The mHealth events that are happening are also now on the whole a lot smaller eg. the mHealth Summit drew in nearly 4,000 delegates just a few years ago is now (renamed as the Connected Health Conference after merging with the Partners Connected Health Conference – the ‘rival’ conference that operated in this space) draws in just a few hundred delegates.
With 2019 fast approaching so it’s time to start compiling a definitive collection of the mHealth meetings planned for 2019. If you know of any that I’ve missed please share a link in the comments below and I’ll update this listing to include them:
“Although telemedicine visits have increased sharply in the U.S. in recent years, the vast majority of American adults still receive care from doctors in person rather than via remote technology, a new study suggests. The goal of telemedicine is to help improve access to specialty care, particularly in rural, underserved areas of the country, researchers note in JAMA. As of 2016, 32 states have passed so-called “parity” laws requiring insurance coverage and reimbursement for telemedicine visits”
I think this is a classic misunderstanding of what Telemedicine actually is by researchers who for a variety of reasons want it to be all about remote Doctor video consultations.
“To see whether these laws translate to more use of telemedicine, researchers examined private health insurance claims data from 2005 to 2017 from OptumLabs Data Warehouse. Overall, annual telemedicine visits increased from 206 visits in 2005, or less than one per 1,000 people in the study, to more than 202,000 visits in 2017, or more than seven per 1,000. Most of this increase happened over the last few years of the study, with an average annual compound growth rate of 52 percent from 2005 to 2014 and an annual average compound growth rate of 261 percent from 2015 to 2017”
“If the growth rates we are observing continue, in a decade telemedicine will be seen as quite common,” said lead study author Dr. Michael Barnett of the Harvard T. H. Chan School of Public and Brigham and Women’s Hospital in Boston. At this point, telemedicine is still rare. It’s growing most rapidly in areas where a shortage of mental health specialists is prompting more patients to consider this alternative to in-person visits, Barnett said by email”
“During the study period, 53 percent of telemedicine visits were for mental health visits, followed by primary care exams at 39 percent. By the final year of the study, primary care was the most common form of telemedicine”
“It does not capture telemedicine visits for which there was not an insurance claim,” Linder said by email. “Patients could have paid out of pocket or, perhaps just as likely, the physician did not think or go to the trouble of submitting an insurance claim.”
I think this sounds about right.
““The limitation is that there is no physical exam and payment options are limited (mostly to fee-for-service),” Portnoy added. “Facilitated visits (which replace in-person visits) are more difficult since there needs to be a facility to do a physical exam and a facilitator where the patient is located.”
Abraar Karan (an internal medicine resident at the Brigham and Women’s Hospital) shares a fascinating opinion piece in the BMJ.
“The physical exam needs to change to make the most of technological advancements, says Abraar Karan. I received my first stethoscope from my mother, a psychiatrist who unsurprisingly had little use for the maroon instrument. I remember thinking that I wanted to be the doctor who knows how to use this better than anyone else. I went through clinical rotations paying close attention to the signs on a physical exam that could help secure a diagnosis for my patients. As a resident, I keep that same maroon stethoscope snug around my neck—yet for most of the day, I find I have little use for it”
“I’ve found that the physical exam is essential when I’m evaluating a sick patient who is decompensating, but less so in routine day to day care. When I was an intern, one of my jobs in the morning was to see the patients before the rest of the team and to report my findings on rounds. For most patients, I began to notice that their exams were largely unchanged from previous days—to the point where the clinical presentation quickly became a simple declaration of “unchanged from yesterday,” before I presented laboratory and imaging data”
It still stuns me how little interest Hospitals have in documenting how Patients feel. We’re seeing hospitals like University College London spend £400Million on an EPIC Electronic Healthcare Record and the idea of Patients even seeing the record (or adding information to it) is not even an after thought.
“The physical exam alone can rarely obviate the need for more testing in cases where a patient has any other compelling findings from either their history or routine labs. For instance, a patient who I admit with fever and a cough will be better evaluated by a chest x ray than by my auscultation of their lungs with my stethoscope. In fact, even if my exam were to be completely normal, we would still send them to the x ray machine—and if that was normal and the patient became more ill, we would probably upgrade to a CT scanner.
