WHAT’S INSIDE
NEWS, REVIEWS, CLINICAL DATA, mHEALTH APPLICATIONS
The
Journal of mHealth The Global Voice of mHealth February 2014 | Volume 1 Issue 1
Digital Health
Your insight into mHealth The Inaugural Edition
ARTICLES
REVIEWS
CLINICAL
Read the Latest Research
mHealth Apps & Services
mHealth in Practise
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The
Journal of mHealth The Global Voice of mHealth
Editor's Comments
Welcome I would like to take this opportunity to welcome all our readers who have subscribed to the new Journal of mHealth. We hope that you find this and subsequent editions engaging and informative. Our aim with the Journal has been to provide a publication that bridges the different areas of the mHealth industry in order to provide an authoritative source of information for all parts of healthcare community. Through the Journal we will be looking to provide industry insight into the ways in which mHealth is being used, developed and implemented across all the possible technical use cases. In practise this means the Journal will include academic research, industry studies, reports and clinical trial data, as well as news and updates from the global Digital Health industry. We will also feature regular company and organisation profiles looking at the work that different businesses and organisations are doing around the world to develop and implement mHealth services. Having consulted extensively with participants from across the industry it is hoped that the Journal will become a trusted resource for anyone with an interest in mobile medical applications, devices, and services. In this our inaugural edition we set out to understand some of the issues affecting the current global mhealth landscape, with reports and articles covering projects from around the world. Our feature article considers the Global perspectives of the mHealth market. We have reports from the Health and Development Foundation of Russia, the European Public Health Alliance (EPHA) Briefing on Mobile Health, and an analysis of the FDA Guidance on Mobile Medical Apps. We also have sections that will make a regular appearance in each edition, including industry news, company profiles, and events news. Finally, let me take this opportunity to thank everyone who has been involved with helping us launch The Journal of mHealth, and for all the contributions and submissions made to date. Without you all, we wouldn’t be where we are today. Thank you for subscribing and we hope you enjoy reading!
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.simedics.org 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 or publishers. Although the highest level of care has been taken to ensure accuracy the publishers do not accept any liability for omissions or errors or claims made by contributors or advertisers, neither do we accept liability for damage or loss of unsolicited contributions. The publishers excercise the right to alter and edit any material supplied. This publication is protected by copyright and may not be reproduced in part or in full without specific written permission of the publishers. Š 2014 Simedics Limited
Matthew Driver Editor
1 The Journal of mHealth
Table of Contents
mHealth...A Global Market
In This Issue 4
mHealth... A Global Market For our inaugural edition we deliver an insight into the global mHealth market, and consider some of the major industry trends.
27
nowledge
Cost Effectiveness
Policy
Legal
Operating Costs
Demand
Technical Expertise
European Public Health Alliance Briefing on mHealth—Read the complete briefing from the EPHA, relating to the European mHealth landscape.
Infrastructur
40 5.2% 6.7% 23.8% Less than 1 month 12.5%
1-3 months 3-6 months
EPHA Briefing on Mobile Health
The Health and Development Foundation National Survey Among Participants of the Maternal and Child mHealth Program
6-9 months 9-12 months 27.9%
23.9%
2 February 2014
Over 1 year
Read the report containing a summary of results from the Health & Development Foundation (Russia) 2013 national survey among participants of the maternal and child mHealth program.
Table of Contents
Industry News 8
Scanadu Secures $10.5 Million in Funding
8
CES 2014...A Digital Health Showcase
9
9
10
10
13
15
Tactio Health Group
16
Innovative Smartphone Game Seeks to Discover Cancer Cures
17
FDA Issues Final Guidance on Mobile Medical Apps
22
Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit
24
News Highlights from the 2013 mHealth Summit
38
Can mHealth Provide Answers to the Rising Costs of Chronic Condition Management?
48
Product Profiles
49
Company Profiles
50
Upcoming Events
50
Advertisers Index
Google Unveils Contact Lens Sensor Capable of Measuring Gluclose Levels
Affordable Care Act
Samsung Receives FDA Clearance for S Health App
mHealth Alliance announces move to South Africa
QardioArm...A Revolutionary Blood Pressure Monitor
To advertise in
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The
Journal of mHealth
Journal of mHealth
Please visit our website at www.simedics.org
Contact Matthew Driver matthew@simedics.org +44 (0)1756 709605
The Global Voice of mHealth
The Global Voice of mHealth
For editorial, research and paper submissions please contact Matthew Driver at matthew@simedics.org
3 The Journal of mHealth
mHealth...A Global Market
mHealth...
The global mHealth market is growing at a rapid pace. A report published by Kalorama in 2013 [1] suggests that the size of the market grew by 237% within the five-year period from 2008. With similar predictions being made for the market in the near future, digital healthcare looks set to be a significant element of the wider healthcare market, sooner rather than later. The same report describes the market as still being in its infancy, considered to be small to
4 February 2014
A Global Market
moderate in size. However, the effectiveness of the solutions on offer are providing benefits that can be valued far beyond the capitalisation figures suggest. “Currently mobile penetration is reaching saturation in developed markets and is rapidly increasing in developing markets such as Asia-Pacific, Latin America and Africa. Moreover, increasing exposure to smartphones along with 3G and 4G
networks is futher boosting the rate of adoption of mobile devices across markets and particularily in healthcare systems. Furthermore, a shift can be observed from hospitalcare to personal-care as mobile healthcare systems are providing seamless support and care to patients irrespective of their locations. On top of that, the advent of a new generation of connected medical devices and personal health tracking monitors are making it easier for
mHealth...A Global Market healthcare providers to serve patients effectively and at a lower cost.” [2] North America leads the regional landscape of the global mHealth market followed by Europe and Asia Pacific. However, by 2020, Europe and Asia Pacific are predicted to take away this lead, with each occupying more than 28% of the market. [2] It is also predicted that the next few years will see the commercialisation phase of the mobile healthcare services market, as the industry begins to more effectively monetise the solutions that are already on offer, or in development. Estimates are that this phase will push the market value
mHealth services: - Ageing population. Ageing populations and the associated increase in chronic illness across the developed world is fuelling the growing demand for innovative delivery solutions. Healthcare organisations and national health provision is responding to this growth in demand by seeking methods that improve the access to, and efficacy of services provided, as well as increase consumer engagement with treatment and care pathways, and reduce hospital admission rates. - Increases in healthcare costs. As costs of healthcare provision continue to rise, health providers, organ-
helping to drive consumer-led health provision and reduce the number of physical interactions required in the doctor-patient relationship. - Wearable technology. Wearable technology also shows signs of significant residual growth. The world market for wearable technology reached $8.5 billion in revenues during 2012, shipping 96 million devices that year. By 2018, unit shipments are forecast to reach 210 million, driving $30 billion in revenue. These figures include a diverse range of product types and applications including healthcare, fitness, infotainment, industrial and military. [4]
In this article we take a snapshot of the global mHealth market, considering some of the issues influencing the industry, in a variety of different regions around the world upwards of $26 billion by 2017 [3]. “With the growing sophistication level of mHealth applications, only 9% of the total market revenue in the next five years will come from application download revenue,” suggests Patrick Houck in a statement in the same report by mobile research company Research2Guidance. “84% of total mHealth application market revenue will come from related services and products such as sensors.” Factors generating the need for
isations, and governments are all searching for solutions that can keep pace with growing demand, whilst delivering real-term cost savings. mHealth, telehealth, remote monitoring and telemedicine are all methods that have become attractive solutions to these problems. - Advances in technology. Innovation is rapidly changing the dynamics surrounding the delivery of healthcare. Tailored solutions are
UNITED KINGDOM A recent report published by PwC [5] highlights the growing interest for mHealth solutions in the United Kingdom. The report references the many projects and initiatives that are underway across the UK to increase the wider use and efficacy of mobile enhanced services and Digital Health solutions. The UK National Health SerContinued on page 6
5 The Journal of mHealth
mHealth...A Global Market Continued from page 5
vice has recognised the benefits of using telehealth and telecare solutions with the recent introduction of the “3 million lives” campaign. This massive undertaking by the Service aims to use connected solutions to enhance the way in which patients are treated across the whole health system. The campaign, which comes about following the NHS whole system demonstrators (the long-term NHS trials used to determine the efficacy of eHealth and mHealth services), has estimated that the increased use of telehealth and telecare services could help to reduce emergency admissions by up to 20%. As well as decreasing the rates of elective readmissions, the number of bed days required by patients, and overall reduce rates of mortality [6]. In fact in the UK six in ten clinicians and payers (NHS insurers and private payers) believe that the widespread adoption of mHealth is inevitable in the near future [7]. A recent survey [8] conducted by research company YouGov on behalf of legal firm Pinsent Masons found that: » 31% of respondents agreed mHealth services could improve the NHS » 33% of respondents would be willing to use mHealth services to have their health monitored remotely » 50% of respondents would be willing to use an application to book an NHS appointment This recent shift in attitudes is helping to push the mHealth issue and driving the implementation
6 February 2014
of projects, across the country. The Manchester mHealth ecosystem [9] is a good example of the way in which collaboration between healthcare providers; universities; and industry partners are helping to develop solutions that integrate between stakeholders. The Manchester organisation is part of a wider network of ecosystems for the European Connected Health Alliance [10] that is seeking to widen the scope for shared learning and innovation, and facilitate access to the international mHealth marketplace.
in the UK, France, Germany, Italy, Spain and Belgium. The survey took a plain English approach to questioning, removing industry jargon and buzz terms, to help determine whether consumers are open to the increased adoption of mobile centred health services. Across a range of topics from, remote health monitoring, and, diet and activity tracking the survey found that the majority of those questioned are open to mobile applications and services that will help them better understand their health issues.
The market for mHealth is not withIn addition to the consumer-centric out obstacles. The same issues in Europe, research YouGov survey found analysts suggest that 59% that, prior to being the economic given a definition hardships of of patients of mHealth, recent years in emerging the majority of experienced respondents markets use mHealth, in many didn’t know European compared to 35% what the term countries meant. Worse, have forced in developed even when it g ove r n m e n t s markets was explained, 90% to review options stated they never use to control costs in the mHealth services, despite exhealthcare systems, which in amples given including established turn is presenting opportunities for applications such as fitness apps. digital medicine. This demonstrates that there is a significant lack of consumer underNORTH AMERICA standing surrounding the technology and it may be that this proves The United States and Canada curto be a significant barrier to wider rently represent the largest markets adoption. for mHealth solutions and this looks likely to continue between now and EUROPE 2020. The region has an established demand for technology driven The same issues that are affecting products and services, and benefits the UK mHealth market appear to from a population with a well develbe the same primary issues across oped knowledge of technology and many European regions, including, mobile applications. This informed Scandinavia, Germany, France, and consumer base is helping to drive Spain. A recent survey by Bryter the widespread adoption of mobile health solutions and digital health questioned more than 1,100 adults
mHealth...A Global Market services. Within the market a number of trends look set to shape development over the next few years, including: - Smartphone user penetration driving mHealth uptake - mHealth applications becoming more tailored for smartphone and tablet usage - mHealth business models set to mature and broaden - Applications and mobile solutions will enter the traditional health distribution channels The introduction of the Affordable Care Act in early 2014 should also see organisations moving towards the increased delivery of mHealth services with the aim of increasing consumer choice whilst realising cost-savings through technologyled service introduction. The appetite amongst investors for digital health start-ups also shows signs of market maturity. Success stories like Scanadu and FitBit demonstrate the wider sentiment for opportunity within the digital health sector. Demand for remote monitoring solutions has similarly risen in response to aging populations, dwindling healthcare resources, and penalties for readmissions. The report by Kalorama Information estimates that this sector alone in the US was valued at $10.6 billion in 2012 and that it could reach upward of $20.9 billion by 2016 [1]. Despite the significant opportunities for growth there still remain some barriers. The FDA final guidance on mobile medical applications report 2013 [11] (see page 17) has
gone some way to clarifying the regulatory framework for the development and implementation of mobile applications, but there are still a number of areas that will need clarification in the near future. In addition industry collaboration on technical interoperability is needed to help ensure that the mobile health ecosystem has the ability to interact between services and solutions.
EMERGING MARKETS Emerging markets are showing significant growth in mHealth deployment over- and- above the traditional western healthcare markets. Existing healthcare is often scarce — in many cases, mobile technology is the only (rather than alternative) affordable tool to reach people. The lack of existing infrastructure means fewer entrenched interests, so lower barriers. Change is more welcome. 59% of patients in emerging markets use mhealth, compared to 35% in developed markets – Patients and doctors in emerging markets are much more likely to use mHealth than those in developed countries — and more payers in emerging markets cover the cost of mHealth than in developed countries. A study by PwC identifies a number of trends in countries such as Brazil, China, India, and South Africa [12]. In India the report shows that 81% of patients questioned would be interested in having services that would allow them to better monitor their own health. Similar figures were also evident among patient groups in China, Latin American countries, and South Africa. Respondents in China were also particularly open to appli-
cations and services that would integrate with medical devices to help monitor conditions. Indeed, it is predicted that China will represent the second biggest mHealth market by 2017. According to PwC the Chinese government’s establishment of electronic health records, healthcare reform priorities, and an increase in ‘patient-centric’ healthcare delivery will drive an increase in the need for transformative technologies and medical practices. The report commissioned by the China-Britain Business Council suggests that by 2017 China will be the second largest mobile health market, after the US, generating an estimated $2.5 billion in revenues [13]. This edition of The Journal of mHealth includes reports and studies from a number of regions around the world that consider some of the many complexities surrounding the existing mHealth and Digtial Health care sectors, including predictions for the future. 1 Advanced Remote Patient Monitoring Systems, Kalorama Information 2013 2 mHealth Market (Devices, Applications, Services & Therapeutics) - Global Mobile Healthcare Industry Size, Analysis, Share, Growth, Trends and Forecast, 2012 – 2020. Allied Market Research 3 Mobile Health Market Report, Research2Guidance 2013 4 http://www.imsresearch.com/report/wearable_technology_world_2013 5 mHealth in the UK - Paths for Growth. PWC 2012 6 http://www.3millionlive.co.uk 7 Economist Intelligence Unit, PWC 2012 8 http://www.pinsentmasons.com/PDF/DigitalHealth-Winter-2013 9 http://www.informatics.manchester.ac.uk/mhealthecosystem 10 http://www.echalliance.com 11 http://www.fda.gov/medicaldevices/productsandmedicalprocedures/connectedhealth/mobilemedicalapplications 12 http://www.pwc.com/gx/en/healthcare/mhealth/ opportunities-emerging-markets 13
http://www.cbbc.org
7 The Journal of mHealth
INDUSTRY NEWS News and Information for Digital Health Professionals
Scanadu Secures $10.5 Million in Funding One of the big mHealth stories of 2013 came from Scanadu, and the company looks set to keep making headlines throughout 2014. The company announced in late 2013 that following the overwhelming success of their crowdfunding campaign on Indiegogo, they had received $10.5 million in December in Series A funding. Relay Ventures led the round of funding with participation from Tony Hsieh’s VegasTechFund, Jerry Yang’s Ame Cloud Ventures and others with a track record in building disruptive companies of great value in the mobile, cloud, consumer and healthcare industries. This new round of funding will be used to support Scanadu’s go-to market strategy and manufacturing, continue its path to FDA approval and add talent to the team. The company also announced that it has formed a Medical Advisory Board and will conduct its first clinical trials at the Scripps Translational Science Institute. Continued on page 12
8 February 2014
CES 2014...A Digital Health Showcase Digital Health Dominates CES 2014 This year’s Consumer Electronics Show was once again a tech-lover’s dream with the launch of curved screen televisions and ultra high definition screens amongst the many other tech and gadgetry innovations on show. One trend that was evident at this year’s event was the dominance of Digital Health solutions. The organisers have reported a 40% increase, from last year, in the number of digital health exhibitors. In real terms this meant over 300 medical technology exhibitors. John D. Korry, Managing Director of medical equipment technology consultancy at Accenture, attributes this to the growing trends for digital technology across multiple industries. “We believe this is linked to an overarching trend, which is that every business is a digital business and every consumer, or patient, is a digital consumer.” The show also played host to the 5th Annual Digital Health Summit, with keynote speakers across all areas of digital health, focusing on the latest products and growing consumer demand for high-tech health services, particularly through the lens of the Affordable Care Act. Companies on display encompassed solutions for diagnostics, monitoring and treatmeant of a variety of illnesses -- from obesity to ADHD, from poor vision to high blood pressure.
