mHealth Insight: the blog of 3G Doctor

The world of outside broadcasts have been radically transformed by the availability of 3G networks now that all of the major news agencies have acquired multi-SIM 3G devices from Mobile Viewpoint that enables high bandwidth video streams to be routed over 3G and/or WiFi networks replacing the need for a live outside broadcaster to bring with them an expensive satelite equiped van.

Up until now we’ve seen these deployed at trouble flash spots such as the London riots (where it was obviously much easier and less risky to carry this battery powered low cost equipment in a back pack than to take out a £500k+ equipped van) or when a crew need to travel abroad quickly to cover a breaking international news story so I think it’s an interesting sign of maturity of the technology that we’re now seeing it being used by the BBC for this global spectacle.

For one thing the helicopter TV shots of Britain are going to be so much better when the landscape isn’t littered with all those unnecessary TV crew vans!

Mobile ViewPoint Press Release

Still can’t wait until a smartphone app maker hacks a dual (or triple!) SIM 3G smartphone so that I can run this technology over the new multiflow networks to start making 3G HD Video Calls everywhere!

It’s obviously more about the quality than the numbers but even a quick glance at the list of influential healthcare and mobile industry leaders engaging witin this community should remove any concerns about that.

What are you waiting for? Click here to join the discussions today.

Sophie Borland in The Mail reports on the UK’s Department of Health plans to have patients use smartphone Apps to “monitor their health at home rather than seeing a Doctor or nurse” in a “scheme” being rolled out “in the hope it will save the NHS millions of pounds through unnecessary visits to the surgery or hospital”.

The article features some quotes from some interesting British healthcare industry leaders:

“Encouraging people to do something is a good idea but making people do it is a bad idea. You can guarantee that elderly people will not be able to use it or anyone else who isn’t very good with technology. If used wrongly it’s a big mistake. But some people love this kind of thing it really motivates them. Self-care is very important… …GP surgeries could be ‘bombarded with information’ which could divert doctors and nurses from seeing sick patients… …if a hundred patients are texting in their readings every day it’s going to occupy a member of staff all day. Doctors and nurses may need to be doing something else“

Dr Laurence Buckman, Chairman, British Medical Association’s GP Committee

“These apps will help provide patients with more information and give them greater control over their own care… …but they will not be right for everyone, particularly elderly patients who may struggle with the technology. Other systems and sources of information must also be in place to help those patients who are not able to use the technology… …so many people use apps every day to keep up with their friends, with the news, find out when the next bus will turn up or which train to catch“

Katherine Murphy, Chief Executive, Patient’s Association

“So many people use apps every day to keep up with their friends, with the news, find out when the next bus will turn up or which train to catch… …I want to make using apps to track blood pressure, to find the nearest source of support when you need it and to get practical help in staying healthy the norm… …innovation and technology can revolutionise the health service, and we are looking at how the NHS can use these apps for the benefit of patients, including how GPs could offer them for free“

Andrew Lansley CBE, Secretary of State for Health

My thoughts

> First impressions are that all of these siloed SMS and Smartphone App’s could very well be the perfect recipe for further fragmentation of care and an ignorance of the need for a holistic approach to care. Let’s hope the IT guys involved have an appreciation of the best practice in digital Doctor-Patient communications.

> The article reveals that NHS trusts will be provided with SMS services free of charge. I wonder what the impact of give away will have on the mHealth pioneers such as iPlato that have been committed to working so hard over the last few years to get SMS appointment reminder services accepted and implemented by NHS healthcare service providers.

I wonder if this sweeping move will provide any recognition or support to these private sector providers for the vitally important groundwork that they’ve done?

> It surprises me that Dr Laurence Buckman would make such a sweeping judgement on the abilities of seniors to use technology. I’d love to hear what Sir Stirling Moss thinks of this GP’s attitude!

> I’m surprised that there has been no mention of utilising more basic mHealth services despite the higher penetration of feature phones amongst underserved NHS patient groups and the wealth of evidence supporting the benefits and cost saving potential there is to use this huge resource eg. the use of caller ID to link patients and their Healthcare Records when calls are made to 999 emergency services, the expansion of emergency voice calls to enable 3G Mobile Video Calling, etc.