Similarly, if my exam was abnormal—say I heard crackles or minimal breath sounds—I would still, in most scenarios, send the patient for additional imaging. This is to say that the physical exam, which in the past would be the central part of a doctor’s visit with a patient, is now largely an additional data point that is usually, if not always, trumped by more objective, machine generated data, including vital signs (measured electronically), laboratory values (complete metabolic panels, complete blood counts etc), and diagnostic imaging (x rays, CT scans, ultrasounds, MRIs, PET scans, and more)”
This is quite an amazing example of how defensive medicine has become and the reliance Doctors have on imaging results before they’re confident to give a diagnosis.
“Don’t get me wrong—there are still a number of situations in which I find the exam to be clinically essential, and it certainly has a solidifying effect on the doctor-patient relationship, but there needs to be a major shift in how we examine our patients to make the most of technological advancements. One of the key problems with the physical exam is the wide range of variability between doctors. That is to say: two doctors may look at the same patients and have two different interpretations of the exam. Yet this happens with less frequency when using other diagnostics, including advanced imaging such as bedside ultrasounds”
“One example that should be particularly familiar to most doctors is estimating a patient’s jugular venous pressure (JVP) by visual inspection—a common poor man’s diagnostic in heart failure management. Studies have shown that physician estimates of JVP vary widely by the examiner, making the clinical finding hard to truly rely on. And we have increasing data to suggest that for some measures, bedside diagnostic equipment is superior: in a study of internal medicine residents, those who used handheld ultrasounds to assess right atrial pressure did so correctly 90% of the time, versus only 63% of the time in those who did so by physical exam of the JVP. As bedside ultrasounds become cheaper, we will see far more in clinical practice—and we must ensure that clinical training seizes this opportunity as well. Currently, the medical school curriculum on ultrasound is sorely lacking”
“While I predict that the physical exam in the inpatient setting will be most subject to technological transformation, even the outpatient annual physical exam demands a culture shift. The annual physical exam costs the healthcare system an estimated $10 billion, and accounts for nearly 10% of visits to primary care doctors—arguably taking away time from more urgent and necessary visits. Moreover, there is no data to suggest that the annual physical has any direct clinical benefit. In theory, it keeps patients more connected with the health system, which is certainly valuable, but one might question if it’s worth the cost mentioned—and if there are better, more targeted ways to do this specifically for high risk patients.
I am increasingly realising that even if I want to spend more time at the patient’s bedside and less time in front of a computer (which trust me, I do), this may not actually be what is clinically best for the patient. Today more than ever before, doctors are bombarded with hundreds of data points that require quick analysis and decisive decision making. We also have far more therapeutic options now than we ever did before. While it’s difficult for me to admit, I may be doing more for my patients by clicking a mouse through a table of numbers, and typing in text orders that will be executed by excellent nurses. With this in mind, I believe it is critical that we train more doctors in the regular use of affordable bedside diagnostics (including but not limited to ultrasound) to create a new standard for the physical exam”
“Ultimately, putting a stethoscope on my patient may be more of a reassurance for them than it is for me, which makes it still worth doing. But going forward, we need to find a new modern standard for the physical exam that physicians will find clinically optimal”
“What was the promise of reduced admissions and improved health outcomes in patients? This goal has not been achieved and is not happening how we thought it would”
“Scarce evidence for mobile app (mHealth). A recent overviews comes from the scientists from the Centre for Research in Evidence-Based Practice. Located at Bond University in Queensland, Australia. The scientists concluded that there is not enough evidence to decide whether providers should recommend the currently available mHealth apps to their patients”
“Data gathered from 4 databases since 2008. The team inspected four databases from 2008 onwards and the Journal of Medical Internet Research. This collection identified only six systematic reviews with 23 randomized controlled trials (RCTs). Evaluations. Evaluating 22 standalone healthcare apps was the goal. These apps are mostly targeting obesity, mental health, and diabetes. Meanwhile, the mHealth Economics 2017 study states that major app stores feature around 325,000 unique health apps. So, in ten years, only 22 were apps evaluated. According to the researchers, “most trials were pilots with small sample sizes and of short duration. Risk of bias of the included reviews and trials was high.”