Industry News
Google Unveils Contact Lens Sensor Capable of Measuring Gluclose Levels turised glucose sensor that are embedded between two layers of soft contact lens material. The company is testing prototypes that can generate a reading once per second. They are also investigating the potential for this to serve as an early warning device for the wearer, by integrating tiny LED lights that could light up to indicate that glucose levels have crossed, above or below, certain thresholds. It is still early days for the technology, but Google has completed multiple clinical research studies which are helping to refine the prototype. Google continues to push healthcare tech innovation with the announcement that they have successfully developed a remote sensing contact lens that helps diabetes patients monitor their glucose levels. One of the big stories of recent weeks among the mHealth community has been the news that Google is in the process of developing a contact lens that is capable of working as a remote sensor for glucose levels. Much discussion has followed this announcement. Google has stated that it is in the process of testing a smart contact lens that is built to measure glucose levels in tears, using a tiny wireless chip and minia-
Google has announced they are in early discussions with the FDA, but that there is still a lot of work needed to turn this technology into a system that people can use. The company has declared that it intends to partner with companies in order to develop the technology into products that would be available for market. They suggest that these partners will be able to integrate the technology for a smart contact lens into apps that would make the measurements available to the wearer and their doctor. This project illustrates the continued ambition of Google to develop technology and solutions that have potential to become intrinsic in the way healthcare is delivered. ď Ž
Aordable Care Act On January 1, 2014, the entire healthcare industry in the United States changed, with the introduction of the Affordable Care Act (ACA). Technology looks set to play a key role in transforming the way consumers, payers and providers interact within the healthcare ecosystem. Consumers are set to have much greater control over the delivery of their
healthcare, and with this the demand for digital solutions is on course to dramatically increase over the course of the next few years. The Journal of mHealth will be featuring the ACA, and considering the impact it is likely to have upon the mHealth industry, in forthcoming editions. ď Ž
9 The Journal of mHealth
Industry News
Samsung Receives FDA Clearance for S Health App For the first time, Samsung has received FDA 510(k) clearance for its S Health app. The categorisation of the clearance as a cardiology signal transmitter suggests that the clearance will allow S Health to interface with additional connected medical devices in the United States. Samsung’s S Health app originally launched for Galaxy S III users in the UK in the summer of 2012. At the time, it received data from Lifescan’s OneTouch UltraMini/UltraEasy Blood Glucose Meter via a USB connection. It also worked with Omron’s blood pressure monitors and one of its body composition scales via Bluetooth, and similar devices from A&D. That release never found its way to the US, possibly because of FDA clearance concerns. S Health finally launched in the US with the Galaxy S4, but rather than connecting to third party medical devices, it relied on manual entry and purported to connect to three devices from Samsung: a weight scale, a heart rate strap, and a wrist-worn activity tracker. Those devices have still not been made available for purchase in the US, although the weight scale and heart rate strap can be purchased in
Samsung’s UK store. “S Health peripherals, specifically the Heart Rate Monitor Band and Connected Weight Scale, will be available before the end of the year,” the company told MobiHealthNews in an email last August. “Samsung is working on perfecting the S Band and will announce when we’re ready for its commercial launch.” Meanwhile, Samsung has continued to work on the S Health app in several ways. In August, the company added gamified avatar characters to the Korean version of the app. In October, Cigna and Samsung announced a multi-year partnership to enhance the app with content from Cigna. Samsung filed for clearance in July 2013. If FDA clearance is the factor that has held the company back from launching the various UK device connectivity features in the United States, this clearance could pave the way for rapid changes for US Samsung customers.
mHealth Alliance announces move to South Africa The international organisation, composed of more than 300 organisations from 59 countries, has announced a move to South Africa in 2014 and a co-location with the Johannesburg-based Praekelt Foundation, a long-standing leader in
10 February 2014
the development of programs that promote social well-being. Organisation officials say the move “reflects the alliance’s natural evolution to engage in projects and initiatives that focus on specific countries or regions, while still maintaining the
powerful global voice it has cultivated through its relationship with the UN Foundation.” “We’re proud of the catalytic role that the alliance has played in moving the mHealth, as well as the
Industry News broader global health and developin the HIMSS Media mHealth Summent communities, from the quesmit and delivered 26 catalytic grants tion of ‘whether’ mHealth ought and technical support to groups in to be pursued to the question of 14 countries, reaching an estimated ‘how’ to most effectively implement 31 million people around the globe it,” said Patty Mechael, the alliance’s with much-needed healthcare inforexecutive director, in an interview mation and services. The alliance with mHealth also manages News. “In reUn“This is a tremendously Health sponse to this bound, an onshift, the alli- positive development line resource, ance has been and has profor the alliance and the able to expand duced more entire community” its focus and than 20 pubincreasingly enlications and gage with mHealth on the countrytaken the lead in dozens of initialevel – from our work with the Intives for improving mHealth access novation Working Group mHealth in low- and middle-income nations. grantees in 14 countries throughout the world, to our engagement with “This move gives the alliance the the Government of Nigeria’s Saving opportunity to continue our imporOne Million Lives initiative, and now tant convening and global thought to our exciting network of mHealth leadership work, experts on the country and regional but we’ll now be level through the mHealth Expert able to inform that Learning Program (mHELP).” work with more in-country expe“We recognise that with around rience from the 700 days left to achieve the current Global South,” Millennium Development Goals Mechael said. (MDGs), there is need for even “This is a tremenmore concerted engagement on cadously positive depacity building for mHealth at the velopment for the country and regional level,” she alliance and the added. “When we made the decientire community. sion to move to the Global South, it It is something was largely in response to the questhat many people tion ‘How do we best capitalise on have been asking this perishable moment?’” for, and in conversations with a Hosted by the United Nations diverse range of Foundation, the alliance includes mHealth stakefounding partners Norad, the Rockholders we’ve efeller Foundation, the Vodaphone received an overFoundation, HP and the GSM Aswhelmingly posisociation. tive response to this decision. We Through the years, the mHealth Alare looking forliance has been an active participant ward to putting a
full transition plan into action next year.” “The UN Foundation has been proud to provide a home for the alliance and act as its ‘incubator’ for the past five years. This transition represents a unique opportunity to move an initiative beyond incubation and to a point where it can have an even greater impact on achieving the MDGs,” said Kathy Calvin, the UN Foundation’s president and CEO, in a recent press release. “We look forward to staying engaged in the important work of mobile health and to supporting the alliance’s efforts to mainstream mobile technology into health systems. We will also continue to engage in mHealth work through the Mobile Alliance for Maternal Action (MAMA).”
11 The Journal of mHealth
Industry News Continued from page 8
medical communities.
“We focus on backing ambitious entrepreneurs who are using mobile computing to unlock opportunity and create new markets,” said Kevin Talbot, co-founder and managing partner of Relay Ventures. “Walter’s vision for the future of consumer healthcare is profound and Scanadu stands to make a lasting impact on an industry ripe for disruption.”
“We are more determined than ever to make the first medical tricorder a reality,” said Scanadu founder and CEO Walter De Brouwer. “With the experience and expertise of this group of investors and advisors, we know we’re in the right position to take our vision all the way and put FDA approved devices in the hands of consumers.”
“Scanadu is right at the heart of the next generation of computing which combines mobility, sensors, cloud and big data,” said Jerry Yang, co-founder of Yahoo! and founding partner of Ame Cloud Ventures. “I am bullish on Scanadu and its potential to revolutionise the way we think about our health.” In July of this year, Scanadu closed a crowdfunding campaign on Indiegogo that quickly became the most funded campaign in the platform’s history, raising more than $1.6 million. Those who participated in the campaign will be a crucial part of the company’s road to FDA approval by taking part on a voluntary basis in a usability study for
12 February 2014
the Scanadu Scout™ in 2014. Other participating investors in the Series A round include Broe Group, Mindful Investors and Redmile Group. With this round, Scanadu has raised $14.7 million in funding to date.
MEDICAL ADVISORY BOARD AND FIRST CLINICAL TRIALS PAVE THE WAY TO MARKET Furthering the company on its path to market, Scanadu will conduct its first clinical trials for Scanadu Scout™ at the Scripps Translational Science Institute (STSI). Those studies will be conducted as part of the Wired for Health mobile trial, which includes patients who live with diabetes, hypertension and heart arrhythmia. This first baseline study will
help design future controlled studies, and will be designed to empower adults via a Scanadu Scout™ to yield optimal blood pressure. “The era of digital healthcare has arrived,” said Dr. Eric Topol, director of the STSI and chief academic officer for Scripps Health. “We are excited to bring Scanadu to Scripps to further the potential of this technology to improve lives.” Scanadu’s newly established Medical Advisory Board comprises leaders with deep experience from across the medical, regulatory and research fields. These advisors all have a stake in advancing consumer healthcare and will actively advise Scanadu on long-term strategy and facilitate the sharing of knowledge and innovation transfer between Scanadu and the larger research and
Scanadu is developing a portfolio of products that put the experience of an emergency room visit in the palm of your hand. Its first device, the Scanadu Scout™, is a vital sign monitor that analyses, tracks and trends your vitals - temperature, respiratory rate, oximetry, ECG, systolic blood pressure and diastolic blood pressure - in 10 seconds. The company is also creating a disposable urine analysis testing platform, ScanaFlo, which works with your smartphone to offer a complete urine analysis test in minutes. Once FDA approved, it could also measure for pregnancy complications, pre-eclampisa, gestational diabetes, heartrelated kidney problems and urinary tract infections.
Industry News
QardioArm...A Revolutionary Blood Pressure Monitor Qardio, a London-based start-up, is launching two new medical devices designed for those at risk of cardiovascular disease. This spring (2014) it will launch a blood pressure monitor and an ECG monitor, a simple white plastic cross with an Apple-like aesthetic, which send information over the internet to a doctor.
when expenses increase exponentially,” he said. QardioArm is a smart blood pressure monitor that connects wirelessly to a smartphone or tablet. It is controlled through an app, which automatically tracks measurements and uploads them to a dedicated cloud service where it can be shared with family, friends or doctors.
Alexis Zervoglos, a director at Qardio, said it was “completely focused” on the cost-saving drives by the National Health Service in the UK and the Affordable Care Act. The ECG monitor costs $449 and can be used indefinitely, compared with the current option which costs $2,000 for a single day, he said.
The device is a testament to simplicity. There are no buttons, no displays and no wires, just a sleek device whose design was inspired by a bound notebook. Unwrap it and it switches on, tap it and it pairs with your smartphone or tablet, press “START” and the rest is automatic.
“We’re trying to reduce the number of unnecessary doctors’ visits when you go in and take time and the doctor tells you you’re well, as well as focusing on stopping the condition progressing to acute illness
The company have launched the product at CES 2014 and have had considerable early success from their launch campaign on Indiegogo, reaching $25,000 in the first day. www.getqardio.com.
13 The Journal of mHealth
Tactio Health Group
Tactio Health Group Not many digital health companies can boast millions of users worldwide, across 16 different languages, but for Montreal based Tactio Health Group that is the reality of their unique position within the mHealth industry. Established in 2009 by serial entrepreneur Michel Nadeau, the company provides a suite of mobile software and systems that allow people to easily track their health and manage chronic conditions. For Michel the use of disruptive technologies has been a founding philosophy in his career and something that has been eloquently applied to the healthcare market in the creation of the Tactio Health Group. A Professional engineer, Michel was awarded the “Young Engineer Achievement Award” by the Canadian Council of Professional Engineers, in 2000, for his first start-up which used software and off-the-shelf diagnostic equipment, to manage very large scale IP Telephony networks, an industry previously dominated by expensive hardware and specialised computers that barely talked to one another. The vision for Michel with Tactio Health Group was to deliver a health platform that could be entirely
mobile. From the beginning the concept for the diagnostic elements of the system was to utilise software and off-the-shelf connected health devices. In the early days of the company’s development, when connected healthcare was still very much in its infancy, this meant that there were very few products and solutions to work with. Fast forward to the present, and the growth of connected devices and mobile solutions in the burgeoning digital health market means that the solutions developed by Tactio are uniquely positioned to interface with a whole spectrum of different digital health solutions and devices. The company has close to 4 million people worldwide across 16 different languages tracking their health on its iOS and Android health applications, which allow for connectivity with almost 75 different activity and lifestyle tracking devices, and offthe-shelf medical diagnostic tools. In addition to the consumer health market the company serves many large healthcare organisations with its turnkey mobile health management solution TactioRPM™, a solution that delivers healthcare applications ranging from corporate wellness to remote monitoring, all within a disruptive business model. The TactioRPM™ system has three main components: RPM1000™, RPM6000™ and RPM7000™, collectively working together for the patient, clinician and secured cloud respectively. What makes the TactioRPM™ unique is the ability to bring together multi-vendor connected health devices, lifestyle vitals, physical activity and chronic disease measurements into a single mobile platform that applies science-based medical rules to every data point received. Providing instant feedback to patients as to where they stand, how well they are doing or how they are controlling their disease. The solution provides Hospital Groups, Pharmacy Chains, Home Care Service Providers, Nursing Institutions and other care organisations, who need to make the ‘build or buy decision’, with all the components required to deploy a mobile health system and start integrating it with their EHR, Patient Portals, and other digital health systems.
