more effective and efficient services fit for the digital era. The programme works across Leeds Community Healthcare NHS Trust and Leeds and York Partnership NHS Foundation Trust.

Our Approach We chose the name mHealthHabitat to reflect how the programme endeavours to create an ecosystem in our city where mobile health can flourish. We have approached this in four ways: Tactical –‘learning through doing’ which involves identifying services keen to engage in digital innovation and working with them through the process from initial idea through to deployment. This includes carefully identifying problems services want to solve through to contracting with suppliers and advising on issues such as intellectual property and integration. The team provide project management support to each initiative. Habitat – creating an environment in the city for mHealth to flourish which comprises opportunities for the design and developer communities to connect and collaborate with people accessing services, clinicians and academics. The habitat includes regular free ‘show and tell’ evening events; discovery days based on ‘hack’ principles; workshops and talks; horizon scanning; brokering collaborations between different sectors both locally and beyond; development of a systematic approach to mHealth innovation through a digital innovation pathway. Strategic – embedding mHealth within transformation projects and the strategic direction of the NHS in Leeds, collaborating with city-wide initiatives such as Smart Cities, as well as influencing national policy and strategy. Citizen involvement – the digital innovation pathway employs user-centred design and coproduction approaches to ensure people who will benefit from mHealth innovations are fully involved from the outset. We have established regular ‘heart of the habitat’ breakfast workshops which invite people accessing services and citizens to steer the direction of the programme. The website www.mhealthleeds.co.uk and Twitter

December 2014

account @mHealthHabitat are used to share learning as well as create transparency and accountability. In this highly emergent field, the habitat approach ensures that learning happens once and can be applied in many different contexts as well as scale where appropriate. Working across two NHS Trusts enables us to spread the benefits more widely across services for the benefit of the citizens of Leeds.

Our Model As our approach has developed, a model has emerged that provides a simple framework for the mHealthHabitat team to support clinical services. The model has four components: Catalyse – supporting clinical services with bright ideas, wicked problems or hunches they want to test out to investigate if digital can be part of the solution. This space involves discovery days, rapid prototyping and activities which bring people accessing services, clinicians, designers and developers together to share learning, explore and create. Incubate – an incubation space in which projects are defined and prototypes developed using agile project management methodology. This space involves market research, business cases and grant applications, contracting with suppliers, and managing the end-to-end app development process including various options from licensing through to build. Adopt –supporting adoption of existing products in the market or products which have been developed in the Incubate space. This space involves adoption, deployment and iteration of mobile apps and includes evaluation, research and development. Embed – ensuring the sustainability and alignment of mHealth with organisational and city strategic priorities. This space involves supporting city leaders to embed digital within transformation programmes and strategies. It entails cross-organisational bids to bring resources into the city that support mHealth innovation. It involves influencing national policy and ensuring mHealth in Leeds has a place on the national and international stage, building the reputation of the city and supporting the LIHH objective to bring inward investment. A key benefit of the mHealthHabitat approach is a focus relationship development and brokerage with a range of parties from academic institutions through to industry, bringing collaboration and innovation to the city.

Empowering Patients: How the mHealth Vision has become a Reality Where we are now We are finding an appetite from clinical services to integrate digital into service transformation based on an awareness that the expectations and digital literacy of people accessing services is changing all the time. We are working closely with corporate functions to remove barriers and enable even the most simple of innovations, such as e-clinics using Skype type tools, to be realised. Our most developed innovation is an app prototype which enables people accessing the Yorkshire Centre for Eating Disorders to set goals and share food tracking with their clinician. We are also currently in the process of building a bespoke SMS system that enables our Assertive Outreach team to keep low level contact with people who are often unwilling recipients of care; the aim is to create more acceptable and supportive channels of communication. We have just received funding from commissioners to run an 18 month ‘Digital Innovation Lab’ led by young people to develop digital tools for mental health and wellbeing in the city. These are just a few of many projects we have in various stages of development.

At the time of writing we are currently planning our fourth ‘Discovery Day’ which will bring a range of clinical services together with designers, developers and academics to prototype digital artefacts. Using hack and service design approaches, the day aims to accelerate innovative ideas and enable clinicians to address wicked problems.

Future plans We are now nine months in to the programme and our key priority is first and foremost to deliver and deploy the digital tools that we have been busy building. Secondly, we are focusing on options to sustain and develop the programme over the next 12 months. If you’d like to find out more about the programme or are interested in collaboration we’d love to hear from you! Victoria Betton is Programme Director at the mHealthHabitat. If you would like to find out more about the mHealthHabitat you can follow on Twitter @mHealthHabitat or go to the website at www.mhealthhabitat.co.uk. Get in touch directly at mhealthhabitat@gmail.com n

Empowering Patients: How the mHealth Vision has become a Reality ByTim Davis, CEO and Founder, Exco InTouch There is overwhelming evidence that all over the world the cost of healthcare is rising; it is estimated that chronic conditions account for more than 75% of healthcare costs in the USA[1], whilst in the UK non-adherence to medications is said to cost the NHS over £500M per year[2]. Looking back at the historical problems facing patients trying to control and monitor their conditions, it is clear that improvements were not only needed – they were essential. The facts laid themselves bare: a basic lack of patient engagement; the inability of the patient to access their medical data; the patient not being supported with the right information at the right time; little or no transparency on their conditions and what their treatments would require; and poor access to the healthcare professionals. It is for the benefit of not only the patient, but the entire healthcare industry that these mistakes are eradicated, and that steps are taken to approach the treatment of chronic conditions in different, more innovative ways. The numbers involved are quite stagger-

ing. Taking diabetes as an example; in the US alone, there are around 24 mil-

lion diabetes sufferers. While 18 million of those are diagnosed, only 15 million actually receive treatment. Of that number, as little as 6 million patients are well controlled and feel as though they are on a journey that will lead to them taking charge of their condition. This is not just a concern for patients, but also the healthcare professionals and payers. It is estimated that increased patient engagement could decrease care costs of the US diabetes patients from as much as $8,867 to $4,570 per year, resulting in a $4,297 saving per patient[3]. Simple economics show us that by engaging with the patient in a way that will help them understand their condition and empower them to monitor it remotely, not only can the patient take charge of their own lives, but this cost will come spiraling down. Enter mHealth: leveraging mobile technology to engage patients Mobile technology is ideally placed to help meet this challenge. Access to mobile and digital technology has seen huge growth in recent years; there are Continued on page 24

The Journal of mHealth

Empowering Patients: How the mHealth Vision has become a Reality Continued from page 23

estimated to be 6.9bn mobile subscriptions globally and 96%[4] of the world population is now said to have access to mobile technology. Alongside this growth, the use of mobile technology has changed dramatically across the globe; from checking bus timetables through to highly regulatory activities such as mobile banking, we expect to use phones to find information and complete transactions as part of everyday life, and healthcare is no exception! As a result, mobile technology is being implemented across the world to help patients manage their conditions, with the mHealth market estimated to have reached $4.5 billion in 2013[5]. The term ‘mHealth’ is often used to describe the rapidly growing market for health and wellbeing apps. This market is predominantly consumer facing, and typically consists of relatively basic services with a singular focus; activity tracking, diet monitoring or providing condition specific information. As a result, these limited scope apps can often be static and research has found that user attention span is relatively short-lived with an average of only 3.7 uses per week, and less than a third of users are retained for 90 days[6]. So, if mHealth is to truly revolutionise health outcomes, there needs to be a paradigm shift in what it can achieve in terms of patient engagement. mHealth is not simply about patients downloading apps to their mobile devices which do nothing more than display simple metrics; it is all about providing dynamic programs that help patients, and those providing their care, to manage their conditions and improve health outcomes. The key to a successful mHealth program is to engage patients over extended periods of times. This can be done by building integrated systems that use a variety of input materials (medication tracking, medical or lifestyle device data) and patient assessments – diaries and questionnaires – to tailor responses, which, for example, could be dashboards, content on a portal or automated alerts to Healthcare Professionals (HCPs) to make the service interactive and personalized in order to engage the patient over extended periods of time. A truly personal service to overcome health challenges Traditionally, the support offered to

December 2014

patients trying to manage their own conditions was somewhat limited. Not any longer. At Exco InTouch, we work with our clients to create a condition-specific care plan using a modular approach to select the most appropriate tools for each program, including data capture, education, alerts and goals. Each solution is adaptive, meaning that data summaries are tailored to each user (patient, caregiver, HCP, payer), and this capability can be expanded to enable the solutions to evolve over time as the condition progresses. Our platform also allows us to integrate apps and connected devices, such as blood glucometers, bar code scanners, activity trackers and other wearable technology, enabling patients to participate using devices that fit with their lifestyle. The growth of mHealth is enabled by the adoption of a Bring Your Own Device (BYOD) approach, which promotes user familiarity and integrates healthcare regimens into a patient’s everyday life, enabling them to use their own communication devices. Consequently, mHealth services are now able to deliver phenomenal results for healthcare payers without the cost burden of telehealth services that have previously been implemented to provide patient support and monitoring. However, to safely implement the use of patient’s own devices, payers must ensure that Personally Identifiable Information (PII) is protectedin accordance with the regional data privacy requirements, such as HIPAA, Safe Harbor and EU data protection guidelines, all of

which Exco InTouch’s systems comply to. By taking advantage of these mHealth solutions, patients are able to personalise the service through goal setting, for example reduced days off work or sleeping comfortably through the night. This can also be used to build reward through community activity, such as patients working together to walk the distance from Paris to Rome, often a more rewarding achievement than simply setting a personal goal of taking 10,000 steps a day. As a result of providing easy to use and personalised solutions which can easily integrate into everyday life, the use of mobile technology across the healthcare sector as a whole is able to facilitate improved patient adherence, whilst reducing burden on hospitals and clinics. As importantly for patients, the recent advances in best practice for mobile data security and privacy in other industries, as exemplified by the widespread adoption of mobile banking, offer peace of mind and solid vindication that solution providers are able to address all the necessary regulatory requirements. Case study: ‘Me&MyCOPD’ Having recognised the opportunity to enhance the traditional role of the pharmaceutical industry, AstraZeneca are pioneering the development of these ground-breaking integrated health programs having announced their strategic Continued on page 26

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.

Empowering Patients: How the mHealth Vision has become a Reality Continued from page 24

initiative, ‘Intelligent Pharmaceuticals’, which will be implemented across a number of key therapeutic areas globally. The first program to be announced publicly is ‘Me&MyCOPD’, which is initially being rolled out in the UK to support COPD (Chronic Obstructive Pulmonary Disease) patients. ‘Me&MyCOPD’ is an integrated health solution designed to support each individual patient towards better medication and lifestyle management, providing personalized selfmanagement tools for the patient which responds to the individuals needs in the right way, at the right time. The program uses a mobile and internet based platform to capture information, manage medication and support the patient’s existing COPD care-plan, integrating HCPs into the end-to-end process. Ultimately ‘Me&MyCOPD’ empowers patients to take control of their condition and self-manage to improve their health outcomes. Information provided to the patient can be accessed in a variety of ways, whether through internet portals or mobile devices. This real-time interaction means that not only can the patient’s adherence to treatment regimens be monitored, but the patients themselves can be assured that, if their condition does worsen, they will receive further support and guidance and, when necessary, an intervention can be staged, and referral to their HCP can be made.

