mHealth Insight: the blog of 3G Doctor

Iltifat Husain, a 4th year medical student and founder of iMedical Apps, has expressed an interesting opinion claiming that the iHealth and Withings “iPhone Connected Blood pressure cuffs featured at CES are over hyped“. I disagree completely with this opinion and as I’m currently advising a mobile brand on an opportunity very close to this I thought it might be valuable to share my opinions here so the wider market can benefit from them.

“You can use mobile technology for real time medical data gathering, to explain complex pathology with easy to understand multimedia for patients, to transmit EKG data to an emergency room while en route to the hospital, and a litany of other things. But there are obvious limitations to mobile medical technology as well, especially in regards to changing lifestyle and behavior, something that has plagued medical professionals since the dawn of preventive medicine. Last week at CES (Consumer electronic show), two blood pressure peripherals for the iPhone from competing companies received significant attention. CNN even listed the devices as a “top 10″ buzz worthy device that was unveiled at CES. One of the devices is from a start-up in California, iHealth Labs, and they unveiled the iHealth Blood Pressure Dock. The company touts the product being used for daily blood pressure measurements, and a physician spokesman for the company states how patients will measure their blood pressure more frequently now since the device is tethered to their phone — a device that gets frequently”

Of course it’s not surprising to learn that Iltifat aspires to be an emergency room Doctor, but we should be aware of the completely different value of preventative wellness interventions Vs. high tech monitoring of patients when they’re on their way to a hospital emergency room in the back of an ambulance. The big opportunity of the first obviously being that we can help to prevent the damage taking place in the first instance.

“To be clear, this is a interesting and fascinating technology. You can plug a blood pressure cuff into your phone, an app opens up, automatically recording and tracking your blood pressure, and also giving you the option to Twitter or Facebook out your recordings — the thought being you can use social networking “peer pressure” as an incentive to lower your readings. More importantly, you can e-mail the results directly to your physician”

Not so confident that twittering Blood Pressure readings is the best idea eg. in the US for example tweeting that elevated BP might prove a great way of ensuring your employer doesn’t overlook you when considering who’s up in the next round of lay offs.

“So this means patients surely will check their blood pressure more frequently — not necessarily, and more than likely no”

This is a broad statement that I find presupposes that the person willing to have this device in their home has it there somewhat grudgingly – something I’ve seen with many homecare agency provided devices (even if patients are too polite to mention it when being surveys after all ‘I suppose at least they’re trying’). I don’t think people generally go out of their way to buy and place things in the center of their home that they don’t intend to use.

“First of all, if you have a patient that can afford an iPhone and the accompanying data plan, plus the more expensive blood pressure cuff, approximately $100 — you already have a patient that is more likely to be empowered. Lets look at the actual research data behind this to make more sense of why this would have minimal impact on compliance”

Where’s the evidence that people with smartphones are more likely to be empowered wrt their health? It appears the author is mistaken into thinking that there is no overlap of smartphone ownership with the ~50 million individuals who have no health insurance in the USA. Wealthy doesn’t always equal healthy.

“Data shows that just over 30% of iPhone users are above the age of 45. So out of the total iPhone population, you are looking at approximately 30% of users who would actually be in the age range to use the device — and that’s giving a favorable age bracket. In reality, the 55 or over age group would be the real target age group, only 14% of the iPhone demographic”

I’m haven’t seen this data but it is complete nonsense to think that “only patients aged over 45” would “be in the age range to use the device” and that “in reality the 55 or over age group would be the real target“.

The National Center for Health Statistics is reporting as many as 4 million births in the USA annually and every mum could have benefited from more regular blood pressure monitoring. Same applies to anyone who has a range of underlying conditions or is taking a wide range of medications and this would include the ~20 million diabetics (more than 60% of deaths in patients with diabetes are from Cardiovascular Disease) and the ~10 million women who are taking the contraceptive pill today in the USA (all of whom are inside the majority age range for iPhone ownership that Iltifat refers to).

It also dismisses the increasing popularity of “pass me up” iPhones that are being given to parents from children who have upgraded to the latest model. Why not bundle the iHealth with last years iPhone as you give it to your mum as a birthday present?