15 The Journal of mHealth
Innovative Smartphone Game Seeks to Discover Cancer Cures
Innovative Smartphone Game Seeks to Discover Cancer Cures Cancer Research UK has unveiled Play to Cure: Genes in Space - a world-first mobile phone game in which people across the globe will be able to help scientists unravel gene data to find the answers to some of cancer’s toughest questions. When playing the interactive spaceship game, people will simultaneously analyse Cancer Research UK’s gene data, highlighting genetic faults which can cause cancer – and ultimately help scientists develop new treatments. Players must guide a fast-paced spaceship safely along a hazardstrewn intergalactic assault course to collect precious material called ‘Element Alpha’. Each time the player steers the spaceship to follow the Element Alpha path, this information is fed back to Cancer Research UK scientists – cleverly providing analysis of variations in gene data. Researchers can utilise this information to work out which genes are faulty in cancer patients – and ultimately develop new drugs that target them, speeding our progress towards personalised medicine. Each section of gene data will be tracked by several different players to ensure accuracy. Hannah Keartland, citizen science lead for Cancer Research UK, said: “Our world-first Smartphone game is simply out of this world. Not only is it great fun to play – but every single second gamers spend
16 February 2014
directly helps our work to bring forward the day all cancers are cured. Our scientists’ research produces colossal amounts of data, some of which can only be analysed by the human eye – a process which can take years. Genes in Space is trying to help scientists analyse data generated by a technology called gene microarrays. Researchers use gene microarrays to look for regions of our genome that are frequently faulty in different cancers – a sign that they may be responsible for causing the cancer. If scientists can find genes that promote cancer development, they can design drugs to stop them. Gene microarrays are useful for analysing large genetic faults known as copy number alterations – when a whole section of the chromosome is gained or lost. As these large sections of chromosomes may involve many different genes, scientists need a way to work out which are the ones driving cancer, and which
are just “passenger” genes along for the ride. Microarrays let scientists analyse DNA from many thousands of tumour samples simultaneously, to find the most frequent changes that are more likely to be the culprits. Many scientists are trying to use computer software to trawl through the huge amounts of data generated to spot the precise location of copy number changes, but in many cases these are not accurate enough. The human eye is still the best technology we have for picking up these patterns, and Play to Cure: Genes in Space, is harnessing this power. Professor Carlos Caldas, senior group leader at the Cancer Research UK Cambridge Institute, University of Cambridge, said: “Future cancer patients will be treated in a more targeted way based on their tumour’s genetic fingerprint and our team is working hard to understand why some drugs work and others won’t. But no device can do this re-
FDA Issues Final Guidance on Mobile Medical Apps liably and it would take a long time to do the job manually. Play to Cure: Genes in Space will help us find ways to diagnose and treat cancer more precisely – sooner.” Dr Harpal Kumar, Cancer Research UK’s chief executive, said: “We’re enormously proud to launch our first mobile phone game which we believe will build on the great
progress we’re making to discover and develop the most effective new treatments for all cancers. “This is ambitious – it’s no mean feat combining the most advanced genetic data with cutting-edge gaming technology. But Cancer Research UK will go to whatever lengths possible to pursue the most innovative approaches to increase survival
from cancer. “And now we’re calling on our supporters to join in by asking everyone to give up five minutes to play this fantastic game and help us discover cures for cancer sooner.” For more information and to download the game visit: www.genes-inspace.org.
FDA Issues Final Guidance on Mobile Medical Apps
USA
“Our [FDA] mobile medical app policy provides app developers with the clarity needed to support the continued development of these important products” September 2013 saw the U.S. Food and Drug Administration issue their long-awaited final guidance for developers of mobile medical applications. The agency intends to exercise enforcement discretion (meaning it will not enforce requirements under the Federal Drug & Cosmetic Act) for the majority of mobile apps as they pose minimal risk to consumers. The FDA intends to focus its regulatory oversight on a subset of mobile medical apps that present a greater risk to patients if they do not work as intended. Mobile apps have the potential to transform health care by allowing doctors to diagnose patients with potentially life-threatening conditions outside of traditional health care settings, help consumers manage their own health and wellness, and also gain access to useful information whenever and wherever they need it. Mobile medical apps currently on the market can, for example, diagnose abnormal heart rhythms, transform smart phones into a mobile ultrasound device, or function as the “central command” for a glucose meter used by a person with insulin-dependent diabetes.
“Some mobile apps carry minimal risks to consumer or patients, but others can carry significant risks if they do not operate correctly. The FDA’s tailored policy protects patients while encouraging innovation,” said Jeffrey Shuren, M.D., J.D., director of the FDA’s Centre for Devices and Radiological Health. The FDA is focusing its oversight on mobile medical apps that are intended to be used as an accessory to a regulated medical device – for example, an application that allows a health care professional to make a specific diagnosis by viewing a medical image from a picture archiving and communication system (PACS) on a smartphone or a mobile tablet; or transform a mobile platform into a regulated medical device – for example, an application that turns a smartphone into an electrocardiography (ECG) machine to detect abnormal heart rhythms or determine if a patient is experiencing a heart attack. Mobile medical apps that undergo FDA review will be assessed using the same regulatory standards and riskContinued on page 18
17 The Journal of mHealth
FDA Issues Final Guidance on Mobile Medical Apps Continued from page 17
based approach that the agency applies to other medical devices. The agency has stated that it does not regulate the sale or general consumer use of smartphones or tablets nor does it regulate mobile app distributors such as the ‘iTunes App store” or the “Google Play store.”
Specific examples of mobile apps that FDA does not consider to be devices and with no regulatory requirements under the current laws administered by FDA include:
1. Mobile apps that are intended to provide access to electronic “copies” (e.g., e-books, audio books) of medical textbooks or other reference “We have worked hard to strike the right materials with generic text search balance, reviewing only the mobile apps capabilities. These are not dethat have the potential to harm conMobile apps vices because these apps are sumers if they do not function intended to be used as refhave the potential properly,” said Shuren. “Our erence materials and are mobile medical app policy proto transform healthcare not intended for use in vides app developers with the the diagnosis of disease by allowing doctors to clarity needed to support the or other conditions, or continued development of diagnose patients with in the cure, mitigation, these important products.” treatment, or prevention potentially life-threatening of disease by facilitating The agency has cleared about conditions outside of a health professional’s as100 mobile medical applicasessment of a specific patraditional healthcare tions over the past decade; about tient, replacing the judgment 40 of those were cleared in the past settings... of clinical personnel, or pertwo years. forming any clinical assessment. Examples include mobile apps that are: The following extracts from the guidance report sets out the type of apps that the FDA consider may meet the definition of medical device but for which FDA intends to exercise enforcement discretion, and those that the department will not consider to be a medical device and therefore outside of the regulatory scope. That is not to say that these applications will not have to meet other regulatory requirements. Examples of mobile apps that are NOT considered medical devices This extract provides a representative list of mobile app functionalities to illustrate the types of mobile apps that could be used in a healthcare environment, in clinical care or patient management, but are not considered medical devices. Because these mobile apps are not considered medical devices, FDA does not regulate them. The FDA understands that there may be other unique and innovative mobile apps that may not be covered in this list that may also constitute healthcare related mobile apps. This list is not exhaustive; it is only intended to provide clarity and assistance in identifying when a mobile app is not considered to be a medical device.
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• •
• • • •
Medical dictionaries; Electronic copies of medical textbooks or literature articles such as the Physician’s Desk Reference or Diagnostic and Statistical Manual of Mental Disorders (DSM); Library of clinical descriptions for diseases and conditions; Encyclopedia of first-aid or emergency care information; Medical abbreviations and definitions; Translations of medical terms across multiple languages.
2. Mobile apps that are intended for health care providers to use as educational tools for medical training or to reinforce training previously received. These may have more functionality than providing an electronic copy of text (e.g., videos, interactive diagrams), but are not devices because they are intended generally for user education and are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease by facilitating a health professional’s assessment of a specific patient,
FDA Issues Final Guidance on Mobile Medical Apps replacing the judgment of clinical personnel, or performing any clinical assessment. Examples include mobile apps that are: • • • • • •
Medical flash cards with medical images, pictures, graphs, etc.; Question/Answer quiz apps; Interactive anatomy diagrams or videos; Surgical training videos; Medical board certification or recertification preparation apps; Games that simulate various cardiac arrest scenarios to train health professionals in advanced CPR skills.
3. Mobile apps that are intended for general patient education and facilitate patient access to commonly used reference information. These apps can be patient-specific (i.e., filters information to patient-specific characteristics), but are intended for increased patient awareness, education, and empowerment, and ultimately support patient-centered health care. These are not devices because they are intended generally for patient education, and are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease by aiding clinical decision-making (i.e., to facilitate a health professional’s assessment of a specific patient, replace the judgment of a health professional, or perform any clinical assessment). Examples include mobile apps that: •
• • • • •
Provide a portal for healthcare providers to distribute educational information (e.g., interactive diagrams, useful links and resources) to their patients regarding their disease, condition, treatment or up-coming procedure; Help guide patients to ask appropriate questions to their physician relevant to their particular disease, condition, or concern; Provide information about gluten-free food products or restaurants; Help match patients with potentially appropriate clinical trials and facilitate communication between the patient and clinical trial investigators; Provide tutorials or training videos on how to administer first-aid or CPR; Allow users to input pill shape, color or imprint and displays pictures and names of pills that match this description;
•
Find the closest medical facilities and doctors to the user’s location; • Provide lists of emergency hotlines and physician/nurse advice lines; • Provide and compare costs of drugs and medical products at pharmacies in the user’s location. 4. Mobile apps that automate general office operations in a health care setting and are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. Examples include mobile apps that: • • • • • • • • •
Determine billing codes like ICD-9 (international statistical classification of diseases); Enable insurance claims data collection and processing and other apps that are similarly administrative in nature; Analyse insurance claims for fraud or abuse; Perform medical business accounting functions or track and trend billable hours and procedures; Generate reminders for scheduled medical appointments or blood donation appointments; Help patients track, review and pay medical claims and bills online; Manage shifts for doctors; Manage or schedule hospital rooms or bed spaces; Provide wait times and electronic check-in for hospital emergency rooms and urgent care facilities.
5. Mobile apps that are generic aids or general purpose products. These apps are not considered devices because they are not intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. Examples include mobile apps that: •
Use the mobile platform as a magnifying glass (but are not specifically intended for medical purposes); • Use the mobile platform for recording audio, note-taking, replaying audio with amplification, or other similar functionalities; • Allow patients or healthcare providers to interact through email, web-based platforms, video or other communication mechanisms (but are not Continued on page 20
19 The Journal of mHealth
FDA Issues Final Guidance on Mobile Medical Apps Continued from page 19
•
specifically intended for medical purposes); Provide maps and turn-by-turn directions to medical facilities.
•
Examples of mobile apps for which FDA intends to exercise enforcement discretion •
This extract provides examples of mobile apps that MAY meet the definition of medical device but for which FDA intends to exercise enforcement discretion. These mobile apps may be intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease. Even though these mobile apps MAY meet the definition of medical device, FDA intends to exercise enforcement discretion for these mobile apps because they pose lower risk to the public.
•
The FDA understands that there may be other unique and innovative mobile apps that may not be covered in this list that may also constitute healthcare related mobile apps. This list is not exhaustive; it is only intended to provide clarity and assistance in identifying the mobile apps that will not be subject to regulatory requirements at this time:
•
•
•
•
• •
Mobile apps that help patients with diagnosed psychiatric conditions (e.g., post-traumatic stress disorder (PTSD), depression, anxiety, obsessive compulsive disorder) maintain their behavioral coping skills by providing a “Skill of the Day” behavioral technique or audio messages that the user can access when experiencing increased anxiety; Mobile apps that provide periodic educational information, reminders, or motivational guidance to smokers trying to quit, patients recovering from addiction, or pregnant women; Mobile apps that use GPS location information to alert asthmatics of environmental conditions that may cause asthma symptoms or alert an addiction patient (substance abusers) when near a pre-identified, high-risk location; Mobile apps that use video and video games to motivate patients to do their physical therapy exercises at home; Mobile apps that prompt a user to enter which
20 February 2014
•
• • • •
herb and drug they would like to take concurrently and provide information about whether interactions have been seen in the literature and a summary of what type of interaction was reported; Mobile apps that help asthmatics track inhaler usage, asthma episodes experienced, location of user at the time of an attack, or environmental triggers of asthma attacks; Mobile apps that prompt the user to manually enter symptomatic, behavioral or environmental information, the specifics of which are predefined by a health care provider, and store the information for later review; Mobile apps that use patient characteristics such as age, sex, and behavioral risk factors to provide patient-specific screening, counseling and preventive recommendations from well-known and established authorities; Mobile apps that use a checklist of common signs and symptoms to provide a list of possible medical conditions and advice on when to consult a health care provider; Mobile apps that guide a user through a questionnaire of signs and symptoms to provide a recommendation for the type of health care facility most appropriate to their needs; Mobile apps that record the clinical conversation a clinician has with a patient and sends it (or a link) to the patient to access after the visit; Mobile apps that are intended to allow a user to initiate a pre-specified nurse call or emergency call using broadband or cellular phone technology; Mobile apps that enable a patient or caregiver to create and send an alert or general emergency notification to first responders; Mobile apps that keep track of medications and provide user-configured reminders for improved medication adherence;
“Some mobile apps carry minimal risks to consumer or patients, but others can carry significant risk if they do not operate correctly. The FDA’s tailored policy protects patients while encouraging innovation”
FDA Issues Final Guidance on Mobile Medical Apps •
• •
• • • •
Mobile apps that provide patients a portal into their own health information, such as access to information captured during a previous clinical visit or historical trending and comparison of vital signs (e.g., body temperature, heart rate, blood pressure, or respiratory rate); Mobile apps that aggregate and display trends in personal health incidents (e.g., hospitalisation rates or alert notification rates); Mobile apps that allow a user to collect (electronically or manually entered) blood pressure data and share this data through e-mail, track and trend it, or upload it to a personal or electronic health record; Mobile apps that provide oral health reminders or tracking tools for users with gum disease; Mobile apps that provide prediabetes patients with guidance or tools to help them develop better eating habits or increase physical activity; Mobile apps that display, at opportune times, images or other messages for a substance abuser who wants to stop addictive behavior; Mobile apps* that are intended for individuals to log, record, track, evaluate, or make decisions or behavioral suggestions related to developing or maintaining general fitness, health or wellness, such as those that: » Provide tools to promote or encourage healthy eating, exercise, weight loss or other activities generally related to a healthy lifestyle or wellness; » Provide dietary logs, calorie counters or make dietary suggestions; » Provide meal planners and recipes; » Track general daily activities or make exercise or posture suggestions; » Track a normal baby’s sleeping and feeding
habits; » Actively monitor and trend exercise activity; » Help healthy people track the quantity or quality of their normal sleep patterns; » Provide and track scores from mind-challenging games or generic “brain age” tests; » Provide daily motivational tips (e.g., via text or other types of messaging) to reduce stress and promote a positive mental outlook; » Use social gaming to encourage healthy lifestyle habits; » Calculate calories burned in a workout. *When these items are not marketed, promoted or intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, or do not otherwise meet the definition of medical device, FDA does not regulate them. When they are marketed, promoted or intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, or otherwise meet the definition of medical device, FDA intends to exercise enforcement discretion. The publication of this report signifies a step change for developers of applications and services that rely upon mobile delivery for provision of healthcare solutions. The FDA’s clear position allows for developers to more easily interpret the regulatory landscape and to determine the best strategy to ensure compliance. Ref: Mobile Medical Applications – Guidance for Industry and Food and Drug Administration Staff. U.S Department of Health and Human Services Food and Drug Administration. September, 2013. For full report go to: http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ connectedhealth/mobilemedicalapplications
This could be your advertisement Contact Matthew at matthew@simedics.org or on +44 (0)1756 709605 for more details
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Journal of mHealth The Global Voice of mHealth
21 The Journal of mHealth
USA
Cisco Study: 74% of Consumers Open to Virtual Doctor Visit
Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit A 2013 study conducted by Cisco demonstrates the growing acceptance amongst consumers for the provision of healthcare services delivered using technology. The results of the report demonstrate that as information, technology, bandwidth, and integration of the network become the centre of the “new world,” both human and digital aspects are key parts to the overall patient experience. These components lead to more realtime, meaningful patient and doctor interaction. The survey studied the views of consumers and healthcare decision makers (HCDMs) on sharing personal health data, participating in in-person medical consultation versus remote care and using technology to make recommendations on personal health. Views on these topics differed widely between the two groups (consumers and HCDMs) and the ten geographies surveyed. The global report conducted in early 2013, includes responses from 1,547 consumers and HCDMs across ten countries. Additionally, consumers and HCDMs were
22 February 2014
polled from a wide variety of backgrounds and ages within each country.