The ‘Me&MyCOPD’ program rolled out by AstraZeneca and Exco InTouch not only improves the long-term engagement and the pro-active management of COPD among individual patients, it provides a comprehensive system to all of the stakeholders within the healthcare system, including caregivers, HCPs and healthcare payers. The program is the first to employ a personalised, truly mobile approach to monitor, support and empower patients to take control of their condition, utilising their own communication devices. Moreover, the program ultimately allows AstraZeneca to focus their efforts to deliver new medicines that will address unmet needs by expanding their understanding of how patients use and respond to various treatment options. This underpins the ‘Intelligent Pharmaceuticals’ strategy adopted by AstraZeneca and is a leading example of how optimised treatment can improve patients’ quality of life and health outcomes. Defining the future of healthcare As we have seen, the emerging market for mHealth services holds within it the potential to revolutionise how the world will manage health and wellness in the 21st century. Patients need access to information, they need to feel connected, to better understand their condition, be empowered and ultimately to enjoy better health outcomes. Advances in mobile technology, and the growth of access to it around the world, now

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December 2014

References 1. Centers for Disease Control and Prevention http://www.cdc.gov/chronicdisease/ 2. Pharmatimes “Drug nonadherence "costing NHS £500M+ a year" http://www.pharmatimes.com/ mobile/13-02-19/Drug_non-adherence_ costing_NHS_%C2%A3500M_a_year. aspx 3. World Health Organization (2010), “Global status report on non-communicable diseases” 4. International Telecommunication Union (2013), “ICT Facts and Figures: The World in 2013”, http:// www.itu.int/en/ITU-D/Statistics/ Pages/facts/default.aspx 5. GSMA & PWC (2012), “Touching lives through mobile health report” 6. App Engagement: The Matrix Reloaded http://blog.flurry.com n

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enable the development of programs to support patients using their own devices. As a result, patients have access to the information they need when and where they want it, data can be captured simply and easily, and analysed to provide valuable feedback and alerts to the patient, their caregivers and their HCPs. This adaptive combination of remote monitoring, motivation, education and reward empowers patients to take control of their health conditions, reducing the burden of healthcare for payers, improving health outcomes and ultimately leading to improved quality of life for patients.

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Journal of mHealth The Global Voice of mHealth

Conference News International Digital Health Experts to Attend UK Innovation Conference Internationally renowned digital health experts are set to attend a three day open innovation conference in the UK. Digital Health Assembly: Open Innovation will take place from February 10-12 at the SWALEC Stadium in Cardiff and is expected to welcome delegates from the digital health community worldwide. Focusing on the key themes of Big Data, Empowering Patients and Staff and Innovative Business Models, the event will bring together leading individuals from the rapidly developing digital health sector to highlight the opportunities available to create sustainable health-

care if open innovation is embraced. Included among the 35 speakers at the three day conference include Professor Dipak Kalra Clinical Professor of Health Informatics at University College London and President of The EuroRec Institute, Chris Fokke Chief Clinical Information Officer at Hampshire Hospitals NHS Foundation Trust in Basingstoke, Professor George Crooks OBE, Medical Director NHS 24 and Pēteris Zilgalvis, J.D., Head of Unit, Health and Well Being, Directorate General Communications Networks, Content and Technology at the European Commission. Jointly organised by eHealth Industries Innovation (ehi2) Centre, College of Medicine, Swansea University and the Medical Research Council funded The Farr Institute of Health Informatics Research, the three day event will focus on the topics of Empowering Patients and Staff, Big Data and Innovative Business Models through a series of workshops, presentations, roundtable discussions and innovation sessions. Each conference session will explore the potential that open innovation can have on organisations operating within the digital health sector with an industry report created following the discussions had throughout the conference’s unique daily discussion format.

Each day roundtable panellists will ignite a discussion which will open out onto the floor for wider deliberation via a hot topic panel discussion. Delegates will then be invited to continue debating the topic and potential solutions in innovation sessions. Speaking ahead of the conference, Conference Chair Professor David Ford, Professor of Health Informatics at Swansea University said, “Digital Health Assembly: Open innovation will bring together a diverse collective of innovative minds from the healthcare and technology sectors worldwide, with a view to establishing new cross sector partnerships and opportunities.” Edwina Hart, Minister for Economy, Science and Transport said: “I am delighted that support from the Welsh Government helped bring this importance conference to Wales. The value and importance of developing a culture of Open Innovation is wholeheartedly supported by the Welsh Government as collaboration and sharing of ideas can deliver further technological breakthroughs and real business benefits.” For futher information on the event and to register visit www.digitalhealthassembly.com Email info@digitalhealthassembly.com or follow the event on Twitter at @ DHAssembly n

The Journal of mHealth

Conference News

Digital Health Community Comes Together for mHealth Summit 2014

The Journal of mHealth team was pleased to be able to attend this yearâ&#x20AC;&#x2122;s HIMSS mHealth Summit, earlier this month. The event, which is the largest of its kind in the industry, gathered together a uniquely diverse international delegation, representing all areas of the mobile and connected health community. For anyone who was unable to attend the event or who missed parts of the packed schedule, we have compiled a round-up of some of the key topics on discussion which ranged from wellness, fitness and disease management to population health, clinical trials, emergency services, regulation, public health, investment, healthcare access and disparities.

The Market for mHealth A significant focus of the event was on key market trends and the potential future growth areas in the mHealth arena. Speaking in the panel session â&#x20AC;&#x2DC;Untapped mHealth Marketsâ&#x20AC;&#x2122; Milos Todorovic of Lux Research made some very interesting points that related to some of the developments we can expect in the mHealth market, in the foreseeable future. One of these predictions was that as the acceptance of digital within healthcare environments begins to mature, we are likely to see a significant shift in the size of the market for clinical facing solutions, rather than purely consumer based services and products.

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This is significant, as in recent years investment and healthcare venture funding has tended to focus on digital solutions targeted at a consumer audience, as the barriers to widespread adoption in the consumer space are generally less than their clinical counterparts, and as such solutions can often be commercialised more rapidly. Todorovic suggested that, going forward, this consumer audience will remain attractive given the size and potential returns, but that the future of the market may present its own set of difficulties. One particular problem in the consumer space is that usage often wanes very quickly, leaving solution developers to continually work on new ways of encouraging consumers to engage with a product or service. Todorovic therefore recommends that digital health developers approach this issue by developing platform based technologies, built around established products and services, that will allow them to target an initial audience of consumer users, whilst being flexible enough to allow them to, in the future, pivot towards the clinical audience, as this market matures. Developers should try to incorporate features that prepare for this clinical transition from the early stages. This could mean, collecting evidence (beginning with the results of small pilot trials before gradually introducing more robust clinical trial data), preparing for regulatory conditions,

Conference News

and matching services to existing reimbursement mechanisms. Data presented during the session also highlighted a number of niche markets within the clinical solution segment that are likely to offer significant potential for future growth, these included: vital sign monitoring technologies, in vitro diagnostic devices/ solutions, and imaging. Speaking in the same session Jody Holtzman of AARP reinforced this need to consider which areas of the market are most likely to be able to pay for digital services. Holtzman presented AARP research that identifies how solutions that target certain aspects of the consumer digital health market have a much greater potential for success. For example, an emergency detection system may primarily target the elderly, but it will have a significant secondary market for younger family members or care providers who are looking for peace of mind. This obviously increases the market potential for adoption and ultimately revenue generation. Some of these growth sectors identified

by Holtzman include: medication management, social engagement, physical fitness, ageing with vitality, care navigation, diet and nutrition, behavioural and emotional health, and emergency detection.

Reimbursement Reimbursement will ultimately be a factor that ‘makes or breaks’ many patient facing mobile and digital health initiatives, particularly in the US market. In general there seemed to be optimism amongst delegates at the conference, following the recent announcements that CMS may look to begin reimbursing physicians who deliver home based chronic care management, remote patient monitoring of chronic conditions and other services provided via telehealth. It seems that the prospect of receiving significant financial compensation for deploying telehealth and remote monitoring solutions could encourage many physicians to rethink the use of these technologies. In his keynote speech Dr. Harry Leider the Chief Medical Officer and Group VP for Walgreens’ proposed that, in his opinion, solution developers need to look to payers as a key part of their market strategy, rather than simply targeting the consumer sector. In fact he went so far as to suggest that some of the predictions for growth in the consumer digital health market, particularly relating to wearable technologies were vastly overambitious, and unlikely to yield the expected returns. This sentiment of caution towards the so-called ‘consumer boom’ in digital health solutions, was echoed at other sessions during the event. Leider reinforced his remarks by suggesting that developers need to consider adopting strategic business models that can provide both conveniences in the market place as well as demonstrating genuine cost reductions for payers. He continued by saying that any tangible cost reductions need to be delivered within a 12 to 18 month window as people in the US tend to change care plans each year, resulting in a 20-25 per cent turnover rate. Therefore, health plans are unlikely to invest in solutions, like a health and Continued on page 30

The Journal of mHealth

Conference News Continued from page 29

wellness plan, that may only deliver a return on investment years down the line.

Strategic business models The need to consider new business models centred on digital solutions was also discussed at the mHealth Summit Pharmaceutical, Pharmacy and Life Sciences Roundtable session. Eddie Chan, Vice President of Mobile Health at Sanofi suggested that whilst demonstrating beneficial clinical outcomes is always a priority, it must be accompanied by the design of effective user experiences that are capable of engaging and building relationships with the user. Without these, solutions are destined to fail to become a meaningful tool for a patient or user, which in turn means they are unlikely to deliver any real tangible benefit.

Developer insight A range of solution providers were represented at this yearâ&#x20AC;&#x2122;s event who have taken this exact approach. We met with Jon Michaeli, CMO at MediSafe, during the conference, to learn how they have applied a platform approach to the development of their medication management solution. Targeting cross-market segments of consumer users, physicians, and pharmaceutical manufacturers the MediSafe solution has been built as a platform that can be leveraged in a wide variety of ways. Helping, primarily, to improve medication adherence, but simultaneously providing actionable data to help drive improved outcomes, cost reductions for physicians, and deliver real-time intelligence to enhance the complete pharmaceutical vertical from manufacturer, through to the person taking a particular medication. As well as effectively helping deliver medication adherence, the MediSafe solution incorporates educational and learning modules, as well as social elements to help maintain regular engagement, and to provide beneficial insights into a personâ&#x20AC;&#x2122;s medical conditions. The platform also works as a tool for physicians in that it can provide real time data on the behaviour of patients in relation to medications, highlighting actionable events or correlations with other data sources and in turn deliver greater intelligence to the medication process.

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Showcase of solutions The expansive exhibition floor was one of the highlights of the Summit, with a complete range of products, solutions and services on show. Major names in connected healthcare such as IBM, Symantec, Qualcomm Life, Samsung, and Nonin, were present alongside less well known start-ups covering everything from remote patient monitoring to compliance management. Pavilions like the Startup Showcase, featuring 70 new and emerging companies as well as incubator and accelerator programs, received heavy foot traffic from delegates keen to experience and learn about the latest mobile and digital offerings. Other featured areas on the exhibition floor included the Walgreens sponsored Consumer Engagement and Wearables Pavilion, the Games for Health Pavilion, the mHealth Showcase, and the Qualcomm Life Ecosystem Pavilion.

Collaboration to deliver digital solutions The many benefits of developing strategic partnerships and industry collaborations were clearly on show at this yearâ&#x20AC;&#x2122;s event. Perhaps more so than any other industry, technology developers and solution providers in healthcare, must come together with provider organisations, payers, and patients if they stand any chance of gaining significant traction in the highly idiosyncratic

Conference News

health industry. Ecosystems that connect networks of stakeholders are proving to be an effective method of delivering change. By providing standardised information flows, cross-network interfaces, and consistent user experiences, ecosystems like the Qualcomm Life 2net network aligns all the relevant interfaces to allow stakeholder partners to access a convenient, facilitated, environment. What was interesting at this yearâ&#x20AC;&#x2122;s event was the significant number of ecosystems that are beginning to form around different parts of the connected health community, as a means of improving access to solutions.

Interoperability Information exchange and interoperability of systems always tends to be a regular discussion topic as this type of event, and it was clear from a number of panel sessions as well discussions with delegates on the exhibition floor that this remains an important question in the digital health equation. We spoke to a range of service providers, exhibiting at the event, who are developing solutions designed to try and reduce some of the difficulties surrounding this issue. Of particular interest was a discussion we had with Thanh Tran CEO of Zoeticx, a digital health technology company that has developed a proprietary middleware solution designed to improve the flow of information within healthcare information systems. Middleware can be described as the software layer that lies between the operating system and the applications on each side of a distributed computer network. Typically, it supports complex,

distributed business software applications. Middleware has been deployed extensively in manufacturing and financial industries for a number of years, with the purpose of facilitating information flows, yet it is not something that has been widely used in the healthcare setting. Zoeticx have created an EHR agnostic solution on a mobile platform, which can facilitate providerpatient and provider-provider communication, which in turn Tran hopes will foster an ecosystem that will allow developers to concentrate on building effective solutions, rather than having to constantly redesign solutions to work with different existing networks. Interestingly, Zoeticx are also leveraging mobile functions, such as Near Field Communication to provide novel (onetime authorisation) access methods to existing patient health information, wherever that may be in the myriad of EHRs and different medical information storage silos.