“Now lets look at more data about the iPhone and affluence. iPhone users as a whole are more affluent than not only the normal population, but in comparison to other smart phone owners — with an average household income of $100,000. There is data that shows compliance to physician recommendations, such as medications and blood pressure checks is less in lower income households. Some of the reasons being access to health care and expensive of medications”

The smartphone = affluence argument is bogus. Most wealth in a society like the US is owned by those aged 50+. The average 50+ citizen doesn’t have a smartphone. An Anecdote that I find interesting: My colleagues and I are more likely to see fancy smartphones in the hands of patients in NHS clinics than in some of worlds most expensive private clinics in Harley Street.

As Ilifat rightly points out a key reason why many patients from lower income households don’t comply with medications is because of their ongoing expense. I like to refer to this more accurately as: ‘they don’t see the value in expensive 5 minute consults with uninformed Doctors who pass them off with expensive prescriptions’. Blood Pressure monitoring with an educational mobile application that helps an individual manage their BP and general health better would unlikely face this same economic pressure as there is no real ongoing expense involved in taking your own BP with a device, exercising more and making healthier decisions about your diet. Packaged with appealing design, a neat user experience and feedback mechanisms the value can be enormous.

“So basically, those who would be in a position to buy these iPhone blood pressure peripherals are more likely to be compliant patients anyways, and would most likely be checking their blood pressure as prescribed. Obviously, there will be anecdotal examples that will counter this, but from a populations approach — you most likely wouldn’t see any significant change”

The response to this is complicated because it involves appreciating that change can happen. These device makers all have an interest in partnering with retailers, mobile device manufacturers and mobile operators. If these sales channels can:

> Increase footfall to their retail space via promotion of these devices
> Increase sales of Smartphones by bundling them with this additional device
> Increase the ARPU (eg. monthly spend) of customers if they give away this accessory
> Reduce churn of customers by bundling this device with their phone contracts

Then I see no reason why these partners wouldn’t want to subsidize these devices and make them available to patients who can then begin to take more care of their health.

I can also see no reason why mobile software developers wouldn’t work to build apps that can enable these devices to work with mobile phones from other manufacturers.

If this happens “those who would be in a position to buy these iPhone blood pressure peripherals” will become everyone. Together with positive clinical outcomes, the competitive mobile sales industry will ensure that it won’t be long before customers will be asked: “Would you like the free connected weighing scale and blood pressure monitor with your new Motorola?” in the same way that various insurance services and accessories are upsold at the point of sale today.

The competitiveness of the ‘me too’ mobile industry will continue to ensure that todays smartphone tech/accessory feature on tomorrows feature phones and in my opinion this is how the “from a populations approach” will be met quicker than any government initiative to promote BP/Weight monitoring initiatives.

“So from a preliminary standpoint, these blood pressure cuffs are very interesting and a very niche product — but certainly not the game changers they are being touted as by many news sites”

I disagree on this, from what I’ve seen so far they have easily exceeded the usability and design challenges. There is no doubt these devices look great:

(Withings Blood Pressure Monitor)

(iHealth Lab Blood Pressure Monitor)

Whether their go to market strategy is enough is another thing but the success of the weighing scale from Withings indicates they’ve got some great form with this:

(Withings weighing scale)

I’ve been helping patients enter their blood pressure and weight readings into their phones as part of health programmes for years. I’ve found these patients don’t need an automated connected device because they’ve already got a blood pressure monitor and are convinced of the value of keeping these records eg. better health management, longer more active life etc. Well designed software on the mobile device may makes this easier to do:

But for this to become a mainstream thing I’m convinced there is a huge requirement for connected peripherals that automatically update this information in our personal health records from where it can be shared appropriately and paired with valuable mHealth services (just telling me my blood pressure isn’t enough!).

These devices from Withings and iHealth Labs follow on from the work of A&D and Medic4All in making this future and it’s great to see that they haven’t cut corners with design or usability. The importance of this should not be underestimated.

(AnD Bluetooth Blood Pressure Monitor)

(Medic4All Wrist Clinic)

One mans ceiling may forever be another mans floor but with the modern world facing an obesity epidemic why shouldn’t the media and mobile industry be confident to promote (or “hype”) companies that are prepared to use their entrepreneurial enthusiasm to bring preventative health concepts to the consumer market?

UPDATE SUNDAY 16 JAN: Over in the comments on the iMedicalApps website, Iltifat Husain, gave this very well thought out response to this article:

Thanks for sharing this David!