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Most North American consumers – nearly eighty percent – are comfortable submitting a complete medical history and diagnostic information to help ensure they have all the information available to treat them and offer the most personal diagnosis possible. Ninety percent of Russian consumers expressed comfort, while fifty percent of Japanese customers expressed discomfort with the idea of submitting DNA.
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Though roughly half of HCDMs believe data protection is adequate for protecting health and medical data privacy in their respective countries, fewer consumers believe data protection is adequate. The largest discrepancy among consumers and HCDMs is observed in Brazil, as approximately twothirds of consumers feel data protection in their country is adequate while about 8 in 10 HCDMs believe otherwise. In the U.S, close to sixty percent of HCDMs expressed confidence while only forty percent of consumers shared that sentiment.
PRIVACY AND PERSONAL SERVICE This portion of the survey focused on how comfortable consumers and HCDMs are with sharing personal health and medical information for a better experience. Overall, health care practitioners were more willing to share personal and private information than patients or other citizens. The degree to which all clinicians, patients and citizens are willing to share personal health information and to improve the quality of care varies by geography. Key findings: » Most consumers are comfortable with having all of their health records securely available on the cloud except for those in Germany and Japan. »
Nearly half of the consumers surveyed and two-thirds of the HCDMs surveyed would be comfortable sharing and receiving health information through social media channels.
Cisco Study: 74% of Consumers Open to Virtual Doctor Visit
IN-PERSON VS. VIRTUAL CUSTOMER SERVICE The report findings challenged the assumption that face-to-face interaction is always the preferred health care experience. While consumers still depend heavily on inperson medical treatments, given a choice between virtual access to care and human contact, three quarters of patients and citizens would choose access to care and are comfortable with the use of technology for the clinician interaction. Key findings: » Three quarters of consumers indicate they are comfortable with the idea of communicating with doctors using technology instead of seeing them in person. »
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In China, Russia and Mexico, nearly three-quarters of consumers would be comfortable communicating with a specialist using virtual technology (e.g. video chatting, text messaging) for a health condition. More than 60 percent of consumers from Germany, Japan and the U.S. indicate being comfortable with the idea of being treated by a specialist using virtual technology. Patients and citizens will give up anything, including cost, convenience and travel, to be treated at a perceived leading health care provider to gain access to trusted care and expertise.
HOW MUCH DO CONSUMERS AND HCDMS RELY ON TECHNOLOGY? As machines become connected and networked, they play an even larger role in the overall health care experience. Interest in accessing health information on mobile devices is growing rapidly and is the No. 1 topic of consumer interest In Mexico, Brazil and China. Key findings: » About 4 in 10 consumers indicate they would be interested in receiving recommendations about doctors, hospitals, medication, etc., automatically through their computer or mobile devices. »
While the majority of consumers who have health care apps on their mobile devices indicate their apps are related to healthy eating and exercise, 25 percent indicate they are for chronic disease management.
» Nearly one in four indicates receiving health-related reminders on their device. “The patient and care provider experiences are top of mind in health care around the world. Due to the increasing convergence of the digital and physical, there is an opportunity to provide increased collaboration and information sharing among providers to improve the care experience and operate more efficiently,” said Kathy English, Public Sector and Healthcare Marketing, Cisco.
23 The Journal of mHealth
News Highlights from the 2013 mHealth Summit WebMD Health Corp the leading source of health information, announced at the mHealth Summit that it is expanding the beta program for its Patient Instructions feature, which enables physicians who use Medscape Mobile to securely send education and instructions on thousands of conditions, procedures and drugs to their patients who use the WebMD app for iPhone, or access WebMD on a PC or other mobile device. “WebMD is partnering with innovative companies like Qualcomm and developing new products and services like Patient Instructions to make health information more actionable and accelerate consumer-provider connectivity,” said David Schlanger, Chief Executive Officer at WebMD. “As consumers and providers assume more financial risk for the provision of care, WebMD believes that facilitating this kind of engagement is essential to producing quality outcomes and reducing the cost of care.” Qualcomm Life and WebMD first announced plans to enable consumers to upload biometric data to WebMD in an effort to proactively manage health and fitness, as well as chronic health conditions such as obesity and diabetes, at the HIMMS confer-
24 February 2014
ence in March 2013. WebMD will introduce its new app and set of services that deliver personalised content and actionable insights, as well as a new online storefront where consumers will be able to purchase a variety of biometric devices from the industry’s leading providers, in the first quarter of 2014. “WebMD is uniquely positioned to facilitate consumer-provider connectivity and accelerate the roll-out of quantified health solutions to the masses,” said Bill Pence, EVP, Chief Technology Officer and Chief Operating Officer, WebMD. “Our Patient Instructions service will enable consumers and their providers to jointly manage their care, and our partnership with Qualcomm Life will provide consumers with a more personalised WebMD experience that makes biometric data more actionable.” As part of the expanded Patient Instructions beta, Medscape providers can simply select from a set of over 4,200 clinically reviewed patient instructions and provide them to patients securely and confidentially by enabling patients to access and review the information in the WebMD app or in their browser. In addition, providers can manage lists of patients and
save favorite instruction sets for easy retrieval during the course of their daily workflow. WebMD expects to expand this capability over time to allow for more customisation and other types of information and services to be sent securely to patients. WebMD initiated the Patient Instructions beta in September 2013 to a limited number of Medscape Mobile physician users, and early feedback regarding features, functionality, workflow and the overall user experience confirmed strong interest in, and demand for, this capability. The beta is being expanded now to provide WebMD with additional feedback, which will be used to inform future product enhancements.
BIOSENSICS AND AVENTYN INC. ANNOUNCE A PARTNERSHIP TO OFFER A MOBILE REMOTE MONITORING PLATFORM FOR PHYSICAL ACTIVITY, ECG, GAIT, AND POSTURE PAMSys™ is a unique platform for long-term objective evaluation of individual’s physical activity during everyday life. Combined
with Aventyn’s Vitalbeat chronic disease management ecosystem, this web-based solution will enable hospitals, physician offices, university medical centres, home care providers, hospices and clinical researchers to remotely monitor patient physical activity and capture relevant changes in activities of daily living. The patented PAMSys technology is based on over 10 years of research supported in part by the National Institutes of Health. PAMSys is a lightweight, wearable motion sensor that uses advanced signal processing algorithms and novel biomechanical models of human motion to monitor body position, evaluate walking patterns, automatically detect falls, and assess sit-to-stand and stand-to-sit postural transitions. Vitalbeat™ is a simple, cost effective remote patient monitoring and integrated chronic disease management system for managing long term conditions. With Vitalbeat and advanced telehealth sensors like PAMSys, clinicians remotely monitor patient vital signs and activity levels securely using smartphones and tablet computers, and design long term disease management programs for co-morbidities associated with heart failure, diabetes, obesity, and many other conditions. Patients
manage diet, physical activity, and medication compliance by configurable alerts and reminders based on personalised thresholds, goals and clinical requirements. Patient electronic health record data integrates with Vitalbeat along with social networking sites like Twitter and Facebook to provide care continuity, group sharing and networking with clinicians, family and like-minded friends.
ton, D.C., Eric Dishman, Intel Fellow and general manager of Intel’s Health & Life Sciences Group, reiterated Intel’s belief that next generation technology for continuous monitoring of patient vital signs, such as ViSi® Mobile by Sotera® Wireless shown live during the keynote, could transform the delivery of care and benefit health outcomes, patient satisfaction, and healthcare costs.
PAMSys™ with Vitalbeat™ is selectively available for clinical research and commercial deployment by healthcare providers and payers. The two companies plan to provide remote patient monitoring solutions and subscription services for a variety of disease conditions to be billed under existing CPT codes for ambulatory electrocardiographic monitoring, education and patient self-management, and fall risk assessment, as well as new CPT codes based on clinical outcomes from ongoing and future clinical trials.
“A great example of mobile technology that holds promise to improve patient safety and the whole experience of being a high-risk patient is continuous monitoring of vital signs in the hospital,” said Dishman. “Rather than inconvenient manual spot checks that yield intermittent data, this mobile technology makes it possible for the first time to monitor all vital signs continuously through a small, wearable device that transmits data wirelessly.”
VISI MOBILE PRESENTED DURING ERIC DISHMAN’S MHEALTH SUMMIT KEYNOTE ADDRESS Following his keynote address at the mHealth Summit in Washing-
A finalist for CONNECT’s 2013 “Most Innovative Product” Award, the ViSi Mobile System packs powerful patient monitoring capabilities into a 4 ounce wrist-worn device ensuring clinicians anytime, anywhere access to accurate and trended vital sign information. With the recent addition of continuous, cuffless nonContinued on page 26
25 The Journal of mHealth
News Highlights from the 2013 mHealth Summit Continued from page 25
invasive blood pressure (cNIBP) technology, the ViSi Mobile System is the first body-worn monitor able to non-invasively measure all core vital signs on a highly accurate, beat-to-beat basis. Today, most patients who reside on general medical/surgical floors in hospitals lack access to continuous monitoring and instead receive infrequent vital sign spot checks throughout the day and night approximately every 4 hours. To collect vital sign measurements hospital clinicians must wheel monitoring equipment from patient to patient and use various tools, such as a blood pressure cuff, and finger clip to obtain vital sign readings at finite time points. Patients often complain that the process is disturbing, especially to measure blood pressure with a cuff, while clinicians must rely on limited, sometimes hours-old data to evaluate their patients’ health. “Spot checks are labor-intensive and analogous to driving a car and opening your eyes every 4 hours to make sure you are still on the road,” said Gunnar Trommer, Ph.D., Sotera Wireless vice president of marketing. “Potentially dangerous patient deterioration can occur unnoticed in the intervals between manual vital sign spot check measurements.” Trommer believes that the ViSi Mobile System’s unique capabilities will eventually change the standard of care by which nonICU hospital patients will be
26 February 2014
monitored in the very near future: ViSi Mobile is the only monitor on the market that allows continuous monitoring of all five core vital signs (SpO2/PR, ECG/HR, Resp, BP, Skin Temp) with ICUlevel accuracy in a wearable package that does not limit patient mobility.
alert is sent to the remote viewing/alarming device of choice. The resulting clinical / economical value includes: »
Avoiding expensive, preventable adverse events.
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Keeping patients in lower cost beds (e.g. out of the ICU) and allowing for faster patient disposition due to greater availability of “monitored beds” on the general floors.
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Not waking patients up in the middle of the night only to check their vitals, allowing for restful sleep – which will also increase financially relevant patient satisfaction.
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More efficient use of clinicians’ time – avoiding human error and time gaps in measuring, documenting and interpreting vital signs.
The nurse has access to the vital sign information “whenever
wanted”, meaning he or she can view patients’ vital signs on the wrist monitor itself, or on various remote viewing devices (central station, mobile tablet PC). The vital sign information can also be automatically fed into the patient record in the EMR. If a patient deteriorates, and a notification to the nurse is needed to prevent worsening of the patient’s condition, an automatic
“Eric Dishman’s vision of care anywhere aligns with our longterm strategy of connecting patients to clinicians across a multitude of healthcare settings – including the home. Adapting our healthcare system to such change begins in the hospital, where the advantages and benefits of comprehensive and wireless patient monitoring are imminent,” said Trommer.
Find out what’s on across the mHealth industry in our Upcoming Events section on page 50 The
Journal of mHealth The Global Voice of mHealth
EUROPE
EPHA Briefing on Mobile Health EUROPE
EPHA Briefing on Mobile Health The European Public Health Alliance (EPHA) is the European Platform bringing together public health organisations representing health professionals, patients groups, health promotion and disease specific NGO’s, academic groupings and other health associations. This is the full version of the briefing reproduce with permission of the EPHA.