Interestingly the article uses an image that highlights how easily a video link to a qualified medical professional can greatly and inexpensively improve the quality of medical care in the community. It’s important that care providers appreciate that as they start trying to provide and support more care in the community there will be increasing levels of incorrect/inaccurate use of medical devices. It’s going to become obvious that video (both live and prerecorded) is critical to effective communication especially when you appreciate that the vast majority of care in the community is provided by medically untrained friends and family.

Imagine how a quick and inexpensive informed 3G Doctor style consultation could inform this patient how to properly record a blood pressure reading – potentially saving yet another >£1k emergency medical transfer.

I’m delighted to be presenting on our experiences here at 3G Doctor during the mHIMSS organised and Intel sponsored mHealth Symposium taking place as part of this years European eHealth week in Copenhagen, Denmark.

eHealth Week is the largest eHealth event that takes place in Europe and was established in 2002 by the European Commission to serve the networking and educational needs of serving European health ministers, government officials and key stakeholders. In 2012 the theme is “Smart Health – Better Lives” and the event will be supported by the Danish Presidency to promote an innovation agenda to benefit European citizens and economies.

The mHealth session will be held on the first day of the conference, Monday 7 May 2012, and will be focused on existing mhealth solutions with a view on success stories and challenges. The content is designed to give you the knowledge, and demonstrate concrete practical examples showcasing how mHealth services are transforming healthcare. The mHealth Symposium will also offer some exclusive networking opportunities.

Presenters already confirmed on the agenda include:

Brian Dolan, Editor, MobiHealthNews
David Doherty, coFounder, 3G Doctor
Denise Silber, eHealth / Web 2.0 Strategist, Basil Strategies

Click here to book your delegate ticket to attend this event (only €199), view the full programme and find out about mHealth sponsorship opportunities.

If you’re thinking of visiting Europe in May I’d also thoroughly recommend you try and also make the trip to Paris for Doctors 2.0 taking place 23-4 May – an event organised by Denise Silber (moderator and organiser of the mHealth Symposia).

The Healthy App Challenge launched by Surgeon General Regina Benjamin, MD, at the December 2011 mHealth Summit in Washington DC, and sponsored by the Office of the National Coordinator for Health Information Technology, has awarded awards to the following 4 smartphone applications to promote her vision for a healthy and fit nation:

Fitness/physical activity category

“Lose It! helps individuals achieve their nutrition and physical activity goals by setting daily calorie budgets that require users to record their food intake and physical activity. It also has a feature that allows users to invite their friends to view their logs on Facebook”

Nutrition/healthy eating category

“GoodGuide makes it easy for individuals to get the information they need about their food, personal care, and household products to help make healthy choices. It has a bar code scanner that allows users to scan products while they shop to get this information”

“Fooducate helps you make healthy food choices. When shopping you can scan the product bar code for a quick read on the nutritional values and additional information such as nutrients and additives; the app can offer healthier alternatives and compare two products side-by-side”

Integrative health category

“Healthy Habits recognizes that good health is not just about staying active and eating well, but is also reliant on other factors, such as sleeping well and mental health. This application addresses health issues such as smoking, wearing sunscreen, and reducing stress by tracking the user’s success and goals”

Other apps that received a strong recommendation included:

Fit Friendzy

MapMyFitness

Max’s Plate

Short Sequence: Kids’ Yoga Journey

My thoughts

Whilst there is no doubt the winners represent some very interesting smartphone mHealth application innovations but I’m quite surprised at the focus of all this from the Surgeon General’s office. According to the website the apps “were assessed against a range of criteria including innovativeness, usability, the ability to generate and download personal data, and whether they made the health-promoting activity fun. They also had to be available for free”.

Here’s why I think this focus was a poor choice:

1) Why is it limited to Apps?

Okay so I’m obviosuly quite critical of public health approaches where smartphone apps are heralded as a simple fix all but I also appreciate the importance of recognising the efforts of innovators. Whilst these innovators deserve recognition I personally think a lot more could have been achieved if the focus of the competition was different and aimed to recognise more joined up services.