This ‘research’ is terribly flawed. It’s just a shocking headline to sell you on expensive research reports.
“The possible harm of under-researched healthcare apps. This lack of proven credibility lowers the chances of healthcare apps to become full-fledged care delivery tools used in clinical settings and in patients’ homes. Instead, apps that are healthcare apps will be either perceived as a huge market of novelty toys or even a harmful technology”
“Non-studied apps: good, bad, or evil? One of the recent studies discovered that the use of fitness trackers and calorie-counting apps can exacerbate eating disorders — increasing eating concerns and triggering dietary restraints. So who do we believe?”
“NHS-accredited apps is a library for apps that have been developed and studied for the healthcare system. This group of apps are put together claiming to help patients with many conditions. These conditions include disorders such as bipolar disorder, bulimia nervosa, and post-traumatic stress disorder (PTSD). Who tests the testers? Meaning how do we check for validity? These tests were found to be of questionable efficiency. These apps had no scientifically reviewed data to prove they are indeed helping patients with depression or anxiety caused by mental health disorders”
I think it’s important to appreciate that all the apps in these libraries that need to be downloaded from the AppStore or Google Play at which point there’s another customer rating score. So perhaps the bandaid of a NHS Accredited library is just another temporary stop gap and the NHS should work to help EDUCATE Patients/clinicians to use the app stores that exist or work WITH the mobile giants (Apple & Google) if it wishes to encourage Patients and Clinicians to use mHealth apps with more confidence.
“Another research, also touching upon the currently available apps for mental health, concluded that there is a significant gap. App vendors, the scientific community, and clinical stakeholders do not all match in their outcomes”
“Lack of consistency in outcomes hurts all areas of healthcare. This lack of collaboration in the creation of apps causes a stopgap in the system. Some claim to relieve the symptoms of complex psychological conditions. This will harm every party involved”
I don’t agree with this. Senior medics know that there is a huge lack of consistency in the effectiveness of drugs and the sick care industry makes do with that.
“Without solid proofs of efficiency, the resulting product can’t be openly suggested to anyone who may need it. This makes the situation where the user base won’t grow as fast as it could and should. Providers won’t get improvements in patients’ health results. Patients certainly won’t be able to use reliable mobile self-management tools”
“The app “supposedly” helps identify the ovulation day, length of follicular and luteal phases. The app suggests on red and green days for having unprotected sex. Natural Cycles’ creators claim is that this app’s efficiency is comparable with traditional birth control methods. IF the app actually worked — it would be great. But something like a birth control method has to have a a much higher proof rate. proving it with the largest study of natural birth control methods. Still, even the app creators also admit the need for more research following their largest study of natural birth control methods. In January 2018, over 37 unwanted pregnancies among the Natural Cycles’ users at a major Swedish hospital. The app’s co-founder Elina Berglund initiated an internal investigation to find out that the algorithm’s efficacy rate stayed within the declared 93 percent. It’s not fun at all to see that there are unwanted pregnancies. This case got a loud public outcry because the efficiency of a birth control app is quite easy to track — and the cost of failing is obvious too. Natural Cycles’ developers made “hard to see through” (ambitious).”
I’m going to have to research this in more detail as I wonder how the hospital has settled the legal repercussions of this? If the app developer is still in business presumably the Hospital has covered them against claims.
“Now, let’s think again about all those thousands of applications that enter the market with ZERO proven research put into their creation. Basically, if we won’t be able to find out which apps really bring value to patients and providers, all new mHealth applications will be the waste of time and effort on ineffective or even harmful products”
I think this is a common misconception about the mHealth app market. That somehow Patients are a group of buffoons ready to put their lives in the hands of a developer in a garage making cookie cutter apps that they find on the App Store with zero positive ratings.
Surely the reality is mHealth apps that smart caring medics (eg. ones that have taken the mHealth training course that we helped develop) can identify apps that actually bring value for Patients and Healthcare Professionals and they can then prescribe them to their Patients fast tracking mHealth apps? Isn’t this what happens already with printed books/leaflets and websites that Medics recommend all day everyday to their Patients?