INTRODUCTION The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery (...) A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services and the continued growth in coverage of mobile cellular networks [1]. To date, no standardised definition of mHealth has been established. According to the National Institution of Health in the United States, it can be defined as ‘using mobile and wireless devices to improve health outcomes, healthcare services and health research’ [2]. It is a subcomponent of the larger discipline of eHealth [3], which in turn describes the use of Information and Communication Technologies (ICT) for health purposes. Due to its wider accessibility via mobile devices – especially smartphones and self-monitoring gadgets - mHealth is a key emergent area in health today [4]. It includes solutions for direct care provision in health services, real-time monitoring of patients’ conditions, the provision of healthcare information to health professionals, patients and re-
searchers, and it can support public health, e.g. by collecting community and clinical health data. As stressed on the European Commission’s Digital Agenda for Europe website, ‘mobile health doesn’t focus exclusively on the device, but on the fact that the information and data is mobile (…) The information is able to be collected wherever it is needed and transmitted wherever it needs to go,’ [5]. A commercially lucrative sector with global reach, mHealth could become an important growth market under the Digital Agenda [6], as evidenced by hundreds of smartphone ‘apps’ placed on the market every week. But mHealth’s adaptability and faculty to provide information ‘on the go’ also poses new challenges for healthcare. The Commission’s eHealth Action Plan 2012-2020, rightly declares that ‘(…) such applications potentially offer information, diagnostic tools, possibilities to ‘self-quantify’ as well as new modalities of care. They are blurring the distinction between the traditional provision of clinical care by physicians, and the self-administration of care and wellbeing.’ [7] While the extent of its impact on health systems is difficult to predict, mHealth is set to play a
role in renegotiating the relationship between health professionals and patients. In so doing it triggers ethical questions about who is steering and managing health, and what this means for society. Crucially, while mHealth holds potential for improving access to healthcare services and mitigating health inequalities, it cannot substitute face-to-face contact. Like other eHealth solutions, it is best deployed as a complementary tool for the benefit of end users. Provided that the challenges described below can be overcome, It can help improve quality and continuity of care [8], inter alia by facilitating elements of healthcare provision and remote monitoring, allowing crossborder and interregional collaboration between health institutions and professionals, and providing more user-friendly and comprehensible ways for different categories of patients to manage health, including disadvantaged groups in need of ‘tailored’ support. Recent Developments in Healthcare In the majority of EU Member States healthcare systems are in need of reform as a result of budContinued on page 28
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get squeezes and workforce shortages, coupled with ageing populations and the simultaneous rise in chronic diseases. In the absence of political prioritisation, the public sector is forced to save healthcare costs while trying to cater to an increasingly diverse clientele demanding quality services. Hence policy makers are looking to foster innovation and efficiency in healthcare delivery. Many patients and older people also wish to be more engaged in their own care. In order to take advantage of personalised treatment regimes they require information and state-of-the-art technology. In this regard, mHealth can offer customised ‘toolkits’ for predictive, participatory and preventive care. While arguably, Europeans are becoming more informed about health thanks to online information, individual circumstances regarding access to technology, as well as competences regarding ICT use and applying health knowledge, still differ greatly between social groups, regions and Member States. About a quarter of Europeans have never used the Internet [9], and there are significant differences between Member States when it comes to computer access at home and on mobile devices [10]. Those who use eHealth regularly, confidently and efficiently can be more aware of the treatment options, medicines and medical devices [11] available to them. In stark contrast, most people struggle with various literacy problems, and lack of support and empowerment can lead to misunderstandings when putting online information into con-
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text, and to inaccuracies when apers by text for ensuring treatment plying it to health decision-making. compliance (e.g., patients receiving For example, self-diagnosis and SMS messages about the correct treatment based on data derived time and way of taking a medicine) from mobile technologies can be and keeping medical appointments, harmful if findings are not disis one of the strengths of mHealth. cussed with qualified health proAt the same time, sophisticated fessionals. The challenge is to find technologies merging the intricate the right balance between convenfeatures of eHealth and medical tional and ICT-enabled healthdevices provide the backbone for care that can support the work of functions involving real-time rehealth professionals while mote monitoring and transfer empowering patients of patient data in outpaand expanding tient settings, e.g. for Remote their (e)health managing chronic literacy. diseases. A conaccess to nected function centralised That said, concerns supthe founporting health EHRs can reduce dations for informaadministrative the digitaltion systems isation of and providing burdens by 20 to healthcare point-of-care 30% are already support. Morewell in place – over, broader aims electronic health in support of public records (EHR) and health management, e.g. wireless communication and redata collection and disease surveilporting devices are commonplace lance to control pandemics, can be in many EU Member States. While achieved. health professionals may not always easily embrace new technolSome specific examples (including ogy, they share the hope of many wireless health and electronic care patients that it can make routine solutions) include the following, tasks easier. which testify to the increased convergence of health technologies mHealth Applications and tools [12]: Currently mHealth can fulfil a number of different functions, many of which have been implemented in the developing world where mobile phones are fundamental due to the absence of conventional health system technologies.
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Medical devices acting as remote patient monitors – used in clinical, home, mobile & other environments
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Software applications allowing patients to upload or download health information at any time
Indeed the ability to perform simple tasks, such as sending remind-
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Clinical body area network sensors for wireless capture and
EPHA Briefing on Mobile Health forwarding of physiological data for further analysis »
Medical implants for neuromuscular micro-stimulation techniques: used in order to restore sensation, mobility & other functions to paralysed limbs and organs
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Medical device data systems allowing the transfer, storage, conversion or display of medical data through wired or wireless hubs, smartphones or broadband enabled products.
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Mobile diagnostic imaging applications making it possible for doctors to send or review medical images from virtually any place and at any time
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Patient care portals which can be accessed everywhere, allowing patients to share experiences, engage in self-reporting and self-management
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Accessible clinical decision support tools allowing doctors to help patients in real time with diagnosis, treatment options, necessary medical calculations at the point of care
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Broadband enabled health information technology infrastructures for healthcare providers to share electronic health information across institutions and geography
Since smartphones and other devices enable end users to be both senders / receivers of information and active agents in data generation, mHealth is arguably more engaging and interactive than other
health technologies.
mHEALTH STAKEHOLDERS Chances are that over time, mHealth will become routine as it reflects wider societal trends towards mobility and individualisation, coupled with issue-specific social networks. Especially for young people, there is no distinction anymore between on- and offline identities. This phenomenon heralds profound changes for healthcare. Apart from the principal stakeholders mentioned below, there is a broader range of players taking part in mHealth, including other formal and informal health providers, regulators, NGOs and manufacturers of products able to converge with mHealth. Patient-consumers mHealth can be a potentially useful tool for patients and consumers, whether by providing more control over disease management and treatment, assisting parents in safeguarding their children’s health, or by helping individuals improve their fitness and wellbeing. Convenience features such as managing hospital and health professionals’ appointments, updating prescriptions, accessing personal health records and advice hotlines facilitate patients’ engagement with health providers and can heighten customer satisfaction. By being able to self-monitor vital signs (e.g. blood pressure, pulse) and condition-specific measures
(e.g. glucose rate) through smartphone ‘apps’ and other gadgets, people are able to keep an eye on their health. They may stimulate individuals to become more ‘ambitious’ about their health – even competitive in a group setting – as they encourage users to practice self-control, e.g. by attaining daily or weekly exercise targets. However, caution must be taken when it comes to self-testing and diagnosing given the differences in quality, reliability and capability of mobile technologies, especially phones. A number of ‘apps’ are designed to restore patients’ personal autonomy, e.g. people with dementia and Alzheimer’s, while others encourage people to control their health behaviours, for instance intake of alcohol, smoking and nutrition. While mobile technology can benefit the immobile (e.g. remote monitoring via interactive terminals installed at home) it also holds appeal for those habitually mobile themselves: travellers can access up-to-date information about health threats, such as disease outbreaks and epidemics, and they can transmit self-generated information to health professionals at home in case of problems. Research undertaken by the Boston Consulting Group demonstrates that patients, when assuming more self-responsibility, generally become more (pro)active in improving their health. 86% of women having adopted this approach undergo breast cancer screening (compared to an average of 57%) and 99% undergo cholesterol testContinued on page 30
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Health Professionals
gets at the bedside can help illustrate conditions and reassure patients that they are being looked after by competent staff. Health professionals are also able to instantly record and share vital information during consultations (e.g. diagrams, instructions).
For health professionals, mHealth can also bring multiple benefits. In a climate of workforce shortages and scarce support, they can be empowered by accessing accurate information and evidence anywhere and anytime, while communication with colleagues becomes
It has been shown that monitoring and diagnostic ‘apps’ are more reliable if they involve transmission of information to qualified health professionals who analyse the information remotely. Given the range of tasks smartphones can perform – from recording to
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ing (compared to an average of 55%). Meanwhile, proactive care results in a 10 percent reduction in primary and urgent care visits. [13]
Thanks to mHealth, a larger percentage of the population can be served, including vulnerable individuals who may be more comfortable using mobile devices as they allow them to explore and ‘practise’ mHealth step-bystep, in their own time, and in informal settings. easier to better coordinate care. In addition, it allows for closer, more direct contact with patients. By being ‘virtually available’, health professionals can demonstrate their commitment, ask direct questions and provide targeted advice in an unobtrusive way, which may help them better understand patients’ concerns. Communication with patients living in geographically isolated or underserved areas also becomes easier, and condition- or community-specific health information can be sent directly to particular categories of patients. The use of tablets and health gad-
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planning and reporting on data – their use will likely become more common as bodily functions are monitored automatically. Another interesting use of apps supports, for instance, the identification of medicines and of counterfeit products by pharmacists. Nevertheless, mHealth will not work if it creates new professional burdens. For example, overloading health professionals with additional data input/processing and electronic communication tasks compromises rather than boosts quality of care. That is why these devices must be designed according to end
users’ needs. Continuous professional training in eHealth will also help build up confidence in using new technology. Vulnerable Groups The rapid expansion of smartphones is bringing the digital world closer to those who were hitherto excluded from ICT. This is because they are portable, compact, multifunctional (including camera, texting, diary / logs, GPS, maps, entertainment, e-mail, etc.), and with easy user interfaces (e.g. touch screens). ‘Apps’ provide relevant information in a more condensed, practical, and intelligible fashion than traditional Internet content. Mobile content also tends to be more adapted to quick reading and sharing. More importantly, smartphones are relatively affordable compared to other mobile technologies such as laptop computers or tablets although the cost of phones and related charges is still high enough to make them off-limits to the poor in many parts of Europe. While the ubiquity, speed of change and complexity of new technology can be overwhelming, older people may benefit from mHealth solutions that are easy-to-use and that assist them in checking their conditions, combined with regular supervision by qualified health professionals. This can make them feel safer and more in control. At least in theory, vulnerable groups such as migrants and other minority populations (e.g. Roma communities) can also benefit from mHealth, e.g. by accessing
EPHA Briefing on Mobile Health tailored information in their own language(s) and reporting problems. Given the plethora of difficulties (social, legal, discrimination, etc.) vulnerable individuals are subject to, health is often neglected and pain endured. There is potential for mHealth to reach out to people on the margins of society, e.g. by providing anonymous advice, meaningful and multilingual content (e.g. respecting religious and cultural peculiarities) and location tracking for people in danger. The possibilities for customisation are extensive since mobile content
surprisingly, those who make the most use of ‘apps’ are individuals living in technologically advanced Member States [15] while the poor and lesser educated have little if any exposure. Industry mHealth involves the IT and telecommunications sectors, the pharmaceutical industry, medical devices companies and consultancies. For all of them it represents an interesting market to tap into, especially in the current economic
While mHealth can create efficiencies, it must be underlined that health decisionmaking requires more than raw data, including information obtained from faceto-face contact that can put the data into context, which is unique for each individual. does not rely on traditional literacy skills. Instead, it can integrate pictograms, voice-recognition, video content, etc. If a concerted effort is made to ‘Include Everyone’ as recommended in the eHealth Task Force Report [14], mHealth could represent a step towards reducing health inequalities. Conversely, much remains to be done to improve the availability and functionality of ‘apps’: each technology requires its own approach regarding design and content. Many are presently either too ‘cluttered’ or only available in English, hence they remain inaccessible to the majority. It is also problematic that some require social media memberships as a prerequisite. Un-
climate in which healthcare is difficult to deliver without private investments. At European level, the European Innovation Partnership on Active and Healthy Ageing [16] stimulates multi-sector partnerships for providing eHealth and mobile health solutions, e.g. in the areas of ambient assisted living and domotics. The market for mHealth ‘apps’ is still highly fragmented and immature. Many solutions are being developed without much consideration of health and social inclusion objectives. In 2012, the first European Directory of Health Apps [17] was launched by the European Commission’s Directorate-General for Communications Networks,
Content and Technology (DG CONNECT). This repository of health and wellness apps reviewed by patient groups and consumers provides a status quo of what is available, with products ranging from the useful (e.g., toilet finder) to the quirky (e.g., yoga poses). In order to find long-term viability and focus, solutions will need to have both mass appeal and be flexible enough for tackling health inequalities. Clearly, fostering equitable mHealth depends on the extent to which end users are able to influence the policy-making and design process. mHealth takes eHealth to another level in the sense that it moves health into a consumer realm that can be difficult to control and legislate, as the experience of unauthorised internet pharmacies and bogus health websites has shown. Hence, it will be crucial to develop ethical guidelines and sustainable business models in line with end users’ needs. Partnerships must be formed to ensure that stakeholders understand the stakes and constraints (including legal, operational, security, educational and access issues), and to avoid that mHealth aggravates offline health inequalities in the face of mass unemployment and austerity measures. [18] Governments and Healthcare Managers mHealth is of importance to national and regional policy makers as it promises significant savings by providing services remotely and targeting specific population Continued on page 32
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groups. In this context it will be important to recall the importance of ‘Health in all Policies’. mHealth only makes sense if it is integrated into overall health system policies – it must not exacerbate workforce shortages. Practically speaking, it can help reduce paperwork and bureaucracy in hospitals and health settings while speeding up processes, reducing human mistakes (e.g. medication errors), increasing interdepartmental communication and avoiding duplication of work. Remote access to centralised EHRs can reduce administrative burdens by 20 to 30%. More savings can be gained through better patient compliance with treatments and drug adherence, and better observance of medical appointments. Interoperability, training and task division are critical prerequisites.
POTENTIAL BENEFITS AND DISADVANTAGES Digitalisation in healthcare: support or hazard? Many hail mHealth as a potential panacea for the health system challenges described above. Projects worldwide have resulted in the following positive observations [19]: »
Increased access to healthcare and health information, e.g., for hard to reach populations
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Increased efficiency and lower cost of healthcare service delivery
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Improved ability to prevent, diagnose, treat, care and track
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Timely, more actionable public health information
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Expanded access to ongoing health education and training for health professionals
However, all new technologies are disruptive by nature: it often takes several years for end users to accept them. This means that, before mHealth will become integral to health system structures, experiences are bound to be based on trial and error. Improving Access & Reducing Health Inequalities
time, and in informal settings. Although focused on the individual, mHealth also encourages individuals to join networks. To improve access, two courses of action could be pursued. One involves creating incentives for health professionals to become active users of mobile broadband-enabled technologies for current and preventive care. The second would be to ensure universal access to mobile broadband for households in underserved areas. However, both depend on the removal of regulatory barriers. In developing nations, mHealth is already providing access for larger segments of the population while maximising health professionals’ time [20] but more research and evaluation is required to determine how this can be ‘translated’ in Europe.