2) Limitations of “FREE”

I think this is not only a pointless precondition for this competition but it’s also limiting the selection pool for potential applicants and could be seen by some as calling into question how the US government thinks and values mHealth – and the service providers who might want to provide it. Obesity is costing the US government billions of dollars annually and childhood obesity is undermining all future plans so what’s so wrong with an app provider charging for something that makes money while helping to address this intractable challenge?

It’s also a bit odd when you look at this from a mobile commerce perspective as the company that is providing most of these “free” apps (Apple) is making huge profits selling ads all over them and retailing the devices that they are run on. The reality is even on mobile nothing is really free and for digital experiences the conventional “free” normally just means advertiser funded.

The screenshot from the MapMyFitness website (above) highlights the consumer experience with these. The lack of regulation of the advertisers, what they sell, how they capture patient data (eg. web bugs, cookies, etc) and the very uncertain third parties that they share personal health data with is something that the US Surgeon General should pay close attention to.

There is another rather obvious advantage of paid for apps over free apps that’s linked to the sense of value they can generate in their prospective customers. Why shouldn’t a healthcare provider be encouraged to engage on mobile and expect a ROI or at least some payment for their efforts?

If we evangelize only the “freemium” digital business models I wonder if this might be further alienating existing healthcare brands – a group that should be looked to as one of the biggest potential advocates for mHealth.

3) “usability”

Unfortunately several of the apps were available for the iPhone only which gives the impression (to me at least) that from the viewpoint of the organisers of this competition usability = having a iPhone. It is a big shame that this competition has ignored the biggest opportunity mobile offers us to take control of healthcare expenditure – connecting senior citizens.

4) “the ability to generate and download personal data”

It doesn’t surprise me that there is no mention of the creation of “actionable information” or the “ability to put personal data to effective use”. Too many people are focused on this personal data generation process but it’s not what makes people change their behaviour. Weighing scales are in most US homes creating data but it’s not in itself dramatically changing anything as there is already too much data and too little interpretation and comprehension being made of that data. Once again the advertising (paying for these ‘free’ apps) is conflicting with this data too.

5) Focus on children

I think it would have been better if the focus had been more on apps for parents rather than for the kids. There’s a whole world out there beyond the mobile and parents shouldn’t be actively encouraged to provide their kids with more smartphone apps to use.

I’d very surprised if much research was done into the health impact of what appears to be an unsupervised child yoga app. I also think the “plate filling guide” app targeted at children (Max’s Plate) seems to be a little misconceived in as much as it’s probably not best practice for children to be responsible for choosing what’s being put on their plates.

Focusing on iPhone apps for kids is also side stepping the major issues schools are facing as children bring these expensive devices with them outside of the home. Perhaps governments should be sensitive to the pressures there are on parents to be buying expensive iPhones for their children rather than giving the children another excuse to ask for one.

If I was to pick a smartphone app on the criteria provided I would have loved to give it to an app that taught parents more about preparing and eating healthy meals with their children. I’m not overly familiar with US celebrity chefs but I know there’s a wide range of good quality apps available eg. Jamie Olivers 20 min healthy meal app:

How could the organisers of this competition improve it?

I think it would be a tragedy if the mHealth community didn’t work to try and maintain the momentum that has been started by this “on high” recognition of it’s work, but perhaps it could be better focused?

If it was up to me I’d scrap the headline grabbing name, instead of “Healthy App Challenge” I’d rename it the “Mobile Health Service Challenge” or “The Surgeon General’s mHealth Challenge” so that it can be more inclusive of a wider variety of opportunities – especially services that use the native features of mobiles (eg. SMS, Voice, Mobile Web etc).

If it were up to me I’d focus on recognising and supporting community efforts that:

> use far more basic processes of mobile engagement. I would have loved to have seen something that used SMS recognised for it’s ability to reach new audiences with important and timely healthcare messages eg. a Bone Marrow Donor recruitment drive such as HelpSameer.org.

If you’re not familiar with SMS abilities and think it’s only smartphone apps that have the power to make change please read this article by mobile industry guru Tomi Ahonen that shows how effective SMS has been for Obama – who started campaigning with SMS in 2007.