It amazes me that a report of this importance starts talking about ‘satnavs and smartphones’. Just stand in London traffic and observe driver behaviour you will see that satnavs haven’t just converged to mobile but in 2018 mobile phones are categorically better satnavs than satnavs.
It’s not just your Uber driver but even the highest spec luxury cars have had their satnav/displays taken over by Apple thanks to CarPlay.
“Yet the state of online services, basic IT and clinical tools in health and care is far behind where it needs to be. Despite much good practice and some pockets of excellence, for many people – patients, service users, carers and staff – we still need to sort the basics”
Here’s a short talk I gave at Doctors2.0 in Paris where I explain how the consultation process needs to be transformed:
“Technology systems used daily across hospitals, GP surgeries, care homes, pharmacies and community care facilities don’t talk to each other, fail frequently and do not follow modern cyber security practices. As a result, some people are getting suboptimal care,1,2staff are frustrated and money could be saved and released for the front line”
“Just being able to make the best use of mainstream products and services would transform health and social care in this country. But it’s not just about getting the current systems to work better – our ambition should be for the use of the best technology available for the NHS and social care sector. The potential of cutting-edge technologies to support preventative, predictive and personalised care is huge”
“For example, we could use more data-driven technologies such as artificial intelligence (AI) to help diagnose diseases or conditions and to gain better insights into treatments and preventions that could benefit all of society. Or we could use robotics and voice assistants to support people and their carers in rehabilitation, dementia support or medication management. And appropriate use of NHS data could radically reduce the cost and time needed to generate new evidence on the effectiveness of interventions”
“To reach this potential we need to focus on getting the basics right: the digital architecture of the health and care system – the building blocks. Open standards, secure identity and interoperability are critical to the safe and successful use of technology, ensuring that systems talk to each other and that the right data gets to the right place at the right time”
“We need modular IT systems, where any module can be easily switched out, to create a market where providers compete on – and are rewarded for – quality. We also need to make sure patients and people who use care services have confidence that their data is held securely and used appropriately”
The only way of achieving this is via a mobile first approach. It should be obvious that Mobile authentication and notifications when your data is being used/accessed are standard in banking and travel industry eg. Here’s why ‘Mobile’ should be your NY2016 resolution.
“But the gap between where we are and where we want to be is only getting bigger. We need to take a radical new approach to technology across the system and stop the narrative that it’s too difficult to do it right in health and care. The UK has the chance to lead the world on healthtech. We already have some of the world’s leading healthtech companies bringing new innovations and advancing the international reputation of our excellent science and research base. And, in the NHS, we have the world’s biggest health institution. We have the opportunity to build an ecosystem that continually creates the best healthtech – technology that can be exported, alongside new methods and insights that can contribute to health outcomes globally. We are committed to working with partners to make that happen”
I’m surprised that the UK and NHS are not prioritising the export of the highest quality service because they can’t compete with the low ethics that are easy to find across the rest of the world.
“Our ultimate objective is the provision of better care and improved health outcomes for people in England. But this cannot be done without a clear focus on improving the technology used by the 1.4 million NHS staff,3,4 1.5 million-strong social care workforce and those many different groups who deliver and plan health and care services for the public”
Imagine having just the communication needs to talk to this many staff and the efficiencies a MobileFirst strategy would give you?
“We don’t have all the answers – this should be the beginning of an open conversation about how we can iterate to best achieve what is needed and work with the many brilliant, forward-thinking people in the system to get it right”
“Privacy and security. It is critical that we maintain public trust in how we hold, share and use data. Clear and mandated standards, guidance and frameworks for this will underpin the delivery of the best services and outcomes that meet user need and are based on the General Data Protection Regulation (GDPR) and consent where appropriate.