Funding issues Securing finance and venture funding was the primary topic for the Venture+ Forum Pitch Session, which saw twenty-two early-stage companies, and the entrepreneurs behind them, participate in a rapid-fire presentation session, designed to inform the audience about provider and patient solutions for improving health outcomes and allow them to hear from leading investors about mobile health funding trends.

Regulation and data stewardship The evolving regulatory landscape surrounding mHealth was also well represented on the Summit agenda. Navigating FDA guidelines as a mHealth solution developer remains a difficult process despite a number of announcements made this year aimed at clarifying the issue. Similarly, privacy and security concerns surrounding data collection, transmission, access and use are frequently areas of concern when it comes to digital health. Developing a robust data and information risk management strategy is now an essential strategic task for any mHealth company. Panel sessions dealing with data privacy, ownership, liability, and cyber security were well attended as delegates sought to gain a greater understanding of the underlying issues and the relevant regulations and guidelines. n

The Journal of mHealth

Tackling the Myths about Patient Data & Use of Technology with mHealth

Tackling the Myths about Patient Data and Use of Technology with mHealth

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. I recently sat at a conference in the UK and heard some of the same statements that I have heard in the past rear their heads again, I had hoped they had been dealt with and we had moved on but it would appear not. "We don't want to collect too much data about the patient we wouldn’t know what to do with it, it would swamp us, and besides we don't need it.” Clearly when it comes to collecting patient data, both information that the process has collected in an automated fashion but also information entered by the patient, we have to make sure that this data is encrypted and delivered into the appropriate locations safely and securely, while also be cognisant to the fact that we are holding sensitive data about the patient. However, here is where it gets interesting for me, too many people say ‘we don’t want lots of data just tell me the following things and I don’t need the rest.’ At no point has Amazon or Google, just to name a couple, decided to stop col-

lecting data about my usage on the internet when searching for things or when shopping. They haven’t gone – ‘oh look we have too much data about Keith’s shopping habits lets stop collecting it now we know all there is to know about him.’ No, they continue to collect the data that I produce, with my authorisation, and they then make sure that the services and the offerings that they give me are as tailored, and as personal, to me as possible as that delivers me the best service. Why is healthcare different? We should be doing exactly the same with patient data. Keep collecting the data we have permission for and then we can study it on a personalised, and a non-personalised, level to help us better understand lots of things that we always need to know more about: »» How the patients find the system they are using »» How does it let them live their lives in a way that they want to - freedom etc

»» When their conditions are better and when they are worse »» What triggers these episodes »» How can we better manage our populations by understanding their needs and requirements

Then we can start tailoring better healthcare services to those patients. Come on. Let’s not lose out on what might be one of the best opportunities to study healthcare, patient outcomes and services that we might ever get. "We can't use mobile phones and tablets with patients as older patients don’t like them and they certainly can’t use them." Technology is spreading so rapidly across all age groups currently and yet this misnomer seems to come up again and again. I have deployed systems and seen people into their nineties using technology like tablets and

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

December 2014

Philips and Breast Cancer Care Partner to Launch Breast-Check App smart phones to manage their lives. Someone better than me once said "the mobile phone is the new remote control of life" and they are right - it is becoming exactly that. The over 65's, in the US, is the fastest growing sector for tablet purchases in the US and given that, now, around 90% of all phones shipped by telecoms providers are smart phones, at some level we should be taking this

opportunity and really making the most of it. Yes, patients may need some training and some help with these systems until they get comfortable but instead of asking patients to take on bits of large, poorly designed equipment and then tether themselves to it with wires or broadband why don't we let patients us the device they already have in their hands, that they chose

and liked, and take them on a journey which helps them use mhealth and all of its virtues to deliver a better quality health provision for themselves, in their own way, on their own terms, and with their own devices. I am hoping that sometime soon when I visit another conference we might have put some of these myths to bed once and for all! n

Philips and Breast Cancer Care Partner to Launch Fully-Interactive BreastCheck Application Philips, in conjunction with the charity Breast Cancer Care, has recently launched an updated and fully-interactive version of their innovative Breast Cancer Care mobile app. The updated app builds on Philips commitment to raising awareness of breast cancer, by providing trusted advice whilst making it easier for women to identify areas of concern. It also forms part of a wider strategy by Philips to continue to deliver market-leading innovation, with Oncology and the prevention, diagnosis, and treatment of different cancers forming a significant area of focus for the company. Breast cancer is the most common form of cancer in the UK with around 55,000 people diagnosed each year. Early detection and diagnosis can save lives and potentially leads to better treatment outcomes. Knowing that many detections start with a self-examination, the Philips Breast Cancer Care app is designed to take the user through the process with simple, easy-to-follow, instructions whilst providing vital education to encourage regular checks and to help users become more breast aware. Alwena Hall, Marketing Manager for Philips Healthcare UK comments, “Philips is dedicated to empowering patients so that they can positively manage their health. Our updated app makes it easier to check for symptoms on a regular basis, to help protect breast health, and our technology provides increased comfort and confidence for people who may be undergoing breast cancer screening.” The aim of the app is to get people to think about each different potential symptom, and to consider whether they may have a problem in that area. It will then help people to identify any areas of concern, and then direct the user as to what to do as a result of those concerns. This most recent version of the app has been updated to make it more mobile-friendly, and the user experience has been enhanced with a more visual and interactive

solution, which in turn makes it easier for people to understand. “Philips has a mission and a vision of saving and improving the lives of 3 billion people a year by 2025. We do this by providing a whole host of solutions across the healthcare continuum, from healthy living through to screening, diagnosis, therapeutic treatment and home healthcare. This app helps us towards that aim, by being at the early end of that healthcare continuum in the healthy living and prevention area.” says Hall. “We are trying to empower people to look after their own health & well being, which we feel is an important part of that vision. We also do a lot of work in the Oncology arena, so it is natural to look at how cancer, and particularly breast cancer in this issue, can be diagnosed as early as possible. One of the ways of doing that is to educate people in breast awareness, by telling them what to look for and to encourage people to do regular checks, so that they can identify any areas of concern, as early as possible.” Continued on page 34

The Journal of mHealth

Philips and Breast Cancer Care Partner to Launch Breast-Check App Continued from page 33

Chris Varian of the Women’s Healthcare division at Philips comments, “Philips has a very positive position with breast cancer screening services, both here in the UK and globally. In the UK, a total of about 2.5 million women are screened per year, between the ages of 50-70, and about 20% of all screening is done using Philips low-dose, high volume, breast screening systems. The reason screening is done across this age group is that roughly 80% of all breast cancers diagnosed, fall within that age range. This means that you still have roughly 20% of women who are outside of that age range where there isn’t national breast screening available. By using this app, we are hoping to educate people to be aware that there is a risk, but that it is quite low, and to help people to be more aware of themselves and their bodies, so that they understand when something isn’t right, and if necessary then refer themselves to their GP.” Education is at the heart of the Breast Cancer Care mobile app. “We have worked very hard to make the messaging clear. The education area is important, there are several things that you need to look for and check, and we have outlined these in a simple and clear way.” said Hall. “Whatever your age, size or shape, it’s important to take care of your breasts. Getting to know how your breasts look and feel, so you know what is normal for you, is an essential part of caring for your body. Around two thirds of breast cancers are found by the patient, so it’s important to notice any unusual changes and report them to your doctor without delay." said Dr Emma Pennery, Clinical Director of Breast Cancer Care. The charity Breast Cancer Care has been involved with the project right from the start, helping to provide content, develop appropriate messaging, and to provide support for users who may have any concerns or worries as a result of using the app. Alwena Hall describes how having a strong partnership from the beginning has helped to shape the app development, and ensure that it fits with the messaging available from other sources and healthcare professionals. “We wanted to make sure that we were consistent with the messaging out there from other healthcare professionals, and with the Department of Health and NHS England guidelines in terms of breast cancer care. We think that it is important to work with a charity like Breast Cancer Care in terms of helping to share the messaging and to give support should people need it.” Alison Raven, Breast Cancer Care Editorial Manager said “We were delighted when Philips approached Breast Cancer Care with the idea to create

December 2014

the app, we’d previously helped them source some images to explain breast awareness. They wanted to make people more breast aware as well to help raise money by offering an option to donate to Breast Cancer Care. We assisted by ensuring the messaging was correct and our clinical team checked medical content. We thought this was a great opportunity to develop an app to get our name out there as the UK’s leading provider of breast cancer information and support, and also to further spread the breast awareness message.” “We hope people who use the app will become more breast aware and will understand the signs and symptoms of breast cancer. By using the app we are hoping to reach people with the breast awareness message who might not have seen our print or online information. We also hope people will know more about us as an organisation and will know where to turn for support if they are ever affected by breast cancer.” This type of digital engagement is just one of many products and solutions that Philips is introducing across a variety of healthcare disciplines. When it comes to Oncology, Philips is already a leading solution provider, but the company hopes to increase their offerings, with a variety of new products and services, that target not just Women’s health but all areas of prevention, diagnosis, and treatment, from simple diagnostic tools like the Breast Cancer Care app, to low dose mammography with MicroDose SI. This includes trialling a first-of-itskind Minicare Home Monitoring service designed to provide improved treatment monitoring for chemotherapy patients that can potentially result in reduced hospital visits, cost savings, and a better patient experience. “Philips is investing considerably in both digital and Oncology technologies” says Hall. “We are producing a lot of new products, technologies and software, from both the consumer perspective and the healthcare professional perspective. We see technology as an important method of helping to provide better care at lower cost.” n

Could Robotic Nurses Help in the Fight Against Ebola?

Robotic healthcare technologies are about to get what may be their biggest and most important showcasing opportunity in the battle to fight Ebola. America’s brightest technological minds have begun brainstorming with healthcare and relief workers to consider the role that autonomous machines might play in combating the Ebola crisis. These new technologies may not be to everyone’s taste. The aim, to put it bluntly, is to industrialise human care. But under discussion is also how to augment it - by developing autonomous systems to not only look after those afflicted, but to also alleviate their suffering and provide protection for their carers. The delivery of food and medicine to the sick, the decontamination of equipment, the burial of the dead, these and many other applications could - theoretically be carried out through telepresence and robotics. How to implement, organise and deploy such technologies with sensitivity has been the subject of a series of conventions across the US, part-organised by the White House Office of Science and Technology Policy.

rom a technological standpoint, the best way to fight Ebola is for the healthy to distance themselves from those who have contracted the disease, this means removing human interaction in the care of the sick. But the prospect of being isolated in quarantine is also preventing people from seeking help, according to Taskin Padir, an assistant professor of robotics engineering and electrical and computer engineering at Worcester Polytechnic Institute (WPI), one of the convention’s organisers. “Companionship through telepresence could be a tool to maintain quarantine conditions,” says Padir. “People are afraid to show up to hospitals because they'll be put in quarantine, and you're left alone and you're away from loved ones. Anything we can do to improve the situation in quarantine, we are open to exploring.” Care providers currently have a 30-step process to follow, in order protect them, prior to contact with someone who has contracted the disease. Robots could augment this by provide interactive checklists—similar to those used by air-

craft pilots for take-off and landing—to medical workers who are putting on and removing safety equipment. They could also act as interpreters between doctors and Ebola sufferers. The industry is understandably reluctant to ride on the coat tails of disaster, but the very scale of the Ebola crisis could see the advancement of technologies fast-tracked. For instance, US company Xenex which produces robots with ultraviolet light to destroying a virus’ or bacteria’s DNA is currently in discussions with the US Department of Defence and several relief organisations about deploying the systems to Africa. The company is also talking with several major airlines about disinfecting cabins. Xenex robots are already in use in over 250 US hospitals. But there is much work to be done and research efforts begun now may not bear fruit until the next epidemic, according to a number of the researchers. Continued on page 36

The Journal of mHealth

Canadian Researchers Create 'Black Box' for Use in Operating Rooms Continued from page 35