> promote opportunities that can actually take people away from digital experiences (especially children) like the TV, iPhone games, Facebook, to help them see the opportunities to switch off and make regular physical exercise a social activity.

It’s also important that we appreciate that whilst the award process rewarded features “that allows users to invite their friends to view their logs on Facebook” this referral is going to a place where the content is largely uncontrolled eg. Facebook shows a range of inappropriate advertising to children who have incorrectly registered their age.

This could also be having a negative health impact on other audiences eg. the young friends and parents who will be spending even more time glued to their laptops watching how their friends are doing rather than getting any exercise for themselves.

> Promote opportunities that mHealth enables care providers to save resources so they can better apply their limited funds and free up time so that they can then use it to improve the patient experience. SMS appointment reminders are a good example as they are a key innovation that all care providers should be introducing as there is plenty of evidence of the multitude of benefits for both provider and patients.

> Promote opportunities that help care providers to effectively interact with patients who are using their initiative and accessing online healthcare resources. Fortunately US clinicians (at the Mayo Clinic) are leading the world developing these – see this video of Dr John Bachman MD for more information.

> Promote services that lead to greater adoption of mobiles by seniors as this is the immediate opportunity the USA has to control future healthcare costs.

Even if you were stuck with just iPhone apps – there are more 50+ adults in the US with an iPhone than there are children aged under 18 but America has fallen far behind other markets in it’s focus on mobile amongst senior audiences despite launching a MVNO for seniors in 2006 (the Jitterbug by GreatCall Inc) as markets like Japan have moved on so quickly (eg. all seniors there have 3G mobiles, most run pedometer style apps and the vast majority use mobile data, etc).

What would have got my vote today in the USA?

Kaiser Permanente – a care provider that is taking the initiative with mHealth by enabling 9 million patients to access their records via mobile free of charge.

I think it’s quite obvious that until this type of integrated step change is made by healthcare providers a lot of the work of mHealth developers will be limited and may in many cases (by increasing fragmentation) be adding to the challenges that both care providers and patients face.

The US Surgeon General’s recognition of KP’s work would have sent a strong message highlighting best practice and reminding other healthcare providers of their role in helping increase appropriate access to the data that already exists.

AT&T, LG and Microsoft for taking the initiative to warn the texting generation on getting a new mobile to be careful using the device when driving. Research shows there have been more than 10,000 deaths and countless more injuries on US roads from drivers being distracted by mobile phones.

In 2012 I really hope we see the networks and device makers across the world working on even more innovative ways to help address this massive problem that mobility has introduced and is capable of solving eg. preinstalling safety video messages on mobiles, enabling phones so that they can automatically select a “driving” profile that diverts calls to SMS etc, etc.

Click here for more information or the press release.

HatTip: Jo Masterson from 2morrow Mobile who commented on my previous post commenting on the delay in the announcement of the competition winners.

The announcement that Messages Beta is replacing iChat doesn’t seem like it’s going to change the world but it’s just laid the foundations for Apple to make the next move and do away with the technical reasons a Apple iPhone customer needs a mobile operator for anything more than a good data connection.

In summary:

> Failure to explore Video Calling ensured telcos missed out on identifying the opportunity in presence

Mobile Video Calls need presence before they make sense as a mass market mobile proposition: it is helpful if a caller knows their recipient is on a 3G Phone, on a 3G network, has enough battery left (especially in the early days), is in a location/time where they can accept it (eg. the lecture has finished), etc, etc. The most obvious use case for a customer to want to have presence is for mobile video calling. In the early days this was abundantly clear.

Note: this hasn’t been a problem for us with 3G Doctor. As an outbound call model where the patient essentially “books” a consultation on their video mobile it’s fair to presume they are ready and reachable. Similarly if the video consulting experience for any reason fails we can always default to an informed voice consultation.

> Operators didn’t reject Apple’s FaceTime move because they’d given up on video calling

The operators who on a wholesale level failed to understand video calling. As a result it failed to generate much consumer interest and after wasting their marketing budgets promoting “so what” use cases that could have been sufficiently served by video messaging (eg. I can show my friends a dress I’m wearing, look at me on a bungee jump, etc) many of the telcos gave up on it. This resulted in them ceasing to buy devices with forward facing cameras, continuing to price the video calls at exorbitant premium rates (even for contract customers with unlimited data plans that allowed them access to video calling alternatives that were much more bandwidth hungry eg. Fring), ceasing to work on the interoperability and user experience issues that made the technology remains a challenge even today (eg. despite Nokia being the first mobile device maker to identify and specifically target the 3G videophone market 7 years earlier, at the end of 2011 when their accountants launched their flagship mobile – the N9 – it featured a forward facing camera but no video call application).

> Apple used Facetime to create presence but stay under the radar of telcos

Realising that telcos wouldn’t pay them to just waltz in and cart customers off with a one stop solution to calls and messaging, Apple acted smart and played to win presence first.

Aware of the operator fear of VOIP (look at the share prices fall when a mobile device maker mentions something like Skype) Apple was smart to realise that the operators had given up on video calling and so wouldn’t mind so much if they toyed about with that even if they were giving it away for free (as long as they left the customers buying text, call and data plans from the operator who was subsidising the customers getting this hardware in the first place).

> 2012 and Mobile operators have given Apple a 5% market share made up of their most affluent and profitable customers PLUS a huge cash surplus that perfectly places them to kill the host

So today we get to see Apple start moving forward with it’s new converged communication offering and no operator is voicing disconnect (publicly at least).

Messages Beta makes it possible for customers to send unlimited messages, contacts, locations, photos, videos and place video calls between one another without even using a mobile network or a mobile phone. All you need is an internet connection and an Apple device (iPod Touch, iPad, iPhone or any Mac). The messaging system also supports a variety of other IM services.

> What next?

Want’s left for telcos when their top 5% of customers move to data plan only tariffs and are happy to buy them off Apple (who will be in a great position to pass on wholesale international-roaming-free rates)?

What happens when Apple launches a cheaper iPhone and creeps this network independent offering beyond the top 5% of subscribers?

Perhaps the pro-competition authorities will help telco’s out?

In light of this move is it any surprise that you won’t see anyone from the world’s most profitable mobile company at the GSMA’s Mobile World Congress in Barcelona later this month?

If they were attending I wonder what they’d think of the GSMA/PWC predictions that the mobile operators will be taking 50% of the global mHealth industry revenues by 2017?

Or perhaps that’ll be okay because as we’ll be seeing increasingly with voice and SMS revenues this 50% may represent the much less profitable segment of the total revenues?

Over at The Health Debate – a 217 member Linkedin networking group set up by Vodafone’s mHealth team – Shannon Schemeczko, Business Development Manager at Vodafone Hutchison Australia has posted an interesting question that I think characterises a lot of the confusion mobile industry execs have over senior audiences and their interests in mobile services:

I think it’s important to realise that it’s primarily the mobile industry’s job to sell this and appreciation of your customers needs is critical. Especially once we appreciate that if anyone is already carrying “old style nokias” then they’re already in the 21st century (after all it is these devices that defined the first decade of it!).

FYI here’s my comments from the thread:

@Niklas Bergvall

Exactly the right approach: start with customer needs/current problems and then work backwards to the technology.

@Andy Hendry

Check out the latest 3G camera mobile from Doro

The device is welcoming, has good feel, branding and visuals and the camera offers lots of important opportunities for personalisation eg. adding a loved one as a screen saver.

Of course you can always be a bit more original and have some fun eg. a 3M adhesive wrap?

It also has lots of smart features that care providers will find very useful eg. fully remotely reconfigurable, ability to call in without answer, preprogrammed SMS buttons, SOS button, GPS services, etc

My favorite is the basic stuff eg. when the device is programmed with “Call me when you get a chance” and “Call me asap” buttons (A, B etc) that can have a massive social impact by helping to connect generations more effectively.

@ Shannon Schemeczko

Have you tried bundling any other benefits into the smartphone to generate interest amongst these specialists? You might try some/all of the following:

> App to replace their need for a separate pager(s)

> Remote mobile monitoring to give them greater convenience about when/where they work

> Smart voice call handling to help them manage OOH cover more conveniently

> App to provide them with more convenient and effective access to clinical textbook content

> App to provide them with easier ways to document the care they’re providing

> Smartphone case to enable them to conveniently record ECG’s

Failing that loan a equipped smartphone or tablet to a junior Doctor – a senior clinician has a good nose for technology that’s just looking for a problem and the chance to see it being put to use to deliver a better patient care experience all too often will prove to be the best possible sales tool.

