mHealth Insight: the blog of 3G Doctor

Richard Meyer, Director of Online Strategic Solutions and former eMarketing Manager/Consultant to Medtronic/Eli Lilly, weighs in with an article over at DTC Marketing discounting mHealth apps:

“Here we go again. Just when I thought everyone had a great handle on mobile health apps more propaganda and non-truths abound all around the Internet saying that mobile health apps are everything from a threat to big pharma to a way to save billions of dollars in healthcare costs. There maybe a future for mobile apps but a lot of work is yet to be done“

Never mind questioning if there maybe a future or not why not look back at the Nokia Decade and appreciate how a single mobile app (the Camera) has already transformed the pharma sales channel. When did you last go to a high street pharmacy to pick up some film, get some processing done or pick up your holiday snaps?

For the record: Mobile, the cannibal of cannibals, was a big threat to Pharma 10 years ago.

“Last year I led some market research into mobile apps across all demographic segments and several disease conditions. While we did uncover some opportunities for mobile health we also learned that patients are very finicky about what they want in health apps and even more finicky about being reminded of their health conditions“

Shelve the research for a moment and check out what’s happening in the real world. Reading about the record adoption rate of Kaiser Permanente’s mHealth services is a good starting point.

“We found, for example, that type 1 diabetics are open to mobile apps that help them better manager their diabetes. This was especially true for caregivers of type 1 diabetics but when it came to apps to help type 2 diabetics manage their health there was a lot of pushback such as “I don’t want to be reminded that I have diabetes” and “I don’t want to have to consult my phone to choose what to eat from the menu”“

I think it’s important to note that no one is saying mHealth is easy or that behaviour change is a walk in the park. It’s probably even harder than creating new drugs (but we won’t go into that one).

“In younger demographics we found that people were more likely to download health apps that helped them make healthier choices in their lifestyles. However the key for these people, since they are tech savvy, is to ensure that the health apps are up to date and provide real value as they define value“

Wait until you see what happens when the quality control is taken over by their clinicians and the patients can use these apps with their clinicians. I’d recommend the work of Consultant Physician and Endocrinologist Dr Roy Harper in Belfast or the team at WellDoc Inc for those interested in this area.

“Now what about apps that remind patients to stay compliant with medications ? Buzzz, sorry, wrong answer. The last thing patients wanted was their smartphones buzzing with a reminder to take their medication because they found it intrusive and they also had privacy issues with it“

Intrusive? Privacy Issues? Really? Where’s Richard living? Young people I see today have mobiles constantly vibrating or beeping. Most women on the pill in our clinics have been using their mobile phone calendar as a reminder alarm for years. Are these patients Richard’s observing not already using SMS, BBM or Facebook updates? How would anyone know THIS buzz was a med reminder and not another all important SMS confirming their social importance eg. inviting them to some cool VIP party?

“In my opinion the future of mobile health is not via smartphone but in devices that patients can use at home to monitor everything from blood pressure to their heart. Patients would use these devices at home and then the devices would wirelessly send the data to either their PC for collection or to their doctor. Physicians would then be able to communicate with patients about the results via eMail or in person“

While I think the big opportunity will always be in feature phones (today’s smartphone is tomorrows feature phone) there is so much wrong with this paragraph that I double checked the date of the article: 14 May 2012.

Apple iPhone and iPad customers are regularly complaing about the need to use a PC with their mobile devices and the vast majority of those online are using cloud based email (eg. gmail/yahoo/hotmail) so I can’t imagine why any patients want their health data sent to “their PC for collection”.

“Does this mean that there isn’t a market for mobile health apps ? No, not at all. What it means is that if pharma wants to get serious about mobile health they are going to have to integrate the level of expertise needed to ensure these apps are user friendly and have utility for their target audience not to mention the back end analytics to measure the impact and keep the apps up to date“

I think this highlights a common misconception I’ve noticed in the pharma marketing industry. Impact for pharma still unfortunately equates to sales and while you’ve got to add value there’s a big leap from this to becoming a care provider that the patient trusts.

For more on my thoughts on the mHealth opportunity for Pharma check out the slidedeck from my “Clear simple steps for patient support and engagement” talk from the recent Mobile Strategies for Pharma conference organised by EyeforPharma in Barcelona.

