The European Commission funds the launch of the EU mHealth Hub

Screenshot 2020-02-18 at 13.42.31

The European mHealth Hub is funded by the European Commission under the Horizon 2020 research and innovation programme, under the action “Establishing EU mHealth Hub including evidence for the integration of mHealth in the healthcare systems” (Grant Agreement No 737427) and is a project promoted by the United Nations International Telecommunication Union and the World Health Organisation that has been developed by the Andalusian Agency for Healthcare Quality and has already attracted 19 partners including the CAMPANIA REGION, EHTEL (EUROPEAN HEALTH TELEMATICS ASSOCIATION), EMPIRICA GMBH, ERICSSON NIKOLA TESLA D.D., FOUNDATION TALLINN SCIENCE PARK TEHNOPOL – CONNECTED HEALTH CLUSTER, ESC (EUROPEAN SOCIETY OF CARDIOLOGY), DOM ZDRAVLJA ZