My thoughts: “mHealth: My Father’s First Cellphone and the Evolution of Risk”

“mHealth: My Father’s First Cellphone and the Evolution of Risk” is an interesting article by British Doctor Layla McCay, Visiting Scholar at Johns Hopkins Bloomberg School of Public Health and former Assistant Medical Director BUPA.

I had several thoughts about the article and thought they’d be worth sharing:

The importance of Doctors to early adoption of Mobile

My father had a cellphone before most people had even heard of them. I remember his proud face that day in 1991, when he came home brandishing what appeared to be a sturdy, oversized briefcase, and announced that we were now a mobile phone-owning household… …But a week or two later, the unwieldy nature of this hefty device, and the lack of anyone else using one, rendered our new phone nothing more than a novelty. With no particular use for it, the whole kit was relegated to the cupboard, and we spent the next decade on our landline

For me this provides a really good reminder of the fundamental contribution that Doctors made to the early adoption of Mobile phones. I don’t know for sure if Dr McCay’s parents were Doctors (it’s quite likely when you consider the % of Doctors who follow a parents career choice) but I’m quite confident that her father wasn’t as there is no way a Doctor in 1991 would find no particular use for the device as by 1991 pagers were already commonplace amongst British Doctors.

In my experience Doctors adopted mobile phones NOT to call people on their mobile phones but to be “reachable” eg. by patients, the clinic, hospital, emergency services, etc. In my opinion it was only by expansion of the need to be “reachable” that I think mobiles became commonplace in society as otherwize we’d be habitually turning the things on and off.

Early mHealth wasn’t obvious

The creep of the cellphone in my city coincided with the millennium. One day nobody had one; the next, every person on the street had a phone attached to their ear. I succumbed to peer pressure: Suddenly, with all my friends sending text messages, I could see a use for the cellphone after all. But it certainly didn’t have anything to do with health. Well, nothing good, anyway. There was a lot of talk about the unproven risks that people feared cellphones might pose to health: cancer from phone masts, brain tumors from holding the phone next to your brain, interference with hospital equipment…

Wow. Okay in 2000 there was still a lot of people using landlines to call emergency services but really nothing to do with health? I can accept that as a young medical student who hadn’t yet entered the wards and been handed a bleep (or 2!) yet this might not have been obvious but I can’t imagine there were many consultants on the wards who didn’t have a mobile – and use it extensively as part of their work – in 2000.

By 2000 even the popular press was picking up on the life saving potential of the mobile phone eg. one of my favorite early good news stories where a 4 year old diabetic in Dundee worked out how to use his mums phone to call for life saving help.

Personally I have vivid memories of using my Nokia Communicator in 2000 to call a surgeon friend from the scene of a major traffic incident (it involved an emergency response vehicle so emergency services had already been contacted).

Did we really accept Mobiles as a potential health hazard?

I even published a paper about how cellphones could turn off defibrillators at close range, that was subsequently cited regularly in hospital policies on the subject. Cellphones were generally accepted as a potential health hazard, but nobody ever suggested they could also be the opposite

I’ve been watching this area very closely and think this isn’t a case of “general acceptance” but more “general ignorance”. It’s also interesting that whilst the paper Dr McCay published refers to the effects of licensed spectrum mobile networks it doesn’t even mention the much greater potential issues associated with unlicensed radio sources eg. WiFi which involves much lower cost, poorer quality, higher power and more randomly located radio sources.

It’s also interesting to note how this student BMJ paper was used by others to contribute to the financial burden patients and their families face as it was used extensively as part of a false argument by a wide range of hospitals who were busy cosying up to private enterprises to extort money from the various Patient Bedside telephone services (many of this stipulated “no mobile” signs where posted in the hospital in order to drive patients/relatives into using the exorbitantly profitable call services they were providing to recoup investments) that we only saw being lifted in recent years. In my experience I notice it also massively impacted on carer productivity (Docs and nurses have for the last decade been forced to play a ridiculous cat and mouse game where they have to keep popping outside the building to use their phones) and slowed adoption of mobile based clinician tools eg. the Dr Companion medical textbook content.