“Getting the approach right could reduce customer turnover and get more users to embrace data plans, which brought in $62.7 billion industrywide last year, according to trade group CTIA. A wrong move would lower the amount of money that subscribers pay, while increasing network traffic and the cost of maintaining networks”

One of the big problems I find with todays M2M mHealth market is that for Mobile operators there’s a stale mate situation and it urgently needs a confident first mover.

Increasingly M2M offerings are entering what many believe is a saturated mobile market and operators in the most part don’t have the imagination to focus on connectivity as they’re consumed in their interest to support the latest free rich content experiences. MVNO’s on the other hand are looking to turn the heads of the dependable customers of the incumbents. Meanwhile apart from a few notable exceptions (eg. Rogers M2M unit) useful devices that should be connected (like Smoke Alarms and Care Monitors) need to make do with Blue Peter style solutions because they don’t appear attractive to either partners because there’s what many regard to be a critically low per-SIM spend.

I’ve tried plenty of Blue Peter style work arounds and found they present lots of unwanted and undesirable customer experiences that are preventing anyone from taking them mainstream eg. even with some contract SIMs I need to take it out of the Smoke Alarm every 6 months and use it in a mobile phone to make a call, I need to take a data plan (and liability) with a SIM even if I only ever want it to be used to send SMS messages, etc, etc.

At times it feels like despite the talks they give to investors the MNO’s don’t want this M2M business to take off at all.

When I first met Tomi Ahonen in 2005 at the 3GSM World Congress (now called the Mobile World Congress) in Cannes I recall the incredible keynote he gave on the “hidden Alpha Customers” that mobile operators were ignoring. These were typically individuals who had small phone bills because they didn’t make many calls but were very profitable because they recieved lots of calls. Tomi’s talk was memorable not for just for his style but because I was shocked at how it took this mobile marketing to make MNO’s wake up to an opportunity of hundreds of millions of $’s that they were totally ignoring. Today systems are in place the world over to ensure these customers are profiled and maintained.

Today I get the feeling someone needs to do the same for the M2M market.

In 2013 every home in America has a smoke alarm. 30% of these don’t work because the battery has been removed or run flat. If the telcos can for a moment stop forecasting what continually-monitored-gamified-quantified-4G-video-headset mHealth possibilities there are in store for us I think they’ll realise that there is a head start on offer to connect this life saving system (eg. giving a free connected Smoke Alarm with every new upgrade this summer).

In 3 years time with a huge installed base of continually connected hardware that’s ultra resistant to threats from competitors isn’t it going to be obvious that the SIM card cost is insignificant if it helps in some way retain your valuable customers and discourages them from even thinking about shopping around?

The M2M market is ideal for incumbents with their retail networks and sales teams but we all know MVNO’s can be more aggressive (look at the rate of change happening in France) and Apple remains a dark horse especially if a MVNO like Free is opening up the marketplace…

“…when you are designing a mHealth solution make sure you identify all of the stakeholders at the outset and that they all win from the new solution if any one of them loses, for example through seeing an increased workload but no upside benefit the system will probably fail and if you work collaboratively you get a collective buy in. No one party can do it all”

Tony Kane, Head of Business Development, mHealth Solutions, Vodafone Group, in a podcast interview.

I think I may have found the achilles heel of Vodafone’s mHealth strategy.

The way I see it one of the biggest opportunities for mHealth is in replacing bloated and unnecessary processes with efficient modern alternatives eg. letters with SMS, flyers with mobile videos, advice lines managed by call handlers with video access to informed carers, etc.

As with any company that has ambitions to change the status quo I think it’s critical to get used to the idea that if you want to make a difference not everyone’s going to be cheering you on all the time.

Click here for a list with links to mobile operator mHealth web pages from around the world

An interesting CNN article by Richard Galant featuring Atul Gawande talking about the importance of checklists for Doctors (watch Atul’s recent TedTalk on the topic here, click here for Project Checklist).

While I agree that the volume of information now means we can’t know it all I find all this talk of the growing need for specialists has arisen not because it’s how we get better healthcare but because we’ve continued to have blind faith in a reactive model that is focused on fixing sickness. Sadly the fundamentals remain rather basic, boring, less profitable and involve changing behaviour: eat well, exercise more, have a family Doctor relationship, don’t smoke, etc.