Just a few points to make.

1) As you mentioned, you have a business relationship in the mobile arena, so naturally I understand you would want to offer a counter argument. Some would argue I have a conflict of interest as well because our content is based on mobile technology and I should be pushing it constantly, but I try to use data in my arguments to at least try and prevent this – and I try to come from an academic perspective (my interest), not a business one.

2) You mentioned on the outset of your article that “it’s not surprising I’m going into emergency medicine”, etc. I would also mention the reason I decided to get a masters in public health is so I would have a firm grasp on prevention and populations based medicine — so the data I used in this article was coming from a comprehensive standpoint, not just how this device could be used in the emergency setting (which it really wouldn’t). Also, in emergency medicine we often see the perils of what happens to patients when prevention is not done properly, so I would argue we have a tremendous understanding of how important it is.

3) Smartphone owners are more affluent then the general population, by the data I presented. If you find something to counter this I would appreciate it.

4) The example you cite, of mothers who are pregnant benefiting from this type of monitor is interesting. I think again, as I mentioned, this would fall into the small niche segment I mentioned. But BP monitoring for all women taking contraceptives is a bit of a odd stretch when it comes to reality. The USPTF states monitoring should start above age 18 — but at the same time, from a realistic standpoint, should all those above 18 buy this cuff and monitor their blood pressure daily or weekly? We need to be practical as well.

5) You mentioned an anecdotal example of a patient who is not as affluent having a smartphone. Do you have some data behind this? Also, there is more data out there showing the age demographics of iPhone skews to the younger demographics.

6) I think the business case you make for this is interesting. But again, my focus isn’t in the business side of this and how much money these peripherals could make and how they would be great for companies to market. One of the reason I decided to get a masters in public health was so I could approach medicine from a populations based perspective. I think there is great hope for mobile technology in regards to the general population as a whole — not just iPhone users — and I mentioned these examples earlier. I read countless numbers of studies on obesity and intervention programs that people thought would definitely work, but did not. As mentioned in the article, changing health related behavior is a very difficult task.

My main point though: I think this technology is interesting and will fill a niche. But I think there is something left to be said about the $75 dollar amazon BP peripheral that also can track your blood pressure for you. If you want BP education there are plenty of free applications for this, even by reputed interest groups. (As an earlier commenter wrote, this is really creating a need, not really fulfilling one).

And also, what about if you decide not to have an iPhone anymore, or if your contract runs out, or if you can’t afford the phone anymore. Or, if your device breaks. Do you have to buy another $100+ peripheral for your Android phone, or another $100 peripheral for your Blackberry phone? There is lack of standards on these devices and this only hurts the medical peripheral market. Even the bluetooth standards for different devices are not in sync yet.

So yes, I’m excited to see what / who actually purchases these devices, but I’m also cognizant that they are not game changers for the population as a whole — yet. In the future could they be? Sure, but in the current, they haven’t proven anything, they are too new to do this.

A recent example. For those using oral contraceptives, sending text messages and education on oral contraceptive use will increase adherence to oral contraceptives right? No — a RCT recently showed this:

http://journals.lww.com/greenjournal/Abstract/2010/09000/Using_Daily_Text_Message_Reminders_to_Improve.13.aspx

Another RCT currently underway out of Columbia is gong to look at this further, but again — just because it makes sense, doesn’t mean the data shows it will benefit.

The only way we can successfully implement mobile technology is if we understand the limitations behind it — and understand that just because something is “cool”, doesn’t mean it will really have a significant impact — at least from a populations based perspective.

Also, I forgot to include this article as well. A review that questions the diagnostic and monitoring efficacy of even doing
ambulatory blood pressure measuring for hypertension. It even gives a cost analysis as well.

http://www.annals.org/content/118/11/867.short

Making this my longest ever blog post here’s what I think:

1) As you mentioned, you have a business relationship in the mobile arena, so naturally I understand you would want to offer a counter argument. Some would argue I have a conflict of interest as well because our content is based on mobile technology and I should be pushing it constantly, but I try to use data in my arguments to at least try and prevent this – and I try to come from an academic perspective (my interest), not a business one

Here we have a difference of opinion. I’m claiming this isn’t “over hyped” and think that this is a discussion of the commercial opportunity of a product being offered by a private business eg. iHealth Labs or Withings.