Eligibility rules for accessing healthcare vary greatly in the EU, depending on available resources, the overall organisation of the health system, reimbursement Home Monitoring schemes, legal barriers, etc. These rules in comA key tool for health bination with the professionals and ...the social deterpatients alike minants of negative are home health cremonitoring impacts of excessive ate vast s e r v i c e s. health ICT use on health Some of inequalithe most outcomes (both physical ties withcommon in and and psychological) condibetween tions being must not be countries. monitored underestimated. are chronic Thanks to diseases, such mHealth, a larger as cardiac probpercentage of the lems that reduce life population can be served, expectancy and quality of including vulnerable individuals life. The application of ICT in this who may be more comfortable area can lead to lower healthcare using mobile devices as they alcosts, more efficient care delivery low them to explore and ‘practise’ and improved sustainability. mHealth step-by-step, in their own
EPHA Briefing on Mobile Health Home monitoring can also greatly improve the lives of the frail and elderly. Sensors connected to home alert systems help prevent incidents, such as falls, turn into lifethreatening events. [21] Smart systems thus provide reassurance that help is only minutes away. Educational and Public Health Use A number of educational tools strive to educate patients and caregivers about the conditions they are dealing with, and they provide relevant information and links to networks where expertise and anxieties can be shared. Other tools build up user skills for navigating common eHealth functions. For health professionals and trainees, there are training modules for specific conditions, purposes (e.g. echocardiographies) and learning objectives (e.g. the extensive ‘Anatomy on the Go’ app [22]), as well as for building up skills for working with vulnerable groups. A number of mHealth solutions, in particular texting via SMS, are more generally useful raising awareness of prevention and health promotion. In the developing world, a number of public health campaigns have been successfully carried out to combat HIV/AIDS infections, outbreaks of communicable diseases and epidemics, and for family planning, allowing recipients to make informed choices and supporting disease management. Promotion of Health and Wellbeing Given its multifunction, mHealth
can be a tool for promoting health and well-being. Its extensive range of gadgets is seductive for patientconsumers as it takes health out of the scientific sphere into the realm of day-to-day activities and social ties, thereby allowing individuals to explore both conventional and emerging health methods, e.g. complementary and alternative medicine (CAM). Through routine deployment, mHealth can also contribute to better prevention and healthy behaviours. It is, however, imperative to recognise the limitations of technology: data can be erroneous, tools used incorrectly, and results may depend on performing tasks in the right sequence at the right time. Moreover, the negative impacts of excessive ICT use on health outcomes (both physical and psychological) must not be underestimated. Gaming ICT-enabled games are ubiquitous as people pass time with their mobile phones 24/7, e.g. in waiting rooms, on public transport, during lunch break, even in bed. Gamification describes the application of game elements and digital game design techniques to non-game problems such as health. While online marketing and inappropriate information to patients (e.g., by unauthorised vendors of medicines) represent a growing concern, especially for individuals unable to distinguish between ‘good’ and ‘bad’ sources of health information, education-oriented health games are arguably a fun way for individuals to become more conscious of their health.
Seen in this way, ICT has the potential to improve quality of life [23], especially since mobile games are played by people of all ages and across social groups. Examples are action games for youth with dyslexia, games offering pain relief via ‘information overload’ (e.g., for patients with permanent pain due to severe burns, etc.), but also Wii sports for people suffering from obesity. [24] There are also interesting solutions for health professionals, e.g. simulations and interactive learning for physicians controlling ‘virtual patients’. It has even been suggested that playing video games can help develop surgeons’ manual dexterity. [25] Cost Reduction vs. Evidence The Boston Consulting Group reported that mHealth can reduce the cost of health services (amongst the old age group) by about 25%, and of data collection by 24%. [26] Patient care can be improved by capturing information for providers and allowing them to rapidly analyse large amounts of information to better understand a person’s health status over time. [27] In addition, mHealth can reduce the number of hospital nights for rehabilitating patients, home monitoring can decrease care costs and improve quality of life for the elderly, and EHRs can cut administrative burden and encourage patients to take more responsibility.
[28]
While mHealth can create efficiencies, it must be underlined that Continued on page 34
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mHealth faces multiple barriers to full-scale implementation Nine key barriers to implementation of mHealth identified by the WHO Share of countries listing barriers as important 60% 50% 40% 30% 20% 10% 0%
Priorities
Knowledge
Policy
Ecosystems barriers Regulatory/policy barriers
Cost Effectiveness
Legal
Operating Costs
Demand
Technical Expertise
Infrastructure
Other
Source: WHO, BCG Report 2012
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health decision-making requires more than raw data, including information obtained from face-toface contact that can put the data into context, which is unique for each individual. [29] What is more, the evidence base for mHealth needs to be further developed. As noted in a study by the European Connected Health Alliance (ECH Alliance), more data is needed to demonstrate that mHealth scenarios do, in fact, lead to improved health system performance, improved health status and health-related quality of life for older people.’ [30] In this context health technology and impact assessments will be important to determine whether investments in mHealth technologies are worthwhile in the long term. As any area in healthcare, mHealth is also open to abuse. For example, under the banner of ‘wellness apps’ are products promising better health outcomes (e.g. weight loss, smoking cessation, stress re-
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duction), which are not backed up by evidence. Implementation Challenges The World Health Organization (WHO) has identified nine key barriers to the implementation of mHealth. They are divided into two groups –ecosystem and regulatory/policy barriers. As shown in the graph below, competing priorities and lack of knowledge are the top challenges for mHealth diffusion. Due to the lack of a strong evidence base to back up its impact on health outcomes, about half of the responding WHO Member States reported competing priorities as their main obstacle. mHealth programmes require evaluation so that policy-makers, administrators and other actors can base investment decisions on facts. [31] Policy Issues Effective and coherent policymaking will become important as mHealth matures. As mentioned before, a key obstacle is lack of access to fixed and mobile broad-
band coverage for health providers and individuals, particularly in rural and peripheral areas. Reimbursement policies will also require adjusting given that remote care and treatment [32] will become more relevant with the transposition of the Cross-border Patients’ Rights Directive. Furthermore, technology changes faster than the legal regulatory framework it is situated in. mHealth is situated in a complex policy and legal environment; the boundary between eHealth and medical devices needs to be clearly defined given that the latter are increasingly digital and integrated into eHealth. One potential way forward would be to maintain a clear focus on technical and data interoperability and to ensure that the eHealth Task Force recommendations [33] are implemented, e.g. by developing policies that are aligned with the technological demands of mHealth. [34] Data protection and patient safety are particularly important in healthcare. The security of personal information entered, transferred
EPHA Briefing on Mobile Health and processed via mHealth tools has legitimately been indicated as a crucial point of concern [35]. Transparency about privacy and confidentiality rules is clearly critical for building public trust, while interoperability is essential for scaling up projects. A particular barrier to using mobile technologies for data collection and disease surveillance is the implementation of multiple health-related data collection systems, flows and platforms within the health system that can track information directly as health services are delivered. Currently there is no standard practice for this and incoherence reigns at system and at policy level, e.g. regarding data collected at community level, within public and private health facilities, within national and district health reporting information systems, and within systems specifically designated for surveillance [36]. There are many mHealth application systems and platforms (both open source and proprietary) but there is still no common ‘architecture’. A key challenge is that there is almost never a single owner of all the information to ensure interoperability.
SOLUTIONS Research undertaken by PwC (2012) [37] has shown that mHealth is beginning to embrace the following principles: »
Interoperability–interoperable with sensors and other mobile/non-mobile devices to share vast amounts of data with other applications, such as elec-
tronic health records and existing healthcare plans; »
Integration –integrated into existing activities and workflows of providers and patients to provide the support needed for new behaviours;
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Intelligence–offering problem-solving ability to provide real –time qualitative solutions based in existing data in order to realise productivity gains;
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Socialisation–act as a hub by sharing information across a broad community to provide support, coaching, recommendations and other forms of assistance;
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Outcomes–provide a return investment in terms of cost, access and quality of care based on healthcare objectives; and
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Engagement–enabling patient’s involvement and the provision of ubiquitous and instant feedback in order to realize new behaviours and/or sustain desired performance.
deployment of mobile technology for public health purposes such as real-time data collection in the community and reporting within health institutions, which could then be linked to larger health information systems for aggregation, provided that secure access is established at regional and national level (the level of access being dependent on the function of the individual within the health system) [38]. Moreover, the development of standards can help foster the inclusion of vulnerable user groups. A comprehensive ‘quality management system’, including impact assessments on various end users, should be part and parcel of mHealth’s development. Regarding ‘apps’, users require guidance for selecting the most appropriate products. Guidelines
Standards for improved Access and interoperability In a resource-constrained environment, one way of overcoming system challenges is to move towards clearly defined and harmonised data standards at EU level for mobile and computer-based platforms to achieve interoperability and transparency. Legal clarity and operational harmonisation would also facilitate
Successful implementation of mHealth services is pursued through the establishment of mechanisms generating a stronger link between evidence and public policy outcomes. Evidence based guidelines can help further implementation of these services through sharing best practice, consolidating and making the evidence base available, including indicators for evaluation and implementation, developing consistent guidance, analysing requirements for new skills and offering direction for the necessary structural changes that will achieve the successful implementation of eHealth services Continued on page 36
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globally and mHealth devices in particular. Develop Digital and Health Literacy To achieve economic, health and social objectives, and mitigate the causes for health inequalities, eHealth literacy must be enhanced in the wider framework of health literacy, so that users are well informed not only about mHealth but are able to make meaningful use of it. Flexible dialogue with end users about mHealth and its exigencies should be the first step. All users must be clear about potential advantages and pitfalls, and the skills required to reap its benefits.
CONCLUSIONS & RECOMMENDATIONS The eHealth Action Plan 20122020 recognises the current lack of legal clarity for mHealth: Given the complexity created by ‘mHealth’ and ‘health and wellbeing applications’ in particular, further clarification is needed on the legal framework applicable to these specific areas. The rapid developments in this sector raise questions about the applicability of the current frameworks, the use of the data collected through these applications by individuals and medical professionals, and whether or not and how they will be integrated in healthcare systems. Clarity of information and ‘user-friendliness’ are also important to consider. [39] Given mHealth’s innovation and employment potential, the Com-
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mission is increasingly exploring it as part of eHealth policies in order to attain the targets of the Digital Agenda and Europe 2020, It will publish a Green Paper in the second half of 2013. As online transactions and communication are commonplace in sectors such as travel and banking, it will be interesting to follow whether mHealth can bring health closer to people by encouraging routine use in a safe, equitable and meaningful way. As demand is rising, it is vital that mHealth products provide tangible benefits. Hence they should be made available and tested by healthcare stakeholders to avoid abuse. [40] From a policy perspective, it is important to take into account existing and evolving pieces of European and national legislation in areas impacting on mHealth, and to systematically monitor the quality of information and tools provided to end users. The following points should be considered as the discussion continues to unfold: »
Develop policies that support integrated patient-centred chronic disease care
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Foster patient empowerment: in the process of self-manage-
ment: patients need to be able to take control of their condition and be reassured that feedback and necessary adjustments from a healthcare professional are available when necessary »
Ensure processes that facilitate meaningful end-user involvement
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Improve mHealth literacy: A perceived lack of knowledge and skills needed to be able to use mobile health services is one of the most common barriers to user acceptance of mHealth. In line with the European Commission’s eHealth Action Plan 2012-2020, initiatives aimed at developing mHealth training and education programmes should be developed, e.g. through relevant EU programmes and/or policy initiatives.
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Clarify data protection regulation as it applies to mHealth, ensuring end-user trust and ease of use, while recognising the ‘power’ of data in disease management, diagnosis and prevention.