For the record I don’t think checklists are new (despite Atul’s TedTalk claims I got a tour of Lord Ara Darzi’s surgical suite at St Mary’s Paddington nearly a DECADE ago and they had these as well as black box recorders!) and I’m a total checklist convert as I think anyone would be if they understand the story of how the Boeing B17 Flying Fortress (a plane declared “too much airplane for one man to fly”) in 1935 won orders and flew 1.8 million miles without an accident because of a checklist short enough to fit on an index card that was full of all the boring dumb stuff like “be sure all the doors are closed”.

But I firmly believe that we’re going to see the real disruption – and the opportunity to impact quality of patients lives – is going to originate from giving patients access to clinically validated checklists…

Sadly Doctors checklists don’t get the scrutiny of their counterparts in the aviation industry, where it’s very hard to cover up a mistake, it’s your own life at stake, there are effective whistleblowing systems in place, etc. As a result I can only see change happening and the workings of the healthcare system being called to account once patients are empowered with interactive checklists.

Now you could give billions in state funding to encourage Doctors to adopt checklists but they’ll only really do this when they have to. It’s obvious to me that patient access to their information and documentation of their encounters is what will make them have to.

After being a little critical of the hype used at last years event it’s interesting to note how the focus has changed for the 2012 event:

“Baby Steps for Big Results. This year we focus on the power of “baby steps” (done quickly!) in mobile health. Why? Because this method — rapid baby steps — leads to success in three areas: behavior change, collaborations, and experience design..“

In a sign of the rapid rate of change in the mHealth world the event is now talking about baby steps but it’s sponsored by Kaiser Permanente – the mHealth innovator responsible for what is probably the world’s fastest ever adopted digital patient experience!

Full speaker line up is a fascinating line up of innovators but it’s rather odd (to me at least) that it doesn’t include any mobile operators (“carriers” for American readers) or mobile device manufacturers (Stanford Medical School was afterall the first US University to supply all students with an Apple iPad and the venue is a 15 min drive from Apple HQ):

Nikhil Arora, Co-founder, Back to the Roots
Kyra Bobinet, MD, MPH, Emerging Businesses, Aetna
Sheana Bull PhD MPH, Asst Prof, University of Colorado Denver
Albert Chan, MD, Chief Medical Information Officer, Palo Alto Medical Foundation, and Medical Director, My Health Online
Tim Chang, Managing Director, Mayfield Fund
Reman Child, Co-founder, OhLife
Cristina Cordova, Business Development, Pulse
Alexandra Drane, Founder & Chief Visionary Officer, Eliza Corporation
Rahim Fazal, Chief Strategist & Co-Founder, Involver
BJ Fogg, Director, Stanford Persuasive Tech Lab/Mobile Health 2012
Vinay Gidwaney, Co-founder & Chief Product Officer, DailyFeats
Eric Hekler, PhD, Asst Prof, School of Nutrition and Health Promotion, Arizona State University
Julia Hu, CEO & Founder, LARK
David Kirchhoff, President and CEO, Weight Watchers International
Emily Knight, Doctoral Student, Western University, Canada
Bernie Knobbe, Senior Director, Global Benefits, Yahoo!
Manu Kumar, Founder and Chief Firestarter, K9 Ventures
Rajiv Kumar, MD, Co-founder and Chief Medical Officer, ShapeUp
Ellen Levy, Founder & Managing Director, Silicon Valley Connect
John Lilly, Partner, Greylock Partners
Maria Ly, Co-founder, Skimble
Sarah Milstein, coAuthor, The Twitter Book
Neema Moraveji, PhD, Director, Stanford Calming Technology Lab & R&D, bLife Inc.
Robert Pakter, MD, CEO, PillJogger Inc
Deborah Rozman, CEO, Quantum Intech & HeartMath
Robert Scoble, Managing Director, Rackspace
Hiten Shah, CEO & Co-founder, KISSmetrics
David Sobel, MD, MPH, Director, Patient Education and Health Promotion, The Permanente Medical Group
Melanie Stuckey, Doctoral Student, Western University, Canada
Gus Tai, General Partner, Trinity Ventures
Richard Tate, Vice President, HopeLab
Hemi Weingarten, CEO and Co-founder, Fooducate
Michael Wu, Principal Scientist, Lithium Technologies Inc
Roni Zeiger, MD, coFounder and CEO, Impatient Science
Leslie Ziegler, Creative Director, Rock Health

The event starts tomorrow click here to follow it on Twitter.