Although autonomous machines have long been used for targeted purposes like surgery and tasks such as disarming bombs, artificial intelligence is still nascent. This means that human dexterity, for instance, is still difficult to reproduce in a computer programme. "As was the case in Fukushima, the Ebola crisis in Africa has revealed a significant gap between robot capabilities and what is needed in the realm of disaster relief and humanitarian assistance,” Gill Pratt, a roboticist at DARPA, told the New York Times. “We have a moral obligation to try and select, adapt and

apply available technology where it can help, but we must also appreciate the difficulty of the problem.” As well as the robots themselves there are contextual challenges: what training will the locals need to operate the robots? How will batteries be recharged? Are Internet connections available? Is the ground hard or muddy? These issues are in addition to potentially negative public attitudes towards robots handling of loved ones or performing undignified burial practices. But as the crisis escalates, what was previously unthinkable and/or unworkable

may begin to prove viable and some of the ideas currently being mooted could be ready in as little as three months. One of these is for a wheeled robot with two attached sprayers to decontaminate equipment or areas where the disease has been found. A prototype has already been developed by repurposing designs in existence, according to WPI's Padir. Reproduced from an article by Innovate UK. Read the original article online at: https:// connect.innovateuk.org/web/ras-sig/article-view/-/ blogs/could-robot-nurses-help-provide-a-solution-toebola-?p_p_auth=InGXrF7W n

Canadian Researchers Create 'Black Box' for Use in Operating Rooms So far, Grantcharov's black box has been tested on about 40 patients undergoing laparoscopic weight-loss surgery. "At this initial stage, we are analysing surgeries to determine how many errors occur and which ones actually lead to bad results for patients," Grantcharov says. Not every error will result in a patient complication. Researchers at St. Michael’s Hospital, Toronto have developed a “black box” for use in operating rooms, similar to that used in the airline industry, designed to improve patient safety and outcomes by identifying where errors occur in the operating room and subsequently teaching surgeons how to prevent them. Dr. Grantcharov has been testing the prototype of his black box for about a month in the operating rooms at St. Michael’s, where he specialises in advanced minimally invasive surgeries, such as gastric bypasses. It is also being tested at two hospitals in Copenhagen, Denmark, with more international sites to be involved soon. The device has the capability of recording almost everything that goes on in the operating room, such as video of the surgical procedure, conversations among health care workers, room temperature and decibel levels. At this time it works only for laparoscopic, or minimally invasive, surgeries that insert video cameras in thin plastic tubes into small incisions in the body that allow the surgeon to see what’s going on inside the patient. The black box will eventually assess everything from how surgeons stitch to how delicately they handle organs and communicate with nurses during high-stress situations. Error-analysis software within the black box will help surgeons identify when they are "deviating" from the norm or using techniques linked to higher rates of complications.

December 2014

Grantcharov's initial research has shown that surgeons generally recognise few of their mistakes, and, on average, make about 20 errors per surgery -- regardless of experience level. Once Grantcharov's team determines which errors affect patient safety, it hopes to be able to provide this information to surgeons in real time. The team has also developed software that can synthesise the recorded data into user-friendly and interpretable information for surgeons. The concept of using a black box in surgery isn't new. But until now, the technology never made it out of the laboratory because it lacked comprehensiveness, Grantcharov says. Earlier surgical black boxes didn't record all the important elements of the operating room, he says, leaving pieces of the puzzle missing. “We want to see where errors happen in surgery so that we can understand how errors lead to adverse events and develop training curricula to prevent these errors from ever happening again,” Dr. Grantcharov said. “It doesn’t mean that we will have perfect surgeries, because we are not perfect. But it means we will learn from our errors, which will make us safer. We will train future surgeons better because we can show them what the most critical situations are, and how to avoid them.” He said research has already shown that 84 percent of errors in

Canadian Researchers Create 'Black Box' for Use in Operating Rooms

bypass surgery happen during the same two steps, so training has been adapted to help surgeons master those two skills. Dr. Grantcharov said he’s looking at performance issues – something the surgeon did or didn’t do, such as apply enough force when grabbing a bowel, which might make it slip and tear. But he’s also looking at less tangible factors that can lead to errors, such as communication and team dynamics. Dr. Grantcharov’s team has done extensive research on surgical error analysis. According to this framework, an error is a minor deviation from an optimal course of action. Errors happen during each procedure; however very few lead to adverse events and therefore go unnoticed by the surgical team. A 2004 paper by Ross Baker, a professor at the University of Toronto's Institute of Health Policy, Management and Evaluation, found that 7.5 percent of patients admitted to acute care hospitals in Canada in 2000 experienced one or more adverse events, which can include everything from reactions to wrongly administered medications to bed sores, falls, infections and surgical errors. The study found that most of these events did not result in any serious harm, but that almost 37 percent were preventable. More recent studies have shown rates of adverse events in hospital of between 10 and 14 percent. Such events cost taxpayers billions of dollars, usually in longer hospital stays. Dr. Grantcharov noted that professional athletes have coaches who point out their wrong moves and help them improve their performance. “For surgeons, we will have data that will allow better coaching and improvements and therefore better patient care,” he said. “We will reduce the risk and complications and show how to make the operating room more efficient, which will also allow us to save money and do more cases.”

Dr. Grantcharov said he also hoped his black box would bring more transparency to the operating room for patients and help change the “blame-and-shame” culture that traditionally has made doctors and nurses reluctant to report mistakes. Recording Mistakes Many surgeons, however, might be uncomfortable with using a black box in the operating room, says Dr. Teodoro Forcht Dagi with the American College of Surgeons Perioperative Care Committee. "If there was a legal requirement to record every operation, then many surgeons would be resistant," Forcht Dagi says. He believes doing so would create a sense of nervousness that would paralyse a surgeon's ability to operate and end up ultimately harming patients. "The black box needs to be used solely by surgeons for their own education, in which case I think it's a great idea," Forcht Dagi says. Errors during surgery have generally been dealt with after the fact, and only once a complication during the patient's recovery occurs. Weeks after surgery, cases with complications are presented to a panel of experts, who weigh in on what may have gone wrong during the operation. Yet in many cases nothing is recorded apart from an audio transcript of the operation, making it tough to identify what caused each complication. The black box would add much needed context. "I would rush (a black box) into service immediately," says Richard Epstein, professor of law at New York University's Continued on page 38

The Journal of mHealth

Canadian Researchers Create 'Black Box' for Use in Operating Rooms Continued from page 37

School of Law. Since most medical lawsuits end up being "he said, she said" arguments, not knowing exactly what happened in the operating room just adds to the level of distrust, Epstein says. In the United States, the Healthcare Quality Improvement Act prevents courts from using data that doctors and hospitals use for peer review, a self-regulation process in which experts or "peers" evaluate one another. The law allows doctors to assess each other openly and identify areas for improvement without fear of litigation. But there are exceptions to this rule, says William McMurry, president of the American Board of Professional Liability Attorneys. For instance, cases where surgeries are recorded but don't receive any peer review can be used in court. While McMurry says that "keeping patients in the dark about the details of their surgery is never OK," he points out that litigation concerns should not derail use of the black box. It will be an asset to the health care system regardless of whether it can be used in court, he says. "We care about better health care, and the black box will provide surgeons with the information they need to avoid mistakes," McMurry says. "It's a win-win situation."

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December 2014

The surgical black box will be tested in hospitals in Canada, Denmark and parts of South America in the next few months. Talks are also under way with a number of American hospitals. If doctors accept it, implementation in U.S. hospitals could happen quickly since the surgical black box isn't considered a medical device and doesn't require approval from the U.S. Food and Drug Administration. For more information on this project visit: www.stmichaelshospital. com/media n

The

Journal of mHealth The Global Voice of mHealth

Diabetes: Going Digital The role of technology in the prevention, treatment, and management of diabetes

A report supplement from The Journal of mHealth published on World Diabetes Day (Nov 14th) 2014. For more information on The Journal of mHealth and to get a FREE digital subscription visit www.thejournalofmhealth.com

SUPPLEMENT Diabetes: Going Digital

Diabetes: Going Digital Contents 40

The Role of Technology for People Living with Diabetes

Diabetes by the Numbers

Using Game Technology to Help Childhood Diabetes

Type 2 Diabetes Clinical Study Shows Lower Blood Glucose when Using Remote Diabetes Care System with Patient App

New Glucose Monitoring System Eliminates the Need for Routine Finger Pricks

Technology Improving the Understanding of Nutrition in Diabetes

Laser Device Could Mean an End to Daily Diabetes Blood Tests

Microchip Test to Diagnose Type 1 Diabetes

New Treatment Option Launched to Simplify Insulin Pump Therapy

Online Diabetes Risk Calculator Developed

mySugr Revolutionises Diabetes Education with New Platform for People with Diabetes

The Bionic Future

The Role of Technology for People Living with Diabetes In this interview Renza Scibilia, Manager of the Type 1 Diabetes and Community programs for Diabetes Australia (Victoria), who has lived with type 1 diabetes herself for 16 years, shares her insight and experience of the role that technology and digital solutions can have in the treatment and management of diabetes. Australia has one of the highest rates of type 1 diabetes in the world. In the past year alone over 3,021 new cases of type 1 diabetes were registered (8 new cases every day). There are 118,000 Australians with type 1 diabetes of whom over 25,000 are young people under the age of 30[1]. Despite type 1 diabetes affecting less than 1% of the general population, complications alone are responsible for 4% of all ambulatory care or hospital

Diabetes: Going Digital

admissions and 5% of all hospital bed days - more than angina or asthma[2]. The annual cost to the Australian health system of type 1 diabetes is at least $570M, with the average annual cost per person with type 1 diabetes costing $4,669 (ranging from $3,468 with no complications to $16,698 for both micro vascular and macro vascular complications[3]). Technology can reduce some of this burden upon the health system, as well as providing significant improvements in the quality of life experienced by those having to live with the condition, on a daily basis. “From a treatment perspective, there are some really great management tools, that make life a little bit easier, particularly for

people living with type 1 diabetes” says Renza Scibilia, who, through her firsthand experience of living with diabetes in combination with knowledge and experience gained working for Diabetes Australia, is able to provide an insightful perspective on the types of technology and digital solutions that can deliver tangible benefits to diabetics. “Looking at type 1 diabetes, insulin pumps have been around for a number of years as have continuous glucose monitors,” says Scibilia, “where things have gotten exciting in the last 4-5 years is where you have an integrated system, whereby a continuous glucose monitor

SUPPLEMENT Diabetes: Going Digital will read directly to a pump, therefore cutting down the number of devices that you need.” Insulin pumps are an excellent tool for consistent delivery of insulin and assist with maintaining optimal blood glucose levels for people who choose to use them, and for whom it is clinically recommended. Some people with type 1 diabetes cannot achieve optimal blood glucose control without the use of an insulin pump. There are more than 14,990 insulin pump users in Australia, around 12% of people with type 1 diabetes. This number is significantly higher in other regions like the USA where it is estimated that up to 25% of people with type 1 diabetes use insulin pump therapy. “There are also some really fantastic blood glucose monitors for people who are self-monitoring their blood glucose. That would be most people with type 1 diabetes, as all people with type 1 diabetes are advised to regularly monitor their blood glucose, as are people with type 2 diabetes using insulin. Even non-insulin treated people with type 2 diabetes may also choose to monitor their blood glucose. If they do, there are some really fabulous monitors that are capable of doing things such as identifying patterns and trends or highlighting issues. For example, they will say ‘you checked your blood sugar at this time in the last three days, and on those three occasions you have been low, so perhaps you need to think about why.’ Similarly, if your numbers have been high, then they will advise you to consider the reasons for that.” Modern blood glucose meters include data analysis functions, which are designed to help people gain a greater understanding of their condition and to learn to improve the way in which they self-manage. Scibilia describes the impact that some of these features can have. “There are some tools that make day-to-day things a little easier. They can provide alerts and identify patterns so that people can respond to them. Modern blood glucose monitors are also much faster, they take less blood, and they are much more accurate. I have type 1 diabetes myself, I have had it for 16 years, and I can remember that my first meter took something like 40 seconds to give a blood glucose reading, it now takes just 5 seconds! It is amaz-