In 2012 it’s sad to see that the legacy of all this is even the worlds most advanced hospitals are still presenting patients and their families with a beleaguering array of outdated private sector business models:

Other Doctors help Dr McCay see the mHealth opportunity

It turned out that again I was too quick to judge utility and relegate cellphones to the back of the medical supply closet… …doctors who use mobile devices in practice to improve patient care. They are using them to communicate with patients, view health records, diagnose X-rays, schedule appointments, issue reminders, make referrals, prescribe medication, monitor diabetes, calculate body mass index, identify medication interactions, check the latest evidence, and prescribe health information. Cellphones are being used in prevention, diagnosis and treatment, from prenatal to the last years of life, right across the spectrum of care. In health and development, “mHealth” (short for “mobile health”) is the new black

It is great to see that on meeting with some Doctors who are actively using technology Dr McCay can be inspired. I hope this is a lesson to those challenged with the task of introducing new tech for clinicians: Nothing is as educational as meeting with colleagues who are already using it.

Are these real patient worries?

But is safety keeping up with technology? My 2003 publication on how cellphones interfere with hospital devices is as outdated as the cellphones it describes. People aren’t worrying anymore about whether their cellphone might turn off their heart monitor; they’re worrying about who might be able to see the information on that monitor. Or their blood results. Or their diagnosis. Or their identity

Wow. I cannot ever recall hearing a Doctor suggest this was a concern. Where are the patients that are worried about a cellphone turning off their heart monitor? Which heart monitors are being switched off by cellphones? As for the privacy of blood results I think it’s not that people are worrying about the privacy of their blood results rather they’re actually asking “can you text me my blood results as I don’t want to have to take the day off to come and get them?”.

Can we please stop perpetuating this “paper is best” myth

Data security was once something that the librarian took care of with a shiny key that locked the medical records office in the hospital basement. Now, it’s digital, and a physical lock can’t protect these records. The question is whether anything can

Let’s put some history straight. Librarians took care of nothing in the way of privacy, a request from a ward and you gave a low paid porter a patients file to transfer around the hospital on a trolley. A request from another hospital and everyone involved with your care would wait days. This wasn’t something we all trusted in, it was yet another weak link in paper based patient records.

The lack of electronic records meant that Doctors would commonly be found talking in public areas and if you know any clinicians who worked in these times they’ll tell you tales of how investigative journalists were discovered riding up and down in the hospital elevators whenever their hospital admitted a celebrity, etc.

At the end of the day who knows maybe there won’t be anything like 100% digital privacy but this is going to extend to the data surrounding the rest of our lives before it reveals our healthcare data. Even if this situation was reached patients will still want their Doctors to have their accurate up to date information when they are being treated. What’s more this is another great reason why there is nothing is worse than a data center losing my information while denying me access to it and yet another reason why we should mandate for patient accessible records.

Where are all these security lapse’s?

The speakers at the event focused on the current mhealth dilemma: We want to free the data, and we need to keep it secure. Doctors, nurses, and patients want to be able to use the new technology and access the data to innovate and drive up safety and quality of care for patients, but to keep it secure that data must be protected with the digital version of the librarian’s shiny key. The real risk is that in the zeal to innovate, mHealth users are outpacing vendors’ mHealth security solutions and health care organizations’ governance procedures. Innovating to achieve the right levels of security is a critical next step in mHealth, and security is one of the key barriers to officially sanctioned progress

It’s a big plus for patient controlled records that I can show you plenty of big data privacy breaches by Healthcare Providers who have access to patients data but we’re yet to see patients complaining that they inadvertently revealed their own data.

As with Layla’s previous caution on mobile phone use in hospitals I think we again have here another over anxious warning. Kaiser have made 9 million patient records accessible via mobile and within the first month over a million have accessed them but we’re not hearing about any leaks or patients sharing this information on Facebook etc.