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Encourage and facilitate mHealth stakeholder engagement: Given the potential of
‘mobile health doesn’t focus exclusively on the device, but on the fact that the information and data is mobile (…) The information is able to be collected wherever it is needed and transmitted wherever it needs to go,’
EPHA Briefing on Mobile Health mHealth in offering innovative and sustainable solutions for the prevention, treatment, care diagnosis and management of chronic diseases, an mHealth stakeholder working group should be created where opportunities and challenges could be discussed and the exchange of information and good practice could be stimulated. The core question is whether mHealth can contribute to better public health or whether it will aggravate health inequalities. In order to harvest its potential for providing equitable healthcare, mHealth needs to be incorporated into health policies so that it becomes a standard element of health systems rather than a market-driven consumer alternative for the wellto-do and educated. This will require dialogue between public, private and civil society actors and a policy and business environment that encourages innovation for health equity purposes. 1 WHO (2011), mHealth. New horizons for health through mobile technologies 2 See http://www.hrsa.gov/healthit/mhealth. html 3 EPHA Briefing on eHealth 4 See http://www.who.int/goe/en/ 5 European Commission, 12/2012. The “Mobile” in “Mobile Health” Isn’t the Gadget; It’s the Data. 6 EPHA Briefing on the Digital Agenda for Europe 7 COM(2012) 736 final, eHealth Action Plan 2012-2020 –Innovative healthcare for the 21stcentury 8 EPHA Position on the eHealth Action Plan 2012-2020(May 2011) 9 See Internet use in households and by individuals in 2012, Eurostat 50/2012 10 Ibid. 11 For more information on the revision of the medical devices legislation, see EPHA Briefing on Medical Devices 12 mHealth Task Force: Findings & Recommendations–September 24, 2012 (pre-publication public draft)
13 BCG Telenor Report, The Socio-Economic impact of Mobile Health, April 2012 14 See lever 5 for change in the eHealth Task Force Report ‘Redesigning health in Europe for 2020’(2012) 15 ‘Italiani, abbiamo tanti smartphone ma ora scarichiamo poche app’, La Reppublica, 7 Sep 2013. The article describes that ‘apps’ are predominantly used by citizens of technologically advanced countries like South Korea and Sweden. 16 More information is available on the EIP on AHA website 17 European Directory of Health Apps 20122013 18 EPHA Position on Reforming health systems in times of austerity 19 Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper; Centre for Global Health and Economics Development Earth Institute, Columbia University, May 2010 20 Ibid. 21 BCG Telenor Report, The Socio-Economic impact of Mobile Health, April 2012 22 For more information see www.thieme. com. 23 See EPHA article ‘Policy dialogue on Active and Healthy ageing –with Information and Communication Technologies (ICT)’ 24 For more information see www.gamesforhealth.org 25 James Rosser et al. ‘The impact of video games on training surgeons in the 21stcentury’. Archives of Surgery, 2007;142(2), pp. 181-186 26 See http://www.who.int/goe/en/ 27 mHealth Task Force: Findings & Recommendations–September 24, 2012 (pre-publication public draft) 28 From eHealth to mHealth –C. Peter Waegemann, see above 29 Ibid. 30 GSMA, AARP, WE , 02.2011.Mobile Health for Independent Living. 31 WHO: mHealth. New horizons for health through mobile technologies, Global Observatory for eHealth series, Vol. 3 32 Ibid. 33 eHealth Task Force Report, ‘Redesigning Health in Europe for 2020 34 BCG Telenor-Mobile-Health-Report (May 2012) 35 See EPHA Briefing on Cyber Security 36 Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper; Center for Global Health and Economics Development Earth Institute, Columbia University, May 2010 37 PwC Report, Emerging mHealth: Paths for growth, June 2012 38 Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper; Center for Global Health and Economics Development Earth Institue, Co-
lumbia University, May 2010 39 EC COM(2012) 736 final on ‘’eHealth Action Plan 2012-2020 -Innovative healthcare for the 21st century’’ 40 Ashley Bolser, ‘Why healthcare professionals can’t afford to ignore the potential of apps’. Guardian Professional, 9 May 2013 Article reproduced in full with permission of the EPHA. [EPHA Briefing] Mobile Health (mHealth), 2013. Original report available at http://www.epha.org
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The
Journal of mHealth The Global Voice of mHealth
37 The Journal of mHealth
Rising UK Costs of Chronic Condition Management
UK
Can mHealth Provide Answers to the Rising Costs of Chronic Condition Management? equivalent to climate change. It is putting pressure into the system, which, unless we change the way we address the problems, will overwhelm the system,” says McShane. “This is the biggest problem facing the health system and the care system and the costs are growing year on year. They are huge already and they will continue to grow.” The soaring number of people with long-term medical conditions such as diabetes and dementia is threatening to “overwhelm” the NHS, one of the health service’s most senior figures warns. The challenges posed by patients with chronic medical conditions are so great that they represent the “healthcare equivalent to climate change” and must force the NHS to undertake a major rethink of how it cares for such patients, Dr Martin McShane says in a recent interview with the Guardian Newspaper in the UK. Looking after the 15.4 million people in England with at least one long-term condition already takes up 70% of the NHS’s £110bn budget – £77bn – as well as £10.9bn of the £15.5bn spent on social care in England, he says. The costs are so huge
38 February 2014
that the NHS could become unsustainable unless it gives those with long-term conditions better care, with much of it provided by GPs performing enhanced roles rather than hospital doctors, says McShane, NHS England’s national director for people with longterm conditions. McShane is responsible for those ongoing illnesses or diseases that see patients become regular users of NHS services, through checkups, tests and operations. They include arthritis, heart disease, breathing problems, obesity and mental health conditions such as depression. Their numbers have risen dramatically in recent years, largely as a result of the ageing population and lifestyle factors such as smoking, drinking and overeating. “I would say it’s the healthcare
The NHS in its current form is not well set up to look after patients who are medically complicated, especially if they have several long-term conditions, such as arthritis, heart failure and the early signs of dementia, McShane says. While the total number of people with long-term conditions is expected to stay at around 15 million, the number with three or more conditions is expected to rise from 1.9 million to 2.9 million by 2018. “People with multiple long-term conditions often fall through the gaps as their secondary [hospital] care is highly specialised and their GP care highly generalised, with little continuum between the two, meaning those with multiple longterm conditions can fall through the gaps when confronted with confusing and fragmented secondary care,” he says.
Rising Costs of Chronic Condition Management The burgeoning costs of managing patients with chronic conditions are a problem facing healthcare providers and organisations the world over. Many of the conditions that are beginning to place these unsustainable strains on the Healthcare systems of the developed world are also becoming issues for many countries of the developing world. A report recently published by UK think tank the Overseas Development Institute suggests that the number of obese people in developing countries has quadrupled since 1980, representing over a billion people. With growing middle classes in these countries growing rapidly, then it seems likely that the global occurrence of lifestyle related illness
and chronic conditions will place, potentially, unmanageable burdens on the healthcare providers tasked with managing these patients. The facts illustrate a potential ‘Climate Change’ event for not just the UK, but for healthcare provision on a global scale. The need to develop and implement new strategy for the efficient management of chronic conditions, has been well identified. Many senior figures across the healthcare industry view mHealth and eHealth services as no longer just a possible option for the delivery of future care pathways, but as a vital and essential format for delivering effective and wide-scale programs to help cater to patient needs.
Healthcare organisations have in the past proven slow to implement technology and mHealth is likely to encounter similar problems. That is not to say that lessons haven’t been learnt. In the UK for example cost overspend and delays with the delivery of network data systems in the recent past have resulted in changes to the way in which the service procures and implements technology, which suggests that mHealth could potentially be more easily incoporated into services. The original article referenced in this report can be found at: http://www.theguardian.com/ society/2014/jan/03/nhs-overwhelmed-long-term-medical-conditions
39 The Journal of mHealth
RUSSIA
Health & Development Foundation - Survey
The Health and Development FoundaƟon NaƟonal Survey Among ParƟcipants of the Maternal and Child mHealth Program The Journal of mHealth, 01 (2014) pp 40-47 Received: 06 February 2014
Dr. Elena Dmitrieva, Sergei Frolov, Marina Grishina, Sara Buzadzhi, Venera Malakhova Health and Development Foundation, 107031, Moscow, Kuznetskiy most 19, b.1, Russia Keywords: SMSmame, mHealth Russia, Text4Baby, Child Health, Maternity
ABSTRACT SMSmame, “SMS to Mom” in Russian, also known as Text4baby Russia, is a free national service sending new and expectant mothers in Russia text messages to their mobile phones with information on caring for their own health and the health of their children. This program is based on the successful U.S. maternal and child health initiative, text4baby, and was developed under the auspices of the U.S.-Russia Bilateral Presidential Commission in 20102011 and launched nationwide in Russia by the Health and Development Foundation (HDF) in February 2012. Text4baby Russia is intended as a general health guideline and system of reminders that encourages women to engage in healthy behaviors and visit their doctors in accordance with a generally accepted timeline. These reminders are also intended to jumpstart conversations between mothers and doctors, and motivate subscribers to seek out additional information from other reliable sources, by notifying women of early warning signs of health problems or introducing new information. Subscribers are also able to participate in free, live webinars with medical experts on text message topics. The program had over 50,000 participants as of the end of 2013. HDF conducted a national survey during April-October 2013 among 751 respondents from 64 Russian regions. Of these, 49 respondents were interviewed at the Federal Kulakov Centre for Obstetrics, Gynaecology, and Perinatology on April 2, 2013. These respondents (pregnant women) were attending two classes led by medical specialists at the centre on the first anniversary of
40 February 2014
the SMSmame program launch. The other respondents were reached through an Internet survey in September-October 2013. Of these, 50 were pregnant, and 652 were mothers whose children were under one year of age.
The Health and Development Foundation recently carried out a national survey among participants of its maternal and child mHealth program, SMSmame. This program (“SMS to Mom” in Russian, also known as Text4baby Russia) provides new and expectant mothers with free text messages to their mobile phones with information on caring for their own health and the health of their children. This program is based on the successful U.S. maternal and child health initiative, Text4baby, and was developed under the auspices of the U.S.-Russia Bilateral Presidential Commission in 2010-2011 and launched nationwide in Russia by the Health and Development Foundation in February 2012. Text4baby Russia is intended as a general health guideline and system of reminders that will encourage women to engage in healthy behaviours and visit their doctors in accordance with a generally accepted timeline. These reminders are also intended to jumpstart conversations between mothers and doctors, and motivate subscribers to seek out additional information from other reliable sources, by notifying women of early warning signs of health problems or introducing new information.
Health & Development Foundation - Survey Figure 1
Age
40.0%
36.5%
35.0% 30.0%
26.4%
25.0% 20.0%
Age
15.6%
14.9%
15.0% 10.0% 4.7%
5.0%
1.6%
0.3% 0.0% under 18
18-24
Figure 2
24-28
28-32
32-36
36-40
40 and over
Text messages are sent to subscribers (pregnant women and mothers with children up until their first birthday, and family members). Message topics include nutrition, safety, substance abuse prevention, legal rights, mental health, exercise, developmental milestones, breastfeeding and more. Subscribers receive personalised information, as messages are organised and sent in accordance with their children’s due date or birth date. Messages contain no advertisements, spam, or product promotions. Subscribers are also able to participate in free, live webinars with medical experts on text message topics. The program had over 50,000 participants as of the end of 2013.
Marital Status 1.9% 3.4% 10.7%
Unmarried Married Unmarried but with a partner Divorced
84.0%
Figure 3
Education 1.5%
0.9% 5.8%
Secondary education, incomplete 16.0%
Secondary education Specialized secondary education
8.9%
66.9%
University degree, incomplete University degree PhD equivalent
This survey was conducted during April-October 2013 among 751 respondents from 64 Russian regions. Of these, 49 respondents were interviewed at the Federal Kulakov Centre for Obstetrics, Gynaecology, and Perinatology on April 2, 2013. These respondents (pregnant women) were attending two classes led by medical specialists at the centre on the first anniversary of the SMSmame program launch. The other respondents were reached through an Internet survey in September-October 2013. Of these, 50 were pregnant, and 652 were mothers whose children were under one year of age.
TARGET AUDIENCE The total number of respondents was 751. Women from various age groups took part in the survey, but the majority were 24-28 (36.5%) and 28-32 (26.4%) (fig. 1) Further analysis of personal informaContinued on page 42
41 The Journal of mHealth
Health & Development Foundation - Survey Continued from page 41
Figure 4
Are you expecting your first child?
tion about respondents revealed that a majority of respondents, 84%, were married (fig. 2) and 66.9% had a university degree or higher (fig. 3).
29.2%
A majority of the pregnant participants surveyed (70.8%) were expecting their first child. However, the fact that nearly a third of respondents (29.2%) were expecting their second child demonstrates that the program is also popular among women who have already experienced pregnancy and motherhood, not only those approaching both for the first time. (fig. 4)
Yes 70.8%
No
Survey respondents had been subscribers to the SMS service for different time periods; clients had been receiving program text Figure 5 messages for 6-9 months (23.9%), How long have you been a subscriber? 9-12 months (27.9%), and over a year (23.8%) (fig.5). 5.2%
The survey was conducted nationally and is comprised of respondents from 64 Russian regions. The most common regions were Moscow (22.6%) and the Moscow Region (6.8%), St. Petersburg (5.7%), Tatarstan (4.5%), and the Chelyabinsk Region (4.5%).
6.7% 23.8% Less than 1 month 12.5%
1-3 months 3-6 months 6-9 months 9-12 months
23.9%
Over 1 year
27.9% The main channels through which participants learned about the program were: posters advertising SMSmame, flyers, and other sources (37.8%); physician recommendations (23.5%), the Internet (18.5%) (including Figure 6 the www.smsmame.ru site). How did you learn about SMSmame? The fact that nearly a quarter of respondents received From my doctor 23.5% recommendations from their From friends, acquaintances doctors speaks to the high 10.9% opinion the professional On smsmame.ru 18.5% medical community has of the initiative (fig.6). Internet (other sources)
PROGRAM EFFECTIVENESS
On social networks Posters, flyers, other sources
Behaviour change in program participants: SMS-
42 February 2014
0.0%
6.9%
2.4% 37.8% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%
Health & Development Foundation - Survey Figure 7
Do you talk with your gynecologist about topics covered in SMS messages? 3.1%
21.8% Yes, on a regular basis Yes, sometimes Rarely 56.7%
No 18.4%
Figure 8
Do SMSmame text messages motivate you to seek out additional information related to message content? 9.1% 15.8% Yes, on a regular basis 18.6%
Yes, sometimes Rarely No
56.5%
Figure 9
Do you like the text message service? 2.2% Yes, I like it very much
0.8%
I like it
21.7% 41.6%
I like some things about it, dislike others I do not like it all
33.7%
I do not like it very much
mame messages as motivation to seek out more information from reliable sources One of the main goals of this initiative is to increase the interest and attention of expectant and new mothers regarding their health, and to motivate them to seek out additional information about pregnancy and child care from reliable sources. The following questions were asked in order to determine whether the program was meeting this goal. To the question “Do you talk with your gynaecologist about topics covered in SMS messages?” 24.9% gave positive answers (“sometimes” - 21.8%, “on a regular basis” - 3.1%). The remaining respondents did so “rarely” (18.4%) or never did so (56.7%). The data shows that at the moment, only a quarter of respondents approach their physicians for further information related to program messages. (fig.7) Respondents were more positive about whether program text messages motivated them to seek out additional information related to message content: 56.5% replied “sometimes,” 15.8% “on a regular basis”, and 18.6% “rarely.” The high percentage (90.9%) of respondents who replied in the affirmative indicates that the program is meeting its goal to motivate a majority of subscribers to seek out additional, reliable information. (fig.8)
PARTICIPANT EVALUATION OF THE PROGRAM The next topic in the survey was a general evaluation of the program by respondents. Figure 9 clearly demonstrates the overall positive nature of participant opinion: 41.6% of respondents say they like the service very much, and 33.7% like it. Only a very small number of respondents did not like the service at all – 3%. Continued on page 44
43 The Journal of mHealth
Health & Development Foundation - Survey Continued from page 43
Figure 10
A key goal of this program is to provide subscribers with important, timely information. How they use the text messages is a strong indicator of whether subscribers feel that the program is meeting this goal. The data shows that 62.4% regularly save text messages to refer to them later and 20.9% sometimes do so (fig.10). A much smaller number never did so (9.9%) or did so rarely (6.8%).
Do you save text messages from SMSmame to refer to them later? 9.9% 6.8% Yes, on a regular basis Yes, sometimes 20.9%
62.4%
Rarely No
Another criteria demonstrating participant opinion of the program is whether or not they recommend it to others. Of all the respondents surveyed, 30% had recommended the service to at least one friend or acquaintance, and 42% had done so two or more times (fig.11). This high percentage of personal recommendations (72.3%) shows that the majority of respondents have an overall positive view of the usefulness and effectiveness of SMSmame. In conclusion, we can say that participant opinion of SMSmame is, overall, positive, as shown by the number of respondents who found message content useful enough to save it for further reference and the number who recommended the service to others.