ing what you can do with those extra 35 seconds when you are doing ten blood glucose tests per day, and it is those sort of things are terrific when we are talking about [how technology can improve] the day-to-day management of diabetes.” The increased availability of smartphones and associated apps are also delivering innovative tools that can help and support diabetics to self-manage their condition. “There are some absolutely fabulous apps out there, where you are able to record all of your data.” continues Scibilia. “They can provide you with graphs, and again pick up trends in all sorts of things that will help you to make some adjustments to better manage your diabetes. I would say my favourite app is one called mySugr, which has been developed by a group of young people, with diabetes, living in Vienna. It has a lot of really innovative features, which include things like being able to photograph your food, and record carbohydrates, but it also has a reward system, which doesn’t just reward what your number may be, but importantly how many times you are checking your blood sugar... The app looks great, it is fun to use, and I think that it is a really good example for younger people through to older people. When you have an app that has been developed by people with diabetes you get rid of a lot of the superfluous stuff, and keep the nuts and bolts of exactly what you need in a recording app.” The use of this type of technology is not always suited to everyone. Scibilia believes that different technologies appeal to different people depending upon their personal preferences. “Some people love to have all of their data in front of them, and they love graphs and that type of thing, and then there are other people for whom it is not interesting for them at all. This type of person will consider the number that they get from their blood glucose meter, as a snapshot in time, to which they will respond at that time, but they are not then interested in knowing about historical data or trends. But, for those data driven people there are some really great apps and solutions that are targeted to them.” “When we are talking about technology I also like to talk about things like social

media as a way of connecting people and providing that peer support that we know is really important to people living with chronic health conditions. The diabetes online community is an incredibly active, vibrant bunch of people and we all seem to harness technology in different ways, but the online presence and using that to form peer networks is incredibly useful for a lot of people who live with diabetes, or, for parents who have kids with diabetes, and for carers of people with diabetes.” Similarly, when it comes to type 2 diabetes, there are a range of digital solutions emerging which have the potential to help prevent the onset of diabetes or assist in the early diagnosis of people at risk from the disease. Scibilia suggests that the wider increase in general health and well-being applications, and technologies, that help people to track and record their individual health, can also be extremely beneficial in helping people to maintain healthier lifestyles and in turn potentially help to prevent the onset of diabetes. By allowing people to take greater ownership of their own medical data, technology can help people to use that information in ways that have a meaningful outcome on their personal health. “Gone are the days when you would go and have a blood test and the doctor would hold onto that data and you wouldn’t have those results. This is a way that you can keep all of that information and track it. You have a baseline and you have all your data recorded. Then when you go back in six months time you can see how that is tracking and use this to have a dialogue with your health care professional i.e. ‘my blood pressure was this last time and it is this, this time – is that something to worry about, or is that an improvement?’.” When it comes to how some of this technology fits into people’s lives Scibilia believes that there are a number of key factors that technology developers need to consider. “Not having everything talk to each other is really, really frustrating. There is absolutely not enough integration. As consumer voices we really would like things to talk to each other, and we would like Continued on page 41

The Journal of mHealth

SUPPLEMENT Diabetes: Going Digital Continued from page 42

the software that we use to download the data to be really easy to use, because at the moment, none of it seems to be.” “The same goes for technology that we are using as a data record. Things need to be easy to use, and be able to be used very discretely. If you have an app that is going to take you 25 minutes to enter a piece of data, then we are not going to be using it, as it will take us away from everything else.” Diabetes is a condition that presents a unique set of challenges for those living with it day-to-day. As someone living with diabetes Scibilia can easily outline some of the pressures that the condition brings. “So much about diabetes is focused on numbers, e.g. ‘what is your blood sugar?’, or ‘what is your HbA1c?’ But, the main thing is the fact that it is chronic.” “Generally, a person with diabetes gets somewhere between 4-6 hours per year with a Health Care Professional and the rest of the time you are mostly on your own. When you look at people who have type 1 diabetes, particularly, then the self-management is fairly intense. We are medicating constantly and our dose changes depending upon what we eat, our exercise level, if we are feeling stressed, and all sort of things that will impact how much insulin we will give ourselves... so getting burnt out, and losing motivation to continually self-manage is a very real thing for most people who live with diabetes.” “Diabetes burn out is something that we talk about a lot these days, but it is really only in the last few years that the psycho-social side of things has been recognised and talked about more and more. It is wonderful that here in Australia we have the Australian Centre for Behavioural Research in Diabetes where we are talking to people about how it feels to actually live with diabetes. We are not talking about how does it feel when you have to give yourself an insulin injection, what we want to know, is what does it feel like to actually live with diabetes? We did a study a number of years ago that surveyed a huge number of people living in Australia called the Diabetes MILES study, which showed significant numbers of people live with diabetes distress on a daily basis. There are a lot of

Diabetes: Going Digital

real concerns. Things like diabetes complications, how diabetes impacts upon the rest of the family, the burden of diabetes, the cost of living with diabetes. Those sorts of things we live with every single day.” “Where technology comes into that, is where you are looking at connecting people with each other. There are weekly tweet chats where people connect and fantastic Facebook groups that augment face-to-face peer support. There are so many ways now that people can locate other people to discuss this side of diabetes, and just hearing other people’s experiences is incredibly reassuring for people. There are hundreds of diabetes blogs out there, where you can read and hear what people are living through and how they cope with that. Generally, people are not writing about what their blood sugar levels are, they’re writing about how they are living on that dayto-day basis of life with a condition that doesn’t have a rule book.” Telehealth and telecare are both methods that can also be used to provide some of this support, particularly to those people who are unable to access traditional care and support options. “We are hearing more and more about people living in rural and isolated areas who are finding telehealth really useful,” says Scibilia, “and for some people being able to have a Skype conversation with an endocrinologist in a major city, because they don’t have any diabetes specialists near them, and using technology as a communication tool and an access tool, is a real benefit.” “I don’t think that we are harnessing this enough. When we are talking about Australia, where the country is huge by comparison to our population, then we really need to be looking at how technology can be better connecting people.” Diabetes Australia is a strong advocate of ensuring that there is equitable access to the wealth of technologies available to help with the management of diabetes. As an organisation social media is also proving to be a significant tool in helping deliver information, advice and support to people living with diabetes. “As an organisation we use social media to reinforce our messages, and to notify

people of our activities, our services, and any events or reports that we have. We have a very strong focus on living well with diabetes, but we want people to also realise that diabetes is serious and for people to understand how they can manage their diabetes in the best possible way.” says Scibilia. The organisation finds that their blogs are extremely well received by members. “That ability to really share your experiences is great as the person writing the blog, but for the people reading it, that feeling of not being alone and reducing those feelings of isolation is absolutely priceless. We constantly hear from people that until you read someone else’s story then you can often think that you are the only one dealing with a particular issue.” So what does technology and digital hold for the future of diabetes? “There are some really exciting things coming through.” says Scibilia. “The first of these is called the bionic pancreas. What this does is to provide a closed loop system, between an insulin pump and a continuous blood glucose monitor. This is where we are going and this is where we will be in the future. Everyone wants a cure, and we are constantly told that the cure is 5-years away, but the truth of the matter is the cure is not 5-years away. However, the exciting stuff is all of this technology.” We would like to take this opportunity to thank Renza Scibilia and Diabetes Australia for working with us on this article. To find out more about the work of Diabetes Australia visit www.diabetesvic.org. au. To read more about living with diabetes from Renza visit her blog at www. diabetogenic.wordpress.com. 1. Insulin Pump Therapy in Australia – The Case for Action. Report published by Diabetes Australia, 2014. 2. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993 Sep 30; 329(14): 977-86. 3. Craig M E, Twigg S M, Donoghue K C, Et al. National Evidence-Based Clinical Care Guidelines for Type 1 Diabetes in Children, Adolescents and Adults. Canberra: Australian Government Department of Health and Ageing 2011 n

Diabetes by the Numbers Type 1 diabetes, which accounts for between 10 and 15 percent of all people with diabetes, occurs when no insulin is produced at all because the insulin producing cells in the pancreas have been destroyed by the bodiesâ&#x20AC;&#x2122; own immune system. Type 2 diabetes accounts for between 85 and 90 per cent of all people with diabetes and occurs when the pancreas either does not produce enough insulin, or the insulin it produces does not work as well as it should (insulin resistance). Some of the risk factors associated with Type 2 diabetes are not controllable, e.g. genetic factors, while others, such as being overweight, can be controlled. There is currently no cure for either Type 1 or Type 2 diabetes.

Treatment For Type 1 diabetes, treatment means multiple daily insulin injections or infusions to replace the bodyâ&#x20AC;&#x2122;s natural insulin, finger prick blood testing, eating healthily and taking regular exercise. For Type 2 diabetes this is likely to involve lifestyle changes, such as diet, weight loss and exercise, which will have enormous health benefits and allow a person to continue their normal dayto-day life. They may also be required to take diabetes medication or insulin, or a combination of the two. n

SUPPLEMENT Diabetes: Going Digital

Using Game Technology to Help

Childhood Diabetes Applying the concepts and features of video game technology to help improve the way in which users engage and interact with healthcare applications and solutions is proving to be an effective tool. For children and younger users, in particular, these types of gamification techniques are proving to be a good method of helping them to engage and understand their health conditions using platforms that are, at the same time, fun and entertaining. As with adults, for children and teenagers with diabetes, the daily regimen of managing the condition, and all the necessary monitoring and recording that goes with that, can rapidly become very repetitive, frustrating and overall difficult to live with. Using games and video game concepts is one method of changing the dynamic through which users access information, manage

Diabetes: Going Digital

their condition, and monitor and record their health, by making it a more fun and entertaining experience. The idea of using video game technology in childhood diabetes care is not particularly new. One of the first efforts around diabetes was a 1995 game for Nintendo systems called Packy & Marlon, featuring two diabetic elephants who taught kids the importance of maintaining glucose levels. In the game, players take the role of animated characters who manage their diabetes by monitoring blood glucose, taking insulin injections, and choosing foods, while setting out to save a diabetes summer camp from marauding rats and mice who have stolen the diabetes supplies. Among children who played the game over a six-month period, emergency-room visits dropped by 77%, according to a 1997 paper published in the journal Medical Informat-

ics[1]. Unfortunately, the game failed to live up to commercial expectations, and was discontinued, but the concept was well proven. The core ideas of gaming technology actually lend themselves extremely well to the management of healthcare conditions. Rewarding positive activity with elements such as points or badges, helps reinforce positive action and to modify behaviours in ways which support improvement. Game user interfaces are designed in ways which allow people to instinctively connect and navigate an application or service. In children and young people who regularly play games, for entertainment, then common user experiences help to create applications that are easily and rapidly understood. This reduces the need for additional training or support on the use of the system. By using features such as incremen-

SUPPLEMENT Diabetes: Going Digital A number of similar trials have demonstrated similar positive results. Video games for diabetes have typically targeted children with type 1 diabetes and used situation problem-solving methods to teach diet, exercise, self-monitored blood glucose, and medication adherence. Evaluations have shown positive outcomes in knowledge, disease management adherence, and clinical outcomes[2]. tal progress i o n and the use of different levels, scores, rewards etc games help users to progress at a pace suited to their individual needs, as well as helping to actively promote and encourage those activities and behaviours that lead to that progression. In a healthcare context this is a valuable method of maintaining patient engagement, and helping people to continue to take an active role in their health or condition management. Video games also help to provide an environment that delivers instant visual feedback via graphical representations which creates an immersive, emotional experience. This in turn helps to encapsulate the normally rather boring elements of managing conditions like diabetes within a fun and interactive setting.

The present widespread availability of smartphones and tablets has presented an even more accessible medium by which specialist healthcare game developers can produce and distribute health games to a wide audience of users. There have been a number of recently released App based diabetes games that have proven very successful, and which are beginning to have significant impact on the lives of their users. Sanofi Diabetes, a subsidiary of Sanofi Aventis, recently launched a health and wellness app called Mission T1D, aimed at improving the understanding of type 1 diabetes among children, parents and caregivers in the school environment. The app is designed to educate primary school-age children about type 1 diabetes and how to live with it.