The fact is it’s safer to have patients looking at these records (they care and are the most interested in this information and can spot mistakes/errors better than most people) plus once you get patient access you’ll start to get systems that will a SMS patients as and when their records are looked at. When you have patients informed of the name and authority of every individual who is logging on to look at their records it’s going to be even more secure than anything we have today.

Is every digital interaction a compromise?

However, according to Friday’s speakers, health professionals and patients alike are already starting to compromise on security to access the potential — emails, text messages, apps, and more. While there are plenty of secure solutions out there, some are as unwieldy and expensive as my father’s first cellphone, and for many vendors of mHealth tools, regulating to demand their use is the equivalent of shutting the door after the horse has bolted

There’s something here I think healthcare professionals need to get an appreciation of. Appart from informing them of the real risks that might unfold there is nothing we can do about patients sharing their data if they want to. Much of the world is beyond the control of healthcare professionals and there is nothing we can do to stop someone revealing even their most sensitive health info on a social network for all the world to see. Healthcare proffessionals on the other will find that the penalties are harsh and their regulatory bodies, patients and courts won’t be so forgiving. You don’t have to remind genuine medical professionals of this as every month they’re in the habit of forking out huge medical indemnity fees to cover this eventuality. If they are fools there are processes that will catch them.

On the other hand let’s not refuse to interact because of fears but use more common sense. As a good example I know of a patient with CF who uses Skype all the time with her Doctor. While healthcare security experts may lecture about how this contravenes all medical privacy requirements and the Specialist would be struck off if anyone knew the fact is if you completely intercepted the 2 way AV on these calls you’d get much less sensitive info than by looking at her public facebook profile/fundraising page.

Why demand and develop when other industries have already addressed these challenges?

The mHealth tools are already too ubiquitous and too useful, and there are too many competing interests to be able to impose high levels of security on them all. But health organizations can work with governments, regulators, health professionals and industry to demand, develop, and contract for that virtual librarian’s key that will keep health information safe on their platforms, and in doing so, enable larger scale, secure mHealth innovation

See above. In exactly the same way that there never was a problem with mobiles in general areas of hospitals there was also never a “librarian’s key” that assured patients of the privacy of their health information. School leavers and volunteers were in complete control of these records as they made their way around (and outside – they had cigarette breaks too) hospitals on trolleys.

Instead of demand and develop we shouldn’t ignore the opportunity we have to FIND and ADOPT based on what’s worked in other industries. Mobile Banking has already worked out 99% of our security issues, Mobile Gaming has worked out 99% of what it takes to build engagement, M2M solutions already shipping in BMW automobiles have already solved 99% of the issues we have with connecting medical devices, Microsoft HealthVault has already worked out how to bridge the gap between consumer and healthcare enterprise Apps, etc.

Why do we think mHealth vendors are ignoring security provisions?

And as the solutions become cheaper, simpler, and more convenient, and higher levels of security become the norm, perhaps this will create new expectations and the market will nudge more and more mHealth vendors to drive up their security provisions in a way that regulation alone may struggle to achieve

If this wasn’t more secure than what we’ve already got do you really think a massive care provider like Kaiser Permanente could make all their medical records mobile accessible?

Of course there will be a kid in a garage somewhere who might be making the coolest healthcare app and sharing the data with anyone who’ll pay for his next server but there isn’t really a exodus of patients who want to share their medical info with him and healthcare providers would be better off learning from her approach and recruiting this talented individual.

What about the things you can’t do with paper?

While it’s important to keep things in perspective (paper medical records are at least as susceptible to getting lost as digital records, as any librarian will attest, and sharing them by fax or post is hardly failsafe), a lot of people could be accessing your personal information through digital channels, without your knowledge, much less your permission, with all sorts of incentives for doing so

This is already happening in the consumer health space eg. PatientsUnlikeMe. Entrusted clinicians are walking a thin line if they tried any of this with patients and they all know it (see above where I mention the fees they regularly pay).