This week I presented at the mHIMSS mHealth Symposium in Copenhagen and got a chance to visit the exhibition floor.

For me the stand out favorite was of course the local Ambulance Service’s demonstration of the paperless Danish Patient Journey. Ask these front line clinicians if they think mHealth and mobile video can save lives or reduce costs and they’ll laugh in your face…

The technology used to get 4G over multiple 3G networks is from Mobile Viewpoint. Solution provider is ViewCare.

Get an idea of the quality of service possible by watching the Olympic Torch Relay that started yesterday in Greece. Worth pointing out that the broadcast has so far been flawless but the torch has already failed once.

In this Huffington Post article Mrs Andrea Coleman, President, joint founder and CEO, Riders for Health makes some sweeping oversights of the mHealth market that I thought might be worth addressing:

“It has to be recognised that despite the exciting potential (of mHealth), there are limits to what a mobile phone can do. Much of rural Africa does not have signal reception – I have found myself climbing steep hills in rural areas hoping to catch a signal. I have not attempted climbing trees but I have seen it done”

I find it funny that foreigners underestimate the convenience mobile offers. I’ve no doubt Andrea would be more interested in climbing that tree if her alternative was an energy sapping or expensive hike. In the eyes of an African the idea of climbing to receive a money transfer (remember more than 30% of GDP in Kenya transits a mobile payment service) is probably not too dissimilar to how those in the UK might make a return trip to a cashpoint.

“It is mobility – the old fashioned technology of the internal combustion engine – that propels the ambulances and other vehicles that are so necessary, and yet so neglected, for equitable health care across Africa”

While it’s obvious that the Riders for Health social enterprise is all about this I’m surprised that there is so much interest in replicating the reactive healthcare systems we have in the west in Africa – where mobile is enabling new ways of doing things that can focus on the preventative opportunities. There is of course an important place for the combustion engine in healthcare but I’d prefer I avoided a condition than had an ambulance that could transfer me when I get one. I’d recommend those who dismiss the opportunity in mobile in favour of the combustion engine watch this TedXTalk.

“Let’s call it ‘thealth’. Transport for health care. The physical movement of people and services to connect the 70% of people who live in rural Africa with health care is one of the most vital yet neglected aspects of health care on that continent. We can’t let the well justified excitement about the potential of the mobile phone distract us further from addressing mobility – physically connecting the health care with the community. This may be an old technology but a hands-on approach to health care will never go out of fashion“

So where’s the rapid innovation that’s going to make this fast forward to the future happen? Is there some prolific growth in vehicle ownership in Africa? Have governments suddenly began supporting their people with commitments to building new road infrastructure?

I think one the biggest opportunities in mobile is that it’s owned by citizens.

“But the day that a mobile phone can immunise children, deliver anti-retroviral drugs, or help prevent a mother suffering obstetric complications will be quite a day“

The future might not be evenly distributed but welcome to that day!

> Can a mobile phone do more than immunise children?

Already is. Immunisation is a process whereby an individual’s immune system becomes fortified against an immunogen. Mobile (and radio etc) communication can be used can help prevent individuals from encountering immunogens. HIV and malaria awareness campaigns are well worth looking to for how this is being achieved.

> Can a mobile phone do more than deliver anti-retroviral drugs?

Already is. Medications for the treatment of infection by retroviruses aren’t needed if individuals don’t have retroviruses. The condom ringtone is a good simple example of how mobiles are being used to help raise awareness of safe sexual practices.

> Can a mobile phone help prevent a mother suffering obstetric complications?

In Bangladesh, Johns Hopkins Bloomberg School of Public Health have claimed that nearly 2 million rural births in Bangladesh will be attended in 2012 by a healthcare worker because of SMS. In Tanzania mMoney is also having a dramatic impact.

This USA Today video interview with Dr Ankush Bansal highlights for me many of the common challenges Doctors face with the concept of remote video consulting:

Here’s a few of the issues I felt were highlighted by the video:

“Virtual” Consulting

It’s unsurprising that people who have never done a remote video consultation with a Doctor refer to it as a “virtual” experience. But there is NOTHING virtual about a registered Doctor consulting with you about your health over video especially if they have your full history.

Arguing it is ‘virtual’ is to my mind like claiming I virtually flew to the Middle East last last week because I arranged it all online.

“Morning! morning Doctor how are you today? Good, can you tell me your name please?”

These opening lines of the video suggest to me this Doctor has very little experience of effective remote consulting.