The free game aims to improve health outcomes in children with diabetes by improving the level of understanding about the disease. Set in a school environment, players must earn points to advance through various levels. At each level, a wise old man—“the sensei”— provides short, practical, and illustrated messages about living with the condition. As well as the app, there are supporting educational packs, which include games, videos and quizzes. Type 1 diabetes affects 400,000 people in the UK and more than 29,000 are children but figures show 94.2 per cent of infants; children and young people with diabetes do not receive all of the diabetes health checks recommended by the National Institute of Health and Care Excellence (NICE). Dr Sheridan Waldron, Specialist Diabetes Dietician, comments: “Children with diabetes and their families face many challenges in their daily lives as they care for a very complex life-long condition. “It is essential that children, parents and carers have the knowledge and skills to manage diabetes but they also need their friends, teachers and other people in the school environment to understand and support them, to care for their diabetes effectively. “Sharing information and fostering a caring environment at school will help children with diabetes to feel normal, happy and ensure that they reach their full potential in a safe environment.” The game is designed to allow children living with diabetes to share basic knowledge about the condition in their school in order to dispel any misconceptions. Rebecca Reeve, Head of Professional Relations at Sanofi Diabetes, says: “As a company, we have entered the diabetes gaming arena to improve health outcomes for children with type 1 diabetes.” “We are committed to making a difference to the lives of children who are struggling with the challenge of managing diabetes, especially in an environment where they can easily be made to feel different.” Continued on page 45

The Journal of mHealth

SUPPLEMENT Diabetes: Going Digital Continued from page 46

“We hope that the teachers, parents and carers for whom this game was developed will make it their mission to make this game a success.” Karen Addington, Chief Executive of JDRF, said: “Type 1 diabetes is a complex and serious condition. Furthermore, when the facts about type 1 diabetes are not appreciated and understood, extra pressure is placed upon those living with it. Thankfully, technology can play a big role in broadening awareness and understanding among people of all ages.” The Mission T1D app is the second game from Sanofi Diabetes that targets younger people with the condition. The previous release, developed as a joint project between healthcare game application Development Company Ayogo Health working with Diabetes UK and Sanofi Diabetes, was called Monster Manor and was designed to encourage children to test and record their blood glucose levels on a more regular basis. Children between the ages of 6 and 13 with type 1 diabetes are expected to take on increasing responsibility for testing and logging their own blood glucose. By incorporating a casual play collecting game, Monster Manor provides a fun and rewarding experience for those children who struggle with this growing responsibility. Testing and logging blood glucose within the game’s built-in tracker generates positive feedback to keep children engaged in this crucial aspect of their self-care with the aim of generating better outcomes. Research shows that just one extra test a day in teenagers leads to a 0.4 reduction in blood glucose concentration or HbA1c, which could be very significant[3]. Michael Fergusson, CEO at Ayogo Health comments, “As game designers, watching children play Monster Manor has been very satisfying, as the kids tell us that it’s fun and they want to keep playing. But for us, fun is only a means to an end; the goal ultimately is to improve health outcomes for the children we work for.” Simon O’Neill, Director of Health

Diabetes: Going Digital

Intelligence and Professional Liaison at Diabetes UK, speaking at the launch of the app in 2013, said: “Parents tell us that their children often find regular blood glucose monitoring very hard to accept and it can often become a source of tension in families. By turning the testing into a game we hope it will encourage young children with diabetes to manage their condition more effectively and help them succeed in achieving tighter blood glucose control in their early years. In turn this would help them reduce the risk of developing the serious complications associated with diabetes in later life.” Ayogo Health is one of the companies pioneering this type of game based intervention, and they have been involved with a number of projects that apply gaming experiences to diabetes care. They have worked with a range of organisations like the American non-profit DiabetesSisters, the Diabetes Hands Foundation, and the College Diabetes Network on game projects that help engage and support people with diabetes. Another diabetes management solution that has successfully incorporated game technologies into an application aimed at children is from developer mySugr. Their product mySugr Junior not only makes it possible for children to be more independent in their day-to-day lives, but it also teaches them in a playful way how to deal with their diabetes. Targeted at 6 to 10 year-olds, the app features a simple, child-friendly userinterface which enables and motivates children to document their diabetes data. They take photos of their blood glucose meters and meals with their smart phones and send them to their parents or show them to other supervisors, who then do the maths for them. This makes it possible for parents to control their child’s therapy even when they are not with them and to take action if needed.

The Junior solution engages younger patients to document their data by employing elements of gamification: Every time they use it, they collect points to feed a diabetesmonster that changes as they get from one level to the next. Following the diabetes therapy becomes a fun and rewarding activity and a habit. At the launch of the app in 2013 Cofounder Fredrik Debong described, “The main goal of the app is to positively influence the communication within the family. In families with diabetes patients there are a lot of ‘have-tos’ and a lot of complaining. ‘You have to do this, you have to do that’ – we want to help to turn this communication into something positive with our app.” 1. Brown SJ, Liberman DA, Germeny BA, Fan YC, Wilson DM, Pasta DJ. Educational video game for juvenile diabetes: Results of a controlled trial. Medical Informatics 1997; 22(1): 77-89. 2. DeShazo J, Harris L, Pratt W. Effective intervention or child’s play? A review of video games for diabetes education. 3. National Paediatric Diabetes Audit Report 2010 – 2011. Published September 2012. Available at http://www.hqip.org.uk/ assets/NCAPOP-Library/NCAPOP-2012-13/ Diabetes-Paediatrc-Audit-Report-pub-2012.pdf n

SUPPLEMENT Diabetes: Going Digital

Type 2 Diabetes Clinical Study Shows Lower Blood Glucose when Using Remote Diabetes Care System with Patient App Professor Kerstin Brismar from Karolinska Institutet in Stockholm has reported that using the Triabetes smartphone app and TriabetesClinic online decision support service in type 2 diabetes treatment helps reduce long-term blood glucose levels. Triabetes, from Swedish medical technology company Diabetes Tools, is a smartphone app and online decision support service for people living with and caring for all forms of diabetes. It can be used by individuals, doctors and treatment clinics, and can be integrated with large-scale Electronic Medical Record (EMR) systems. Results from the first six months of a two-year randomized, multi-centre clinical study show that the blood glucose marker HbA1c is significantly lower in patients being managed by the TriabetesClinic system compared with the control group who is not using the system. The research, which was presented during a seminar for delegates at a meeting of the Swedish Society for Diabetology, aims to detect a minimum 5.5 mmol/mol decrease in HbA1c in the patients who self-report to the healthcare provider’s remote care system using a smartphone app across four different treatment clinics over 24 months. Intention-to-treat analysis was applied to the interim results which show a significant median difference of 5.3 mmol/mol between the smartphone app and control groups during just six months.

“We found that it is clinically worthwhile to use the Triabetes app combined with the TriabetesClinic service to support patients to improve metabolic control and lower their HbA1c values,” said Kerstin Brismar, Professor of diabetes research at Karolinska Institutet. “Our analysis after six months showed that apps are a viable way to help control type 2 diabetes when the patient shares live data with their doctor or nurse, who in turn use a web-based triage service to monitor, coach and suggest treatment strategies.” “I welcome today’s interim results since there are few rigorous studies that report on the clinical use of telemedicine systems in diabetes management,” said Diabetes Tools’ Chief Executive Officer Anders Weilandt. There are 226 patients with Type 2 diabetes taking part in the study. They are spread across nine different primary care clinics in Poland run by the managed care group Medicover. The study uses Diabetes Tools’ Triabetes smartphone app for patients and TriabetesClinic, a web-based diabetes decision support service, for healthcare providers. The research is backed by academics from the Medical University of Warsaw and Karolinska Institutet in Stockholm, Sweden. For more information on the study visit www.diabetestools.se n

New Glucose Monitoring System Eliminates the Need for Routine Finger Pricks The new FreeStyle Libre Flash Glucose Monitoring System from Abbott uses revolutionary new glucose sensing technology. The system reads glucose levels through a sensor that can be worn on the back of the upper arm for up to 14 days. In addition, no finger prick calibration is needed—a key differentiator from current continuous glucose monitoring systems.

The new system consists of a small, round sensor – approximately the size of a two Euro coin – worn on the back of the upper arm, which measures glucose every minute in interstitial fluid through a small (5mm long, 0.4mm wide) filament inserted just under the skin and held in place with a small adhesive pad.

get a glucose result painlessly in less than one second. Scanning can take place while the sensor is under clothing, making testing more discreet and convenient. Each scan displays a real-time glucose result, a historical trend and the direction the glucose is heading. The reader holds up to 90 days of data, providing a histor

A reader is scanned over the sensor to

Continued on page 47

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SUPPLEMENT Diabetes: Going Digital Continued from page 48

ical snapshot of glucose levels over time. Robert Ford, senior vice president, Diabetes Care, Abbott, said: “The FreeStyle Libre System fulfills a major need for people living with diabetes. Our customers told us that the pain, inconvenience and indiscretion of finger pricking were the key reasons they weren’t managing their diabetes as well as they should. “Addressing these concerns has guided the development of FreeStyle Libre – a transformational product designed to not only remove the pain of finger pricking but also seamlessly integrate into their daily lives.” The system’s software has also been developed to enable the collected data to be presented in a user-friendly, visual chart for both healthcare professionals and patients, driving a more productive discussion around treatment and any necessary modification. The disposable, water-resistant sensor can be worn on the back of the upper arm for up to 14 days allowing glucose readings to be taken as many times per day as needed or desired. Each scan provides a current glucose reading, 8-hour history and the direction glucose is heading with the data generated by the system is designed to provide actionable trends and patterns that may help people determine how to modify food and other behaviours to better manage their diabe-

tes in consultation with their healthcare professionals Cliff Bailey, Professor of Clinical Science and Director of Biomedical Sciences Research at Aston University in Birmingham, said: “For decades, people with diabetes have had to prick their fingers routinely to check their glucose levels. The pain and inconvenience of finger pricks has contributed to less frequent testing and suboptimal diabetes management. “By eliminating the need for routine finger pricks, the FreeStyle Libre System will significantly advance the field of glucose monitoring. It offers a convenient

and painless way to get more frequent glucose readings, which should help to improve diabetes management.” The majority of people with diabetes are not at their target glucose levels often because the data generated by their glucose meters does not provide a clear historical picture of where their glucose has been or how their actions impact their levels. The new system provides users and their physicians with the Ambulatory Glucose Profile (AGP), a report providing a visual snapshot of a person′s typical day by utilizing dense glucose data revealing hypoglycemic and hyperglycemic trends to facilitate better patient therapy and education. n

Technology Improving the Understanding of Nutrition in Diabetes Diabetics with type 1 diabetes must control their increased blood glucose values with medications and plan their meals so that the blood glucose level does not sharply increase after eating. The amount of carbohydrates in a meal – such as starch and various sugars – is the most important parameter for an increase in blood glucose after eating. In the course of insulin therapy, the increase in blood glucose after the intake of carbohydrates is lowered again through the injection of the hormone insulin – so called “prandial insulin”. The correct dose of prandial insulin has to be calculated on the basis of the

Diabetes: Going Digital

amount of carbohydrates. But, often it is difficult even for the well-trained diabetic to estimate the carbohydrate content of a meal accurately enough. GoCARB is an app for smartphones, developed at the ARTORG Institute of the University of Bern (in close cooperation with Bern University Hospital) which automatically calculates the carbohydrate content of a meal. The programme enables diabetics to better plan their meals and subsequently makes controlling their blood glucose easier.