Claiming fax or post to be “hardly failsafe” also ignores the fact that in 2012 a lot of medical data CANNOT be transferred via paper in this way even if you really really wanted to. Attempt to print off a full body MRI and you’ll know what I mean…

Don’t underestimate patients

My father has started using a random app on my mother’s iPhone to monitor his body mass index and decide whether to skip that chocolate bar. Unless otherwise agreed, that information should be strictly between him and the chocolate bar. But is it?

There’s an easy answer to this: No, it’s definitely not.

Apple knows that your mother has downloaded and is using it. They’re making money from this data by sharing this with other information about your mother (including location) with the companies who are advertising in their advertising networks eg. on the app store and in app banners etc. The App developer (and any of their affiliates) also knows your mother has downloaded and is using it. They also know some information about your mother depending on what permissions have been granted by your mother when accepting the app. If they run an in app prize competition etc and your mother/father enters their data they will also have this to twin with the information they already have.

The dangers of mHealth that is focused on Smartphone Apps

This article highlights for me the issues that develop when we focus on the Smartphone app opportunity in mHealth.

As you start to appreciate mHealth opportunities it’s worth avoiding this focus and the future horizon gazing to think about all the other massive opportunities mobile offers to reform healthcare experiences eg. integration of your medical record with emergency services so that they have your history when you call, SMS reminders for patients, SMS links to rich video content, connecting the lonely, Mobile connected Smoke Alarms that will SMS service providers when smoke is detected, Mobile connected Care Monitors that can help manage the needs of the independently living, etc, etc.

Don’t underestimate the ability patients have to change

Something I’m left thinking is that Dr McCay underestimates the ability we all have to modify our behaviours when faced with a new environment. I noticed this was also shared in the article authored in student days;

Imagine the chaos if everybody in a hospital had free use of their mobile phones: 24 hour ringing, beeping, and tinny versions of Britney Spears’s latest hit are not conducive to the hospital atmosphere

Is that what’s really happening? Do I live next to a hospital where we have patients ringtones bugging the hell out of us all? No of course not, patients have learnt to stick their phones on silent, off, vibrate only. Their friends and family have learnt to not be ringing their sick relatives at 3am.

Similarly I think patients are going to realise that sharing their health information isn’t always a good idea and smart healthcare providers who (like KP) are prepared to accomodate patient desire for convenience and ease of use are going to be able to leverage this new mass media to extend their brand and services.

Of course you could ignore the power of communities but thankfully in the 2010’s the presence of social media is going to make sure that any brands taking this approach will be kicked into touch very quickly.

My Takeaway: rather than an “evolution of risk” mHealth is our best opportunity to reduce it

Take an appreciation of how risk used to exist before we leveraged patients mobile by watching this video of Dr Layla talking about mental health for men:

End result: you’ve got a video you can watch over and you could contact Layla via Facebook Chat and Twitter between 12 and 2pm on Friday 17 June 2010. After that date (eg. today) the content’s value is substantially diminished.

Now let’s take a mHealth approach, remove the “Chat Live” text banner from the video and you have a complete reform of the patient experience. Imagine being a patient getting this text message from their Doctor:

Hi David, please check out this helpful video. Log on now to your HealthVault account to see more videos from our library and to book an appointment with me. Remember: If you feel you can’t wait to see me in the office you can always request a 3G Doctor consultation at anytime with one the informed colleagues who provide comprehensive out of hours cover for my patients

Instead of the dialogue being viewable by all the various advertisers/affiliates plus my friends and followers on Facebook and Twitter it’s become a private exchange between me and my Doctor.

Instead of requiring patients to allocate time, it’s always on, my Doctor (and her informed colleagues) are always at hand to talk with me about my concerns.

For me this highlights how mobile (the newest mass media) is not an evolution of risk but the best opportunity we have in the digital world to reduce it.

What do you think?

One Response to My thoughts: “mHealth: My Father’s First Cellphone and the Evolution of Risk”

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