This BBC News story highlights a major issue that results when you’re (sometimes unwittingly) sharing data with social media apps.

With so many Doctors already using apps like twitter I wonder how many have actually thought about how they might begin to explain such a data breach to a medical defense lawyer?

A big congratulations to the dedicated team who have worked so tirelessly behind the scenes to bring together the world’s leading mHealth industry summit.

As media partner for the event since 2010 it’s been incredible to get a chance to work so closely with a team that really understands the importance of what they’re doing.

From speaking with delegates on the exhibition floor it’s quite obvious that the passion they’ve built this on has become so infectious that it’s not only brought huge growth in delegate, speaker and exhibitor numbers but also in the quality, focus and independence of the entire event.

I look forward to seeing how the event can develop further with it’s new parents… if you thought the Gaylord Convention centre was busy in December 2011 you haven’t seen anything yet!

This AMA news story by Pamela Lewis Dolan is a very surprising bit of news if you (like me) are improving outcomes by developing digital tools that engage patients.

Taking a closer look at the original research and it’s quite unsurprising that it’s based on a report of such low quality it genuinely surprises me that a Health Communication Journal would publish it.

Here’s why I think it’s completely invalid for the headline conclusion:

1) Apples Vs Oranges

The research contrasts engagement with web based and paper based information. Whilst it tries to accurately measure the clicks of users (once logged into it’s website) it uses a self report process for patients who were in the paper based group.

2) Importance of quality design of the web portal

Of the 170 recruited into the “web arm” of the trial the researchers reported that 20% faced a technical error that made it impossible for them to log on. I think this indicates that there were significant usability challenges with the web portal the patients were being referred to and as such it’s likely many of the other participants just gave up on sight of the poorly functioning portal (many of these probably went off and used Google, WebMd etc independently of the directions they had been given.

I think it’s fair to say that no one would be surprised if patient interest was lowered by significant reduction in the quality and style of paper based patient information so it’s a surprise that the researchers do not even mention this (despite the reported 20% outright failure rate of the portal)

I’m also quite sure that good design and user experience have a huge bearing on patient recall eg. the researchers reported “almost 70% of those who used the Web site did not remember using it 4 months later”. I’ve never met a patient who has interacted with a Doctor online (or via mobile) who has any trouble with recalling that experience even years later. A report documenting the encounter also has a big impact on this.

If you think I’m being unfair consider this of the 170 selected for the web study group the research conclusions are based on only 32 participants and only 6 of these logged into the website more than once:

“Of participants randomized to the Web-based intervention (n = 130), 32 (24.6%) actually logged onto the Web site on the basis of tracking data. For these 32 participants, the majority logged on only once (n = 26)”

> Participation not “Direction”

I think the finding that 4% were excluded “for noninterpretable answers” highlights the wrong attitude from the researchers who seemingly viewed online engagement as something patients should be “directed” to do rather than an opportunity for participation.

I think digital care providers should be aware that experiences should be designed such that patients aren’t ever in a position where they think they’ve done something wrong.

> Dud questions

I’m not surprised that patients gave noninterpretable answers as some of the questions were also nonsensical. Asking a patient who is signed in and looking at your web portal whether they received information about it’s existence is exactly the type of poorly thought through experience that has me checking out…

> Underestimation of patient web use by design

The report seems to ignore content searches made outside of the portal. From watching patients using the internet it’s common to see them opening a new tab or window to search for something. This obviously would be unrecorded by the design of this online portal.

Claiming only “28% visited an external website” might just be ignoring the 72% who just fired open another window and continued their browsing.

> Has the idea of logging on had it’s time?

Ending on a positive note I think the research most definitely highlights the categorical failure that happens when we require patients to log on. With a wide variety of online services such as Facebook, Hotmail etc patients stay logged in, and while I fully accept the privacy challenge that healthcare provides I can also see how mobile can help us move away from this antiquated pull model.