SUPPLEMENT Diabetes: Going Digital The mobile application supports diabetics by determining the carbohydrates in meals and specifying the appropriate dose of prandial insulin. In doing so, the smartphone-based system recognises food items on a plate by means of photos from a smartphone camera and estimates their carbohydrate content. In turn, the app automatically calculates the prandial insulin dose. GoCARB is a four-year international research project directed by Dr.-Ing. Stavroula Mougiakakou from the ARTORG Centre for Biomedical Engineering Research of the University of Bern and Prof. Dr. med. Peter Diem from the University Department of Endocrinology, Diabetes and Clinical Nutrition. The project has been undertaken in close cooperation with Roche Diagnostics and has been financed under the European Commission’s 7th Research Programme. “We want to improve the personalised treatment of patients with diabetes mellitus”, says Stavroula Mougiakakou. “There are already apps which help to estimate the carbohydrate content of a meal. But with those the foodstuffs must be manually recorded and the programmes do not offer any calculation of prandial insulin.” The estimation of the prandial dose is a complex and time-consuming task, dependant on many factors, with carbohydrate (CHO) counting being a key element[1]. Clinical studies have shown that, in children and adolescents on intensive insulin therapy, an inaccuracy of ±10g in CHO counting does not impair postprandial control[2], while a ±20g variation significantly impacts postprandial glycaemia[3]. There is also evidence that even well-trained patients suffering from type 1 diabetes find it difficult to estimate CHO precisely. In one clinical study, of 184 adult patients on intensive insulin, researchers found that on average 8.5% of those studied overestimated the CHO contained in their breakfast and 28% underestimated the CHO contained in lunch. Furthermore, 23% of those in the study underestimated the levels found in dinner, and 5% did the same with snacks[4]. In another recent study researchers found that for children with type 1 diabetes and their caregivers, 27% of meal estimations are inaccurate in the ranges greater than ±10g[5]. The GoCARB prototype offers a very simple method for helping overcome this problem. The user initially places a reference object next to the meal and records two photos with a smartphone camera. The various foodstuffs – such as meat, vegetables and noodles – are segmented and recognised by the programme, while their form is reconstructed in 3D. Based on the 3D model, the results of segmentation and the reference object, the volume of the individual foodstuff is estimated. Knowledge of the nature and volume of the foodstuff enables the calculation of carbohydrate content with the aid of a nutritional value database. Tests on real meals revealed that the system errs by only ±6-7 grams on average. Based on this carbohydrate content and additional information the included bolus calculator module works out the optimal insulin dose for the meal.

more effective, automated and precise determination of carbohydrates in foodstuffs – this shall allow them [to have] better diabetes control and indirectly bring them an enhanced quality of life”, says Mougiakakou. The researchers hope that the prototype solution can be refined and made available on a wider scale. Over time, as the underlying database increases, the system will be able to recognise more and more different food types, making it a valuable assistive tool for anyone living with type 1 diabetes, and needing to accurately determine carbohydrate intake. There are a number of additional different technologies that are both currently available or which are in development that also have the potential to help in this matter. Smartphone applications like mySugr allow users to take photographs of meals and log the relevant data relating to carbohydrates, overtime this builds into a comprehensive database of the types of meals an individual may have, with the related nutritional and carbohydrate value attached. This type of process helps to reduce some of the daily burden on people with diabetes. A number of companies are also developing smartphone augmenting sensors that they suggest could be capable of analysing food material at the molecular level. Devices like the SCiO - from start up company Consumer Physics, which is a tiny, low-cost spectrometer that will fit in the palm of your hand allow you to get instant relevant information about the chemical make-up of just about anything around you, sent directly to your smartphone. At present the application of these types of device are fairly limited, but with time it is conceivable that they could become an accurate method of analysing foodstuff at a molecular level, and subsequently providing valuable insight into the relevant carbohydrate content[6]. 1. Anthimopoulos M, Gianola L, Scarnato L, Diem P, Mougiakakou S. A Food Recognition System for Diabetic Patients based on an Optimized Bag of Features Model. IEEE Journal of Biomedical and Health Informatics Vol. 18, No. 4, July 2014. 2. Smart C.E, Ross K, Edge J. A, Collins C.E, Colyvas K, & King B.R. Children and adolescents on intensive insulin therapy maintain postprandial glycaemic control without precise carbohydrate counting. Diabetic Med, Vol. 26, No. 3, pp 279-285, 2009. 3. Smart C.E, King B.R, McElduff P, & Collins C.E. In Children using intensive insulin therapy, a 20g variation in carbohydrate amount significantly impacts on postprandial glycaemia. Diabetic Med, Vol 29, No. 7, pp e21e24, 2012. 4. Graff M, Gross T, Juth S, & Charlson. How well are individuals on intensive insulin therapy counting carbohydrates? Diabetes Res. Clinical Practice, Vol 50, Suppl. 1, pp 238-239, 2000. 5. Smart C.E, Ross K, Edge J. A, King B.R, McElduff P, & Collins C.E. Can children with type 1 diabetes and their caregivers estimate the carbohydrate content of meals and snacks? Diabetic Med, Vol 27, pp 348-353, 2010. 6. www.consumerphysics.com accessed 03/11/2014.

More information on the GoCARB project can be found at www.gocarb.eu n

“With this prototype we satisfy the need of diabetics for a

The Journal of mHealth

SUPPLEMENT Diabetes: Going Digital

Laser Device Could Mean an End to Daily Diabetes Blood Tests Princeton University researchers have developed a way to use a laser to measure people’s blood sugar, and, with more work to shrink the laser system to a portable size, the technique could allow diabetics to check their condition without pricking themselves to draw blood. In an article published in the journal Biomedical Optics Express, the researchers describe how they measured blood sugar by directing their specialised laser at a person’s palm. The laser passes through the skin cells, without causing damage, and is partially absorbed by the sugar molecules in the patient’s body. The researchers use the amount of absorption to measure the level of blood sugar. Sabbir Liakat, the paper’s lead author, said the team was pleasantly surprised at the accuracy of the method. Glucose monitors are required to produce a blood-sugar reading within 20 percent of the patient’s actual level; even an early version of the system met that standard. The current version is 84 percent accurate, Liakat said.

Diabetes: Going Digital

“It works now but we are still trying to improve it,” said Liakat, a graduate student in electrical engineering. When the team first started, the laser was an experimental setup that filled up a moderate-sized workbench. It also needed an elaborate cooling system to work. The researchers have since solved the cooling problem, so that the laser works at room temperature. The next step will be to reduce the size of the equipment involved. The key to the system is the infrared laser’s frequency. What our eyes perceive as colour is created by light’s frequency (the number of light waves that pass a point in a certain time). Red is the lowest frequency of light that humans normally can see, and infrared’s frequency is below that level. Current medical devices often use the “near-infrared,” which is just beyond what the eye can see. This frequency is not blocked by water, so it can be used in the body, which is largely made up of water. But it does interact with many acids and chemicals in the skin, so it makes it impractical to use for

detecting blood sugar. Mid-infrared light, however, is not as much affected by these other chemicals, so it works well for blood sugar. But mid-infrared light is difficult to harness with standard lasers. It also requires relatively high power and stability to penetrate the skin and scatter off bodily fluid. (The target is not the blood but fluid called dermal interstitial fluid, which has a strong correlation with blood sugar.) The breakthrough came from the use of a new type of device that is particularly adept at producing mid-infrared frequencies — a quantum cascade laser. In many lasers, the frequency of the beam depends on the material that makes up the laser — a helium-neon laser, for example, produces a certain frequency band of light. But in a quantum cascade laser, in which electrons pass through a “cascade” of semiconductor layers, the beam can be set to one of a number of different frequencies. The ability to specify the frequency allowed the researchers to produce a laser in the mid-

SUPPLEMENT Diabetes: Going Digital infrared region. Recent improvements in quantum cascade lasers also provided for increased power and stability needed to penetrate the skin. To conduct their experiment, the researchers used the laser to measure the blood sugar of three healthy people before and after they each ate 20 jellybeans, which raise blood sugar levels. The researchers also checked the measurements with a finger-prick test. They conducted the measurements repeatedly over several weeks. The researchers said their results indicated that the laser measurements readings produced average errors somewhat larger than the standard blood sugar monitors, but remained within the clinical requirement for accuracy. “Because the quantum cascade laser can be designed to emit light across a very

wide wavelength range, its usability is not just for glucose detection, but could conceivably be used for other medical sensing and monitoring applications,” said

Claire Gmachl, a professor of electrical engineering at Princeton and the project’s senior researcher. n

Microchip Test to Diagnose Type 1 Diabetes their age and lifestyle. Professor Brian Feldman, of Stanford University, who led the research, said: “With the new test, not only do we anticipate being able to diagnose diabetes more efficiently and more broadly, we will also understand diabetes better.” Because the chip tests for auto-antibodies, which are present even before a person develops the symptoms of Type 1, it could allow healthcare providers to monitor people at risk and give them treatment much sooner than is currently possible. Researchers funded by JDRF have designed a cheap, microchipbased test that can diagnose Type 1 diabetes in the quickest time yet. The test detects the presence of islet auto-antibodies in a drop of blood. These proteins indicate that the immune system is primed to attack the insulin-producing cells of the pancreas – and are present in Type 1 but not Type 2. Because of this, the test could be used after a diagnosis of diabetes, to distinguish whether a person has Type 1 or Type 2, potentially saving them from being misdiagnosed and receiving the wrong treatment. The portability and low cost of the chip mean it could also be used more widely than current tests, so healthcare providers would no longer have to choose between a slower lab-based test and assuming which type of diabetes their patient has, based on

This could become even more important in future with the development of preventative treatments, as these would be most effective before a person loses their ability to produce insulin. Such treatments are a priority area of JDRF research, which funded the project, as part of its strategy to cure, treat and prevent Type 1. Feldman added: ‘The auto-antibodies truly are a crystal ball. Even if you don’t have diabetes yet, if you have one autoantibody linked to diabetes in your blood, you are at significant risk; with multiple auto-antibodies, it’s more than 90 per cent risk. “There is great potential to capture people before they develop the disease, and prevent diabetes or prevent its complications by starting therapy early.” The research was published in the journal Nature Medicine. n

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SUPPLEMENT Diabetes: Going Digital

New Treatment Option Launched to Simplify Insulin Pump Therapy Novo Nordisk has launched NovoRapid PumpCart, the first pre-filled pump cartridge with an insulin analogue that has been specifically designed for insulin pumps. This new treatment solution, which contains NovoRapid, a rapid-acting insulin, is expected to make insulin pump therapy more convenient for people with diabetes and their care staff.

glucose control without an increased risk of hypoglycaemia[1-2].

The cartridge which has been developed as a partnership between Roche Diabetes Care and Novo Nordisk has been designed to be compatible with the new Accu-Chek Insight insulin pump therapy system from Roche Diabetes Care. “One of the challenges in operating a traditional pump lies in the manual filling of the insulin reservoir, a procedure with multiple steps, which can often be perceived as a complex and time-consuming process by patients and healthcare professionals alike,” commented Dr Parth Narendran, clinical senior lecturer and honorary consultant in medicine at the University of Birmingham. He continued: “This can be a difficult hurdle to overcome when starting on insulin pump therapy, and is exacerbated by the extensive amount of time needed by healthcare staff to provide the necessary support during pump initiation. A simpler process could address this issue and deliver tangible benefits for those patients who rely on insulin pump therapy every day to manage their diabetes.” Compared to multiple daily injections, insulin pumps can provide greater flexibility of lifestyle and potentially tighter blood

“This can provide benefits to certain patients,” explained Dr Mark Evans, lecturer and honorary consultant in medicine at the University of Cambridge. “In Europe, we’ve seen a slow but steady increase in insulin pump therapy uptake in recent years, but there is still room for improvement; in the United Kingdom pumps are currently used by 19% of children and 6% of adults with type 1 diabetes.” An insulin pump delivers insulin from a reservoir inside the pump to a patient’s body using an infusion set and a tiny cannula. The insulin is delivered using continuous infusion and is often used by people with type 1 diabetes who receive intensified insulin therapy and test their blood glucose levels on a regular basis. An insulin pump is suitable for certain patients and provides more flexibility, with the potential to improve glycaemic control and quality of life[1-2]. In Europe, use of insulin pumps among people with type 1 diabetes varies with less than 5% using a pump in some countries to more than 15% in other countries. In the US, 40% are treated with insulin from a pump[3]. 1. Cohen ND, et al. Diabetes Technol Ther. 2013;15:544-9. 2. Pickup J. Nat Rev Endocrinol. 2012;8:425-33. 3. Pickup J. Insulin pumps. Int J Clin Pract. 2011;65(Suppl.170):16-19. n

Online Diabetes Risk Calculator Developed A new online tool will help doctors predict which patients are most likely to develop Type 2 diabetes. The calculator will enable doctors to identify high-risk patients so that they can be tested for the disease and offered lifestyle advice. The test is targeted at people who have been admitted to hospital for emergency care.