We need to maintain a safe and secure data infrastructure that protects health and care services, patients and the public. The digital architecture of the health and care system needs to be underpinned by clear and commonly understood data and cyber security standards, mandated across the NHS, to ensure we are secure by default and that the penalties for data breaches are effective in protecting patients’ privacy”
I’m not so sure that there is a public trust to maintain when you realise the NHS is the world’s biggest buyer of Fax Machines eg. privacy issues aren’t always obvious, most NHS Patients already believe their data has already been hacked by criminals, etc
“Interoperability and openness. Our technology landscape is varied and diverse, and interoperability is poor. This:
increases costs because we are not taking advantage of economies of scale9
has patient safety implications and increases errors10
introduces delays in the transmission of data from one system to another11
slows the digitisation of those parts of the system still very poorly served by technology
The data and technology standards we agree to will be open so that anyone can see them and anyone writing code for use in the NHS knows what the standards are before they start. But it’s not just about technology – agreeing and adhering to clinical data standards will give us much better and more granular detail with which to fight disease and prevent and treat illness”
I think the success Apple is having with Health Records is proof that the NHS is not going to win this battle to drive data and technology standards. I think they can have some important influence but ultimately they’re users of technology not in the business of developing technology.
“We should be using the best off-the-shelf technology where our needs are like everyone else’s, and not building bespoke solutions where they are not needed”
This is easy to say but hard to put into practice. The best off-the-shelf technology in the world exists in the Android and iOS smartphones yet the NHS has been trying to develop it’s own App Store for 10+ years…
“Inclusion: Health and care services are for everyone. We need to design for, and with, people with different physical, mental health, social, cultural and learning needs, and for people with low digital literacy or those less able to access technology. Different people may need different services and some people will never use digital services themselves directly but will benefit from others using digital services and freeing resources to help them. We must acknowledge that those with the greatest health needs are also the most at risk of being left behind and build digital services with this in mind, ensuring the highest levels of accessibility wherever possible”
With 7 Billion citizens having a mobile connection it should be clear that the most inclusive technology in the world is the mobile phone. This is another great reason for the NHS to go MobileFirst, put their best people on making services made for mobile, prioritise mobile interactions over all the paper/PC/faxmachine interactions, etc.
“move to a mobile-first approach and make the same digital services easily accessible from mobile phones, tablets, laptops and assistive technologies like screen readers. We recognise that our users access digital services in a variety of contexts, and technology like mobile alerts and responsive design can be critical to supporting the workforce in their roles”
This is positive but there’s a gap between saying something and doing it that I feel the authors don’t fully understand or aren’t ready to accept or commit to. A mobile first approach for example automatically solves most of these issues eg. you don’t need a screen reader if you have a designed for mobile service (Apple has Voice Over built into iPhone, Android smartphones have TalkBalk and Select to Speak, etc).
“get the benefit of the continual security and functionality improvements that come with the ‘evergreen’ ecosystem of modern browsers and web technologies”
“Internet first. When we adopt internet standards and protocols for our networks and digital services: we maximise the amount of technologies and digital services that will work for us and for those we care for. we maximise the number of developers and software engineers that can help us transform health and care and meet the needs of our users. we minimise what you need to learn to build software and digital services for health and care. we maximise the amount of distributed data we can handle”
I find the value of the report is diminished by the way the authors throw around buzzwords carelessly. Is it a MobileFirst or InternetFirst strategy?
“Our health and care system will never be a centralised service, because it services the citizens of an entire nation, and so too should its infrastructure not be centralised. But appropriate access to our data from any part of it – like you can access your email from anywhere, as long as you have the right passwords – is an important part of delivering care and staying healthy where we want to be”
I find it odd to hear so much confidence about healthcare care ever being a centralised service. I wonder if the authors think the more than a million NHS Patient records that were given without consent to Deepmind/Google in exchange for a free app for dialysis Patients are now centralised?
“Public cloud first. When we start with the assumption that all our services should run in the public cloud with no more locally managed servers: we get the resilience and backups of some of the most cyber-aware and heavily invested companies in the world. we can run and grow projects that work with infinite amounts of data or have unpredictable processing needs. we can share data to increase security – and only those with appropriate access are able to see the data they need. the commodity services we use, like word processing, should be continually upgraded and improved – without massive migration projects”
The problem with an “Mobile First”, “Internet First” and “Public Cloud first” strategy is that clearly nothing is being actually prioritised…
“Digital services. Ensure that digital services meet people’s needs – understand who the users of a system, website or service are, what they need to do, the problems or frustrations they experience and what they need from a system, website or service to achieve their goal”
I think most people have no idea how bad the NHS is at doing this eg. NHS Digital tried to educate the public about healthcare by paying chip shops to offer free internet access, a London Teaching Hospital built an iPhone App to help bereaved children compose electronic dance music tracks, etc.