This is not an academic issue because regardless of whether the products themselves help patients become more involved in the management of their own health, the companies producing these connected peripherals may still be very successful.

I also note in your argument you jump from “academic” to “business” perspectives a lot eg. when you state there is ‘something left to be said about the $75 dollar amazon BP peripheral‘. Surely this is all about the price point and customer sense of value?

I’m lost on why it’s somehow okay to call it “hype” when a company tries to sell a $99 health monitor to iPhone users but no ones up in arms about the hundreds of $’s some customers are spending on in game credits for their Smurf apps!

The problem I sense with your academic perspective is that you risk ignoring many of the key reasons why people pay for and do things. Rather than adding to criticism that this is “really creating a need, not really fulfilling one” consider that despite the presence of “plenty of free applications” that offer the same or more, there will inevitably be another blockbuster fitness DVD out later this year.

A purely academic approach that references published scientific papers also ignores the fact that if the average scientist thought they might have cracked the trillion $ issue that’s stopping patients participating in maintaining their health surely they’d be starting a company to capitalise on this insight rather than continuing to write an academic paper trying to prove it.

In my opinion successful mHealth will come about through promotion by communities, influential patients and their carers rather than by scientific papers or spamvertising. The speed of change is increasing rapidly and the old way will soon appear as ridiculous as me publishing a 2000 page book to tell the world about my solution to preserving the rainforests ;)

2) You mentioned on the outset of your article that “it’s not surprising I’m going into emergency medicine”, etc. I would also mention the reason I decided to get a masters in public health is so I would have a firm grasp on prevention and populations based medicine — so the data I used in this article was coming from a comprehensive standpoint, not just how this device could be used in the emergency setting (which it really wouldn’t). Also, in emergency medicine we often see the perils of what happens to patients when prevention is not done properly, so I would argue we have a tremendous understanding of how important it is

You’ve mistaken my point here. My lack of surprise comes from your stated interest in becoming an ER Doctor and your enthusiasm towards a “Reactive” (eg. the ECG monitor in the Ambulance on it’s way to the hospital) rather than a “Preventative” solution (eg. a Mobile Connected BP monitoring solution that helps patients leverage technology to manage their own health at home)

For the record I have lots of experience of the enormous value of emergency medicine – indeed as I dictate this blog post I am out and about assisting an oncall emergency Doctor.

As for “what happens to patients when prevention is not done properly” I think this is another massively overlooked opportunity for Smartphone connected health monitoring to exceed the effectiveness of the current crop of dumb devices eg. the accompanying app with the iHealth/Withings product could feature a video showing how to properly relax before testing, position the cuff and take the reading etc. something that isn’t so easy to do reliably with the cheaper devices.

3) Smartphone owners are more affluent then the general population, by the data I presented. If you find something to counter this I would appreciate it

X% of iPhones are owned by people with an income exceeding X is an inaccurate estimate of wealth. Most people exaggerate when asked about their income and most seniors live on modest incomes but have more wealth eg. they own their own home, they have savings etc

If you go and get research on the fitness industry you’ll also find that the profiles of people who are members of gyms are similar to Smartphone owners. Anecdotal evidence of this is supported by the fact that most US gym chains have iPhone apps.

There are more than 25,000 gyms in the US that could each probably justify having at least 2 (one for the ladies, another for the guys) iHealths in their changing rooms. Alone that’s $5 million of equipment sales – not bad for a startup!

4) The example you cite, of mothers who are pregnant benefiting from this type of monitor is interesting. I think again, as I mentioned, this would fall into the small niche segment I mentioned. But BP monitoring for all women taking contraceptives is a bit of a odd stretch when it comes to reality. The USPTF states monitoring should start above age 18 — but at the same time, from a realistic standpoint, should all those above 18 buy this cuff and monitor their blood pressure daily or weekly? We need to be practical as well

This is a major ‘business of healthcare’ issue that your academic perspective might cause you to have missed. Although some patients groups may be considered “niche” the contribution they make to total healthcare spending can be very significant eg. only 25% of people in the USA have at least 1 of the top 5 chronic diseases yet they consume about half of the total healthcare spend.