I’m quite confident of this as in 6 years of offering 3G Doctor we’ve never had to ask a patient to tell us their name. Why? Because it’s not an effective way to ensure the identity of your patient (you should at least be referring to a stored facial image in their EMR), there are better ways (like discussing the details in the history they’ve shared before the consultation), it’s a waste of time that’s akin to the lack of purpose and pointlessness you pick up from video call demos in which participants wave to one another due to their discomfort and lack of focus.

“Telemedicine is a fairly new medium”

Really? Ever consider the work of the Royal Flying Doctors? Ever wonder how the Navy, oil rig workers or Astronauts access care?

“I don’t think it will replace traditional medicine. It will just be an adjunct for patients who have simple issues or who are between Doctors or need a refill”

This is really typical of the pessimism surrounding mHealth that still exists amongst some Doctors. It’s a big challenge getting guys like this to appreciate:

> Rather than supplementary an instant connection with a remote Doctor with specialist skills can be life saving eg. check out Rafael Grossmann Zamora, a Trauma Surgeon, who is using an $229 iPod to improve the quality of care and save lives across Maine.

> Rather than patients who have simple issues informed remote care (eg. where the patient has shared their medical history with the Doctor and she has reviewed it and done neccessary research before the consultation begins) will be the only way to provide value for patients with complex medical conditions and treatment histories. The days when there were revolving clinic doors through which Doctors took a history, made a diagnosis and treated the patient in a rushed 5 minute consultation are coming to an end and this is a good thing as except for the simple things these don’t offer patients value and are dangerous.

> Instead of thinking it’s all about patients with a need for a medication refill think about the value that can be offered to a patient who wants to discuss an issue within the 40 minute video that has been given to them by the oncologist who will be operating on them next week. Or perhaps this is a patient that has done their own research and wants to (hold onto your seat!) discuss a video they themselves have found.

Think about how we add value and work with patients who are already wanting to participate in their own care. Then try and have empathy for a patient that has their own unique informational needs eg. they want an opinion on something they’ve read on a online patient community.

“I think when I can do more of a physical exam of the patient”

I’ve heard this over and over (here’s an interesting post on the subject) but whilst I wouldn’t say physical exams are over rated I think it’s fair to say that there are many areas where we’re failing as a society and proactive efforts are needed as reactionary sick care approaches are failing eg. the obesity epidemic or the Veteran Suicide Explosion.

How will we know the corner is being turned by these Doctors?

First of all I think we’ll stop talking about how “Virtual doctors visits catch on with insurers, employers” and start talking about how flexible home working opportunities are helping some of the best Doctors be more productive and provide more value to patients at a time and place that suits them.

Dr Sarah Pearce, GP, Springmead Surgery explains the value mHealth affords patients over and above the static eHealth alternatives:

“Some patients have said they prefer using mobile phones instead of the previous Tunstall system which used a “box” located in the living room… …you have people round and they can see the box, whereas this just looks like a mobile phone and doesn’t label them as having an illness… …Patients can take it away for the weekend, because it is very light, very mobile. If you had a patient who wanted to maintain their independence, they could take it to the shops and it could monitor their condition while they are out shopping“

Health is the leveraging of ‘mobile’ (the newest mass medium) for ‘health’ (the state of complete physical, mental, and social wellbeing). It is a term that is widely confused, as many healthcare information technology professionals tend to consider it to be just a small subset of eHealth, but this is largely due to a lack of appreciation and awareness of the newest mass media. Historically, this has always happened with new mass media, for example, when television was first introduced it was regarded as a smaller subset of the cinema, showing timed slots and having broadcasting hours restricted similarly to opening times. It took more than 50 years before we saw its unique attributes start to be fully explored by tycoons such as Ted Turner, who made his fortune with CNN—the first all-news channel featuring rolling 24-hour coverage

Touch Health Sciences have published my latest “Introduction to mHealth” article designed to help introduce the scope of opportunities to healthcare professionals.

Companies mentioned include Alivecor, Apple, Cinterion, Doro, Emporia, FireText, Greatcall, Kaiser Permanente, Medhand AB, Microsoft HealthVault, Nokia, Samsung, SendTech SeN-Cit and Tomi Ahonen Consulting.

To view it online click here to register (free), alternatively say hi in the comments with your contact details and I’ll send you the 4 page PDF.