“Innovation. Enable healthtech and innovation so the cutting-edge technology developed by our thriving healthtech economy can be more easily developed and used across the health and social care system, and the NHS and social care can benefit from world-leading innovation and research”
I’m not so keen on the cutting-edge. Perhaps they could just start by stripping away the dangerous outdated old processes eg. Fax Machines, printed prescribing formularies, etc.
“Build an open culture, working with innovators, academics, industry, staff and the people who use health and care services to deliver better outcomes for everyone, welcoming feedback and seeking constant improvement”
I wonder why this policy paper wasn’t written as a wiki that NHS Staff and Patients were invited to contribute to?
“Conclusion: We have the opportunity to create the most advanced health and care system in the world, and to become the global leader in healthtech. By harnessing the power of technology and creating an environment to enable innovation, we can manage the growing demand for services and create the secure and sustainable future for the NHS and social care system that we all want to see. When we follow the principles we have set out, we not only transform the health and care system and the healthtech economy to be the most advanced in the world – we also create organisations that can continue to evolve, improve and innovate with the best technologists and disruptors, wherever they may be. We have strong ambitions for the technologies we want to use, and the opportunity to create a world-leading environment for spreading and supporting innovation wherever it comes from. And we must never forget who we are building things for – those who depend on the health and care system to look after them and those who work within that system”
It’s fighting talk like this that makes change happen but it’s a bit concerning that the NHS is so clear about the fact that it’s building things for those who work within the NHS because clearly many of the things that technology most effectively does is replacing the need for workers. Perhaps it could make it clearer that it will use tech to help staff work smarter, more effectively and towards the top of their licence.
“This document is for discussion. We want to hear from you:
Do you agree with these priorities?
What have we missed?
What good work should we support and build on?
What do we need to take into account when thinking about applying these principles to different parts of the health and care system?
A questionnaire has been set up for you to provide comments and feedback on the vision”
Transforming Community Pharmacies into High Street Clinics is a conference organised by NELLPC and will be held from 9-5pm on Thursday the 15th November 2018 at The Arnold Hills, London Stadium, Queen Elizabeth Olympic Park, London E20 2ST.
The conference will highlight the potential of delivering high quality and easily accessible, personalised healthcare in North East London, including clinical and public health services and the NHS 10-year plan. Matt Hancock, Health Secretary, said: “It is important to make the investment in primary care and community pharmacies, so people don’t need to go to hospital”.
Context
Following the recently closed consultation, the NHS 10-year plan is set to include decisions on the future of personalised care and role of community pharmacy in delivery of clinical and prevention services;
Development of the integrated care providers (ICPs) contract, which is intended to allow health and care organisations to be funded to provide services for a local population in a coordinated way.
NHS England aiming to make ICP a mainstream model of care across England by 2020, following the rollout of ICP pilot programmes in 18 areas across England
The Government’s commitment to expand ICP and PHBs to between 50,000 and 100,000 people by March 2021.
Attendance is free & places have been reserved for:
Commissioners of primary care, mental health and public health services and those
working to develop enablers for the delivery of high-quality services locally
Local councillors from the six boroughs including those on health and wellbeing boards
Local voluntary organisations
Hospital colleagues
Local pharmacists
HealthWatch Organisations
* * * Get in touch via the comments if you’d like me to arrange a VIP invite for you to attend * * *
RT @mHealthInsight: How can we help Doctors to see that it's actually therapeutic to have your Patients use the internet BEFORE a visit? ht… 3 weeks ago
RT @DrDave01: @fwmedtech .@AliveCor has over 50 peer-reviewed publications validating various clinical applications for its products. They… 3 weeks ago