In Ireland we would say you were “penny wise pound foolish” if you were to ignore the importance of mothers because they are a “niche”. Good maternal health is particularly important from a preventative healthcare approach as you are not only helping manage the health of a young adult but also her unborn child (and any dependents she may already have).

The USPTF advice on monitoring is a “reactionary” approach that is out of date. For an idea of how healthcare will look in the future look to other industries for examples eg. since the 80’s motor manufacturers have installed technology in cars to continuously monitor the well being of mechanical parts. Instead of going into a garage every year or whenever you broke down (eg. the way todays healthcare system works), modern cars monitor their own engine temp, oil pressure, timing etc etc all the time, motivate the driver to encourage more efficient motoring and tell them when they need to take it to the garage.

5) You mentioned an anecdotal example of a patient who is not as affluent having a smartphone. Do you have some data behind this? Also, there is more data out there showing the age demographics of iPhone skews to the younger demographics

Yes here is a chart showing there are about as many people who own iPhones that are aged over 50 than under 25:

For more stats on mobile refer to Tomi Ahonens Almanac, fascinating stuff.

I think there is great hope for mobile technology in regards to the general population as a whole — not just iPhone users

I agree completely. We started offering our mHealth service before iPhones even existed and I share Tomi Ahonen’s opinion that Apple will probably never increase its market share of the global mobile market.

I read countless numbers of studies on obesity and intervention programs that people thought would definitely work, but did not. As mentioned in the article, changing health related behavior is a very difficult task

As I explained above I think this is because of the nature of the problem: most of the mHealth talent I meet with are working in commercial ventures trying to execute on business goals.

The ones who I think are going to make an impact probably wouldn’t even qualify for scientific research study funding because they don’t have any experience in academic research or healthcare eg. they’re successful mobile marketeers, mobile game/UX developers etc.

And also, what about if you decide not to have an iPhone anymore, or if your contract runs out, or if you can’t afford the phone anymore. Or, if your device breaks. Do you have to buy another $100+ peripheral for your Android phone, or another $100 peripheral for your Blackberry phone? There is lack of standards on these devices and this only hurts the medical peripheral market. Even the bluetooth standards for different devices are not in sync yet

You could say exactly the same thing to all the companies who think an iPhone App = a mobile strategy.

But again you’ve fallen back into your business perspective that treats wellness devices differently to other consumer electronics.

Do you think Apple is hung up on the fact that it’s denying it’s customers access to flash content? Probably not because it’s been a big driver of Apple App Store content.

The great thing about entrepreneurs is that unlike standards bodies that diver and err, they just get on with fixing things or fail trying.

So yes, I’m excited to see what / who actually purchases these devices, but I’m also cognizant that they are not game changers for the population as a whole — yet. In the future could they be? Sure, but in the current, they haven’t proven anything, they are too new to do this

Don’t be so sure about the status quo staying the same. Business is the key to this. The following example highlights this:

If Apple Inc paid for and supplied every gym in the US with 2 of these devices (one for each changing room) I think it is inevitable that they would substantially increase their market share next year in the US.

It would cost them at most $5 million ($99 x 2 x 25,000) – less than a days interest on their huge warchest of cash.

No advertising just straightforward long term engagement with their brand. Integrated into the Gym chains iPhone App this would also add more value to the fitness services offered at the gym and increase the loyalty of the member (who could be given another data point confirming his fitness regime is paying dividends).

A recent example. For those using oral contraceptives, sending text messages and education on oral contraceptive use will increase adherence to oral contraceptives right? No

I’ve read this report and it’s like something I read in 6 years ago here in Europe. There are countless reasons why it’s behind the curve and was doomed to fail to represent the US population eg. the patients were 80% white, 99% graduate, etc.

It also ignores the fact that there is a more reliable cheaper way of achieving this than sending SMS’s that millions of women already use when they set their calender with a reminder at/or about the time they’re having breakfast in the morning.

Also remember: if you could get women to improve their pill taking reliability you wouldn’t be publishing a paper you’d be busy consulting to at least one of the big pharmaceutical firms.

Another RCT currently underway out of Columbia is gong to look at this further, but again — just because it makes sense, doesn’t mean the data shows it will benefit

As explained texting me doesn’t make sense in fact it’s positively behind the curve. Most women we’ve surveyed who take the pill have been using the native/built-in alarm/calender to do this discretely for years:

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