Figure 11
Have you recommended the SMS service to friends or acquaintances?
27.7% 42.3%
Yes, two or more times Yes, once No
30.0%
SATISFACTION WITH MESSAGE CONTENT AND FEEDBACK In order to determine the level of subscriber satisfaction with message content, a key element of program effectiveness, respondents were asked more specific questions about message topics. Pregnant women and new mothers were asked different sets of questions.
Figure 12
Have you received useful information from the SMS service on the following topics?
Recommendations to discuss specific topics with your doctor Healthy eating Information about alcohol, tobacco, and drug use Your emotional state during pregnancy
Figure 12 shows that pregnant respondents received the largest amount of useful and relevant information on the following topics: 1) healthy eating (68.7%); 2) information about government benefits (62.6%); 3) warnings about flu and viral respiratory infection
47.5% 68.7% 36.4% 34.7%
Work and pregnancy Physical exercise
49.5% 45.5%
Information on government benefits Vaccinations Flu and virus epidemic warnings
62.6% 38.4% 59.6%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%
44 February 2014
Health & Development Foundation - Survey Figure 13
Have you received useful information on the following topics?
Recommendations to discuss specific topics with your doctor
48.9%
Information about maternal health after birth
64.8%
Information about newborn health
95.8%
Key developmental stages for children under 1
88.2%
Physical exercise
59.9%
Government benefits and assistance
49.6%
Vaccinations
75.8%
Flu and virus epidemic warnings
69.6%
0.0%
Figure 14
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
The data shows that respondents are interested in expanding the range of topics that SMSmame addresses, which will influence future text message content development.
Which topics would you like to learn more about? Healthy eating
12.2%
Your emotional state during pregnancy
6.1%
Work and pregnancy
4.1%
Physical exercise
16.3%
12.2%
Information on government benefits
Vaccinations
2.0%
Flu and virus epidemic warnings
2.0%
0.0%
2.0%
4.0%
6.0%
8.0% 10.0% 12.0% 14.0% 16.0% 18.0%
epidemics (59.6%). On the whole, information on each topic was useful to nearly half the respondents. The new mothers surveyed indicated that they found information on the following topics most useful: 1) information about newborn health (95.8%), 2) key developmental stages for children in their first year of life (88.2%), 3) vaccination (75.8%) (fig.13). Overall, the data makes it clear that almost all topics were of interest to subscribers. Two more questions about message content quality were given to only the group of respondents who took the survey in person at the Kulakov Centre. Figure 14 displays information about which topics
respondents would like to receive more information on: 1) physical exercise (16.3%), 2) healthy eating (12.2%), 3) information on government benefits (12.2%). Respondents were also asked which new topics they would like to see added to the text message service, and the most common replies were: 1) getting ready for the birth (12.2%), 2) advice for each week (8.2%), 3) advice for fathers (6.1%), 4) information about necessary tests (6.1%). (fig.15)
The last question related to program improvement addressed the frequency of text messages (fig.16). A third (31.6%) of respondents are satisfied with the current rate of 1-2 messages per week. However, a majority would prefer to receive more messages; among that group, 31.1% would like to receive 3-4 messages weekly. The remaining third would like to receive 5 or more messages per week. It is clear from this response that the majority of respondents would prefer greater frequency of messages, indicating the usefulness and importance of the service in keeping them
informed. In addition to directing the attention of program developers to areas for improvement, (expansion and refinement of text message content, message frequency, etc.), survey data also show the overall positive attitude to the service among respondents. The fact that a large group of respondents save text messages for future reference, recommend the program to others, and would like to receive more text messages weekly all demonstrate that SMSmame is meeting the key program goals of providing reliable, useful information to pregnant women and new mothers throughout Russia. Continued on page 46
45 The Journal of mHealth
Health & Development Foundation - Survey
Continued from page 45
Figure 15
What new topics would you like to see introduced?
SUMMARY Reading recommendations (books, articles)
SMSmame, “SMS to Mom� in Russian, also known as Text4baby Russia, is a free national service sending new and expectant mothers in Russia text messages to their mobile phones with information on caring for their own health and the health of their children. This program is based on the successful U.S. maternal and child health initiative, text4baby, and was developed under the auspices of the U.S.-Russia Bilateral Presidential Commission in 2010-2011 and launched nationwide in Russia by the Health and Development Foundation (HDF) in February 2012.
4.1%
Preparing for birth
12.2%
Advice for every week (changes in the mother's body during fetal development)
8.2%
Advice on morning sickness, bloating, etc.
4.1%
What to buy for a new baby
4.1%
Information about maternity hospitals
2.0%
Information about exhibitions and seminars
4.1%
Information about classes for pregnant women
2.0%
Advice for fathers
6.1%
Participation of the father during birth
2.0%
Traveling with small children
2.0%
Information about illnesses among children under 1
2.0%
Text4baby Russia is intended as a general health guideline and system of reminders that encourages women to engage in healthy behaviors and visit their doctors in accordance with a generally accepted timeline. These reminders are also intended to jumpstart conversations between mothers and doctors, and motivate
46 February 2014
6.1%
Information about necessary tests Dangerous symptoms during pregnancy
2.0%
Information about webinars
2.0%
0.0%
Figure 16
2.0%
4.0%
6.0%
8.0% 10.0% 12.0% 14.0%
Number of text messages per week
"1-2"
31.6%
"3-4"
31.1%
"5-6"
16.7%
"7-8"
16.9%
"9 or more"
3.7% 0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
Health & Development Foundation - Survey subscribers to seek out additional information from other reliable sources, by notifying women of early warning signs of health problems or introducing new information. Subscribers are also able to participate in free, live webinars with medical experts on text message topics. The program had over 50,000 participants as of the end of 2013. HDF conducted a national survey during April-October 2013 among 751 respondents from 64 Russian regions. Of these, 49 respondents were interviewed at the Federal Kulakov Centre for Obstetrics, Gynaecology, and Perinatology on April 2, 2013. These respondents (pregnant women) were attending two classes led by medical specialists at the centre on the first anniversary of the SMSmame program launch. The other respondents were reached through an Internet survey in September-October 2013. Of these, 50 were pregnant, and 652 were mothers whose children were under one year of age.
CLIENT SATISFACTION SMSmame clients who responded to the survey reported an overwhelmingly positive opinion of the service: 41.6% said they were highly satisfied with it, and 33.7% were satisfied. Beyond their stated satisfaction, the actions of respondents demonstrated their high opinion of SMSmame. One measure of client satisfaction is the length of time they had been subscribers. Nearly a quarter of respondents had been subscribers for over a year (23.8%) and 27.9% had been subscribers for 9-12 months. Clients continue to participate in programs that provide a useful service. One of the key goals of SMSmame is to provide reliable, relevant health information to subscribers, and the fact that 91% of respondents save program text messages for future reference (62.4% doing so regularly) demonstrates that the program is meeting this goal.
to friends or acquaintances, and 42% had done so more than once.
MOTIVATION TO SEEK OUT ADDITIONAL INFORMATION SMSmame is intended not only as an information resource, but also as a way to motivate subscribers to seek out additional information from reliable sources on message topics. Survey results indicate that the service does indeed function as a source of motivation for the majority of respondents (90.9%). Of that percentage, 56.5% of clients were “sometimes” motivated by text messages, and 15.8% were motivated “on a regular basis.” One area for improvement is client motivation to speak with their doctors about text message topics; only a quarter of respondents were motivated by the service to do so (21.8% “sometimes,” and 3.1% “on a regular basis”). Program developers will take this data into account for future revision and improvement of services.
OTHER AREAS FOR DEVELOPMENT Survey data also indicated other areas in which the program could be developed and improved. Respondent replies show client support for an expansion of text message topics. Respondents suggested the introduction of such topics as advice for fathers, reading recommendations, preparing for the maternity hospital, and more. Survey respondents would also prefer to receive text messages more frequently: a third (31.6%) of respondents are satisfied with the current rate of 1-2 messages per week. However, a majority would prefer to receive more messages; among that group, 31.1% would like to receive 3-4 messages weekly. The remaining third would like to receive 5 or more messages per week. This desire for greater frequency of text messages is yet another positive sign of the value of the service for pregnant women and new mothers. For more information on this project and other projects please visit the
Another telling indication of client satisfaction is that 72% of respondents had recommended the program
Health and Development Foundation at www.fzr.ru/eng.
47 The Journal of mHealth
Product Profiles
Product Profiles SensiMAT for Wheelchairs Canadian company SensiMAT Systems have recently begun taking pre-orders for their SensiMAT for wheelchairs product. A unique mobile enabled system that allows wheelchair users to monitor and track the pressure being exerted by them, as they use the chair, and to identify when high levels of pressure build up. The SensiMAT for Wheelchairs is a thin mat containing pressure sensors that is inserted underneath the gel, air, or foam cushion. These sensors send pressure data to a mobile device, where SensiMAT System’s proprietary PressureRisk™ algorithm alerts the user when there is a high amount of built up pressure, it then facilitates and tracks pressure relieving exercises. The system uses Bluetooth Low-
Energy, to consistently monitor pressure, using a mobile device, completely wirelessly, and without draining the battery. The mat itself is simply charged once a week, making it easily integrated into everyday life. This unique product has great potential to enable wheelchair users to limit pressure related sores and problems commonly associated with the use of a chair. At the same time the system actively encourages people to manage their condition and prevent further complications. In the long-term this is likely to have significant appeal to healthcare organisations seeking to reduce admissions of wheelchair users with common pressure related problems.
Nextremity Solutions adopts GOOGLE Glass for product and surgeon training Recently, North Carolina based orthopaedic surgeon Selene G. Parekh, M.D. utilised Google Glass during a successful foot and ankle surgery in Jaipur, India.
Dr. Parekh commented, “This technology opens up a whole new world for surgery. Not only are we able to obtain a different view of the surgery, we are also able to communicate live with fellow surgeons at the same time. Simply amazing technology.”
Dr. Parekh conducted surgery while wearing the technology and broadcast live streaming video via the Internet. The technology allowed for hands-free recording video without the operating room disruption of a video crew and related risk of infection. Additionally, it provided viewers the surgeon’s unique vantage point during the surgery.
Nextremity Solutions, an orthopaedic medical device company which specialises in forefoot surgery implants, recently obtained Google Glass and will be evaluating its applications in its surgeon training initiatives. The company will work closely with Dr. Parekh to ensure the technology is used in a manner most beneficial to surgeons.
48 February 2014
Company Profiles
Company Profiles Infield Health Infield Health helps patients recover from hospital procedures by putting discharge instructions on mobile phones. Because better educated patients have better outcomes and a lower total cost of care. We include informative video, medication guidance, and two-way communication right inside the app. And because each provider customizes the instructions, patients are guided by a voice they trust. We’ve worked with US organizations such as The National Cancer Institute, the American College of Cardiology, VCU Medical Center and The George Washington University Hospital, and we concentrate in surgical, cardiac, and rehabilitation patient populations. Infield is keen to help UK providers, public and private, engage patients to enhance outcomes and reduce the total cost of care. For more information visit www.infieldhealth.com
Zoeticx Zoeticx, Inc. have announced the launch of their healthcare industry software suite dedicated to improving patient outcomes, enhancing the quality of care, containing costs, and simplifying hospital administration. The suite of four software modules is designed for the new healthcare landscape ushered in by Obamacare and the changes within the medical industry itself. The software will improve healthcare industry profitability by curtailing medical errors that cost the industry billions of dollars annually and reducing preventable deaths. Zoeticx champions these new government and industry paradigms through software innovation with a patient-centric approach. The Zoeticx software suite resides on its Patient-Clarity collaboration platform. The suite is comprised of four modules: CareIntelligence, CareSynergy, CareHistory, and CareCompliance. Zoeticx offers software solutions for the healthcare industry which are dedicated to Improving Patient Outcomes, enhancing the quality of care, containing costs, and simplifying administration. These solutions offer an immediate increase in the quality of care by delivering the right information to the right caregiver at the right time, in a manner that can be easily understood. Additionally, as the Affordable Care Act continues to roll out, healthcare providers will face new challenges which arise whenever there is a transition from an old system of doing business to a new one. Zoeticx helps solve those challenges, allowing care providers to focus on what is most important, the patient. www.Zoeticx.com
49 The Journal of mHealth
Upcoming Events
Upcoming Events 3-4 March 2014
30 April - 1 May 2014
19-21 May 2014
Health and Care Innovation Expo 2014, Manchester, England. For more information visit www.expo.nhs.uk
Pharma 3.0: The Digital Medicine Era, Philadelphia, PA, USA. For more information visit www.event.pharmicaconsulting.com
Saudi Health, Riyadh, KSA. For more information visit www. saudihealthexhibition.com
7-9 April 2014
6-8 May 2014
20-23 May 2014
11th Annual World Healthcare Congress, National Harbour, MD, USA. For more information visit www.worldcongress.com/events/HR14000
Africa Health, Johannesburg, South Africa. For more information visit www.africahealthexhibition.com
Hospitalar 2014, Sao Paulo, Brazil. For more information visit www.hospitalar.com
28-29 April 2014
6-8 May 2014
3-4 June 2014
Medical Informatics World Conference, Boston, MA, USA. For more information visit www.chidb.com
mHealth Summit Europe, Berlin, Germany. For more information visit www.mhealthsummit.org/eu
The European Future Healthcare Forum, Dublin, Ireland. For more information visit www.informa-ls.com/event/ EuropeanHealthForum2014
Advertisers Index Consultation Plus
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Dacadoo
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Dacadoo
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Infield Health
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Tactio Health Group
14
50 February 2014
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Journal of mHealth The Global Voice of mHealth
Contact Matthew Driver matthew@simedics.org +44 (0)1756 709605
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We invite you to work with us... We hope that you have enjoyed reading the inaugural edition of The Journal of mHealth and that you continue to subscribe to our future issues. We will be publishing six editions of the Journal throughout 2014. We would like to take this opportunity to invite readers to interact with us and to help us shape this publication into a leading voice for the mHealth and Digital Health industries. We would love to hear your comments and thoughts on the publication, as well as suggestions for articles and features you would like to see us cover in the future. If you would like to submit a research paper, study or article for publication, please get in touch. We have been overwhelmed by the positive response we have received from the global mHealth/ Digital Health industries, and it is your support that has made this publication possible. Our subscribers are representative of the whole mobile health industry, with healthcare professionals and key industry decision makers from all over the globe. If you are a company or organisation involved with mHealth, Digital Health, or eHealth then we would like to be able to work with you, to help you to reach, and connect, with our audience of readers. We have a range of advertising, sponsorship, and editorial opportunities available so please get in touch to find out more. For more information please contact: journalofmhealth@simedics.org
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