Diabetes: Going Digital

Experts say it could offer a cost-effective way to identify people with diabetes in Scotland as it avoids the need for significant investment in screening. The test, developed by a team from the University of Edinburgh, University of Glasgow and Scottish Diabetes Research Network, calculates a person’s risk of developing diabetes over the next three

years based on their age, sex and the level of sugar in their blood, which is routinely measured on admission to A&E. Blood sugar levels often rise during serious illness but usually drop back to normal when patients get better. This can make it difficult for doctors to identify patients who are at risk of diabetes, which is also associated with high levels

SUPPLEMENT Diabetes: Going Digital of sugar in the blood. Dr David McAllister, Clinical Lecturer in Epidemiology and Public Health, said: “This tool will enable us to identify people at risk of diabetes and give them the opportunity to make positive lifestyle changes to improve their health, without the cost of running a national screening programme.” The calculator will help doctors determine which patients should be referred for diabetes testing when they recover. It was developed by a team led by the University of Edinburgh’s Centre for Population Health Sciences, the University of Glasgow and members of the Scottish Diabetes Research Network. The team linked records from more than 100,000 hospital patients to a national diabetes register to get the information needed to create the calculator. The researchers used the databases to identify more than 100,000 patients aged 30 years or older who were admitted to a hospital for an acute illness between 2004 and 2008 in Scotland, to obtain information on blood glucose levels on admission for nearly three-quarters

of these patients, and to identify which patients subsequently developed diabetes. They then used statistical models to estimate the patients’ risk of developing type 2 diabetes during the 3 years following hospital discharge. Among patients aged 40 years or older, the overall 3-year risk of developing diabetes was 2.3%. The risk of developing diabetes increased linearly with increasing blood glucose level at admission. Specifically, the 3-year risks at blood glucose levels of 7 mmol/l and 11.1 mmol/l were 2.6% and 9.9%, respectively; because glucose levels fluctuate according to when an individual last ate, fasting blood glucose levels of 7 mmol/l and non-fasting blood glucose levels of 11.1 mmol/l are used as thresholds for the diagnosis of diabetes. The diabetes risk associated with blood glucose levels on admission among 30–39-year-old patients followed a similar pattern but was less marked. Finally, high glucose levels on admission were associated with increased mortality. These findings indicate that blood glucose measured during an emergency hospital admission predicts the subsequent risk of type 2 diabetes among patients aged 40 years or older (the analysis specified in the researchers’ original protocol).

Importantly, however, they also suggest that a high blood glucose reading in these circumstances usually indicates stress hyperglycemia rather than type 2 diabetes. The accuracy and generic nature of these findings may be limited by the lack of data on ethnicity or body mass index (a measure of obesity), both of which affect diabetes risk, and by other aspects of the study design. Nevertheless, given their findings, the researchers recommend that any patient with a blood glucose level above 11.1 mmol/l on hospital admission for an acute illness (one in 40 patients in this study) should be offered follow-up testing. In addition, the researchers constructed a risk calculator using their findings that should help clinicians to inform their patients about their long-term risk of diabetes following hyperglycemia during an acute hospital admission and to target lifestyle advice to those patients at the highest risk of type 2 diabetes. The research was funded by the Chief Scientist Office of the Scottish Government, and published in the journal PLOS Medicine. Read the full article at: http://www.plosmedicine.org/article/ info:doi/10.1371/journal.pmed.1001708 n

mySugr Revolutionises Diabetes Education with New Platform for People with Diabetes Startup mySugr has already gained favour with people living with diabetes through their range of innovative smartphone apps, gaining more than 160,000 users. The company has now launched mySugr Academy, an online training program for people with diabetes that has been developed by doctors, dieticians, nurses, and people with diabetes. The first course for people with Type 2 diabetes answers many questions that come during the shock of diagnosis: What does this mean? What can I eat? Will diet & exercise help? Will I need insulin? The content is delivered through fun Continued on page 53

The Journal of mHealth

SUPPLEMENT Diabetes: Going Digital Continued from page 54

animated videos along with playful elements of gamification – without any of the typical guilt or shame so often associated with diabetes diagnosis. “Many patients with type 2 diabetes feel so confused, overwhelmed and discouraged at the time of diagnosis, and traditional approaches to diabetes education often do not address these critical problems.” said Dr. William H. Polonsky, President of the Behavioural Diabetes Institute in San Diego, CA. “mySugr Academy is a series of online videos that aim to breathe a sense of fun and whimsy into diabetes education. People with diabetes need to feel engaged and encouraged, and Academy’s approach is sure to help!” According to the CDC’s 2014 National Diabetes Statistics Report, 9.3% of the U.S. population (29.1 million people) have diabetes. As of 2012 the estimated direct and indirect costs (disability, work

loss, premature death) of diabetes were $245 billion. Payers, both public and private, are working with mySugr to determine how best to integrate mySugr’s impactful method

of educating. The Austrian Social Insurance Authority for Commerce and Industry (SVA) is the first national health insurer to cover the costs of mySugr Academy for its members in Austria. n

The Bionic Future Finding a cure for Type 1 diabetes will always be the hope, but in reality this is still likely a number of years away. In the more immediate future, there is considerable work underway to develop what is often referred to as the ‘bionic pancreas’ - a closed loop insulin delivery system, which it is hoped will offer significant benefits for people living with type 1 diabetes. Type 1 diabetes is an autoimmune condition where the body starts to produce antibodies that attack and destroy the insulinproducing cells in the pancreas. The body can therefore not make insulin, so the person relies on lifelong insulin injections to control their blood sugar. It can be a challenge for people with type 1 diabetes to keep insulin delivery at the right level, which is necessary to keep blood sugar levels within the normal range. Avoiding periods of hypoglycaemia can be a challenge, particularly overnight. A further challenge is that the symptoms of type 1 diabetes usually develop during childhood. This means that children, especially teenagers, can often find the need to stick to a particular treatment “regime” and regularly monitor their blood sugar quite restrictive. However, without such treatment recommendations, they can be at risk of complications, such as hypoglycaemia. Because of this difficulty, a device to help simplify the treatment of type 1 diabetes would be welcomed. The premise of a “closed-loop” insulin delivery system – in other words, an artificial pancreas - is to combine a small device that is connected to the body through a standard insulin pump, to deliver insulin under the skin without the need for con-

Diabetes: Going Digital

tinuous injections, with a real-time sensor that will continuously monitor a person’s sugar level (by measuring the level in the interstitial fluid that surrounds body cells). This system would then automatically make fine adjustments to insulin delivery in response to the glucose level being continuously measured, as would normally happen in the human body with a healthy pancreas. One endeavour that has been established to help develop and test this type of technology is the Bionic Pancreas Project, which consists of a collaborative group from Boston University and Massachusetts General Hospital working together to make automated blood glucose control a reality. The aim of the project is to develop a system that automatically makes decisions about insulin and glucagon dosing every five minutes. The project has conducted a number of studies, to date, using three system components to implement this automated control of blood glucose. A Dexcom G4 Platinum Continuous Glucose Monitor (CGM) is used to measure interstitial fluid glucose every 5 minutes as an estimation of blood glucose, taking readings from a glucose sensor inserted into the body using an automated injector. A transmitter is then attached to enable transmission of glucose data wirelessly to the Dexcom receiver. Using a custom iPhone app the system then acts upon the glucose data by computing how much insulin or glucagon to deliver during each 5 minute episode. Once calculated, the app sends these dosing instructions via Bluetooth to two pumps, one filled with insulin and the other with glucagon (the doses of these two hormones are used

SUPPLEMENT Diabetes: Going Digital to regulate blood glucose). The pumps then deliver the insulin and glucagon doses subcutaneously through separate infusion sets. A number of studies, to date, have used different variations of this type of system and the results suggest that this may be an extremely promising method of blood glucose control, that in the future has the potential to decrease the risk of hypoglycaemia. In one recent study researchers found that when compared with an insulin pump, a wearable, automated, bi-hormonal, bionic pancreas improved mean glycaemic levels, with less frequent hypoglycaemic episodes, among both adults and adolescents with type 1 diabetes mellitus[1]. In another study, that considered the use of a closed-loop insulin delivery system for overnight glucose control in adults with type 1 diabetes, the results showed the time that participants spent in the target optimum sugar range during a seven-hour overnight period was higher when using the closed-loop system (52.6% of the time) compared to when they used the control pump (39.1%), with a significant difference of 13.5%. The research, published in The Lancet medical journal, is also said

to be the first to monitor safety and effectiveness of the closedloop system when used unsupervised in the personâ&#x20AC;&#x2122;s own home over a four-week period. The study found that there were no severe adverse effects associated with using the closed-loop system, over the period[2]. Despite the promise of the artificial pancreas, there is some way to go. All of the trials conducted so far have been fairly limited in their application, and the technology has not yet been proven to be able to operate completely autonomously, and without the need for a person to monitor their blood sugar or adjust their own insulin. However, the concept of the treatment has certainly been proven, and it is hoped that the practicalities of a complete closed-loop autonomous system, will be available in the not-so distant future. 1. Russell S J, El-Khatib F H, Sinha M, Magyar K, McKeon K, Goergen L G, Et al. Outpatient Glycemic Control with a Bionic Pancreas in Type 1 Diabetes. N Engl J Med, 317: 313-325, 2014. 2. Thabit H, Lubina-Solomon A, Stadler M, Leelarathna L, Walkinshaw E, Pernet A, Et al. Home use of closed-looop insulin delivery for overnight glucose control in adults with type 1 diabetes: a 4-week, multicentre randomised crossover study. The Lancet: Diabetes and Endocrinology. Published online June 16 2014. n

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Exco InTouch

The

Journal of mHealth The Global Voice of mHealth

Healcerion 16 Infield Health Pass Group Tactio Health Group

December 2014

38 7 21

Contact Matthew Driver matthew@simedics.org +44 (0)1756 709605

Consult…..connect…..engage……respond……improve In today’s fast changing health landscape understanding and responding to patient needs is becoming ever more critical. Designing healthcare services to match more closely the profile and lifestyle of your local population can bring benefits for patients and the efficiency of the health system. Consultation Plus is an online system tool that helps organisations improve their consultation exercises and encourage customer and user engagement. Designed by communications and engagement experts the system is simple to use and provides meaningful feedback to aid improved decision making via meaningful engagement. »» »» »» »» »» »» »» »» »» »» »»

Easy to use with simple ‘wizard’ menu to guide all users though the consultation and engagement process Low cost – multiple users can access the system via PCs and mobile devices to provide ongoing feedback and up to the minute information about user and customer views and experiences Feedback can be analysed demographically and geographically to give a clear picture of emerging themes and key issues Ability to manage multiple consultation exercises Upload data from meetings, web sites, or community outlets such as GP surgeries, town halls and schools Provides a clear ‘audit trail’ of activity to ensure ‘good practice’ and the meeting of legal requirements such as the ‘duty to consult’ Mapping feature shows ‘hot spots’ to identify areas where greater engagement is needed Analysis of feedback creates presentations for management and public meetings Our team can set up the system and upload an organisation’s existing databases for use in the consultation processes We can also set up and embed a new forward looking engagement approach in your organisation to improve customer and user experiences and enhance service delivery Bespoke solutions – building on the basic system we can add and tailor additional features to match customer’s exact requirements

For further information and a free demonstration email: info@consultation-plus.com

Advertising & Marketing Opportunities We have a full range of advertising, marketing, and content publishing programs available for companies engage with our extensive audience of mobile and digital health professionals.

Global Reach

Our readers come from all around the world, although the majority are based in the UK, North American and European markets.

Targeted Professional Audience

Our current subscriber base is representative of the whole mHealth and Digital Health industries with readers including: Doctors, Healthcare professionals, Government, Business professionals, NGO's and many others.

Advertising

Marketing Opportunities Let us help you to deliver information on your product and solutions to a global audience of digital healthcare professionals.

We have a whole range of advertising formats available across our publications and online channels, with prices to suit all budgets. Please contact us for more information.

We regularly work with digital health solution providers to develop marketing packages that can help significantly raise awareness of a solution and provide targeted industry coverage. To discuss how we can help you, please get in touch.

Report Sponsorship We aim to provide a variety of library resources for our readers, and our report program is very well respected and followed within the industry. We publish a range of reports throughout the year on topics relating to many different aspects of the mHealth and Digital Health sectors. We often collaborate with commercial partners on these reports, to gain additional insight and expertise. A number of our reports are available for sponsorship. Please contact us for more information.

The

Journal of mHealth The Global Voice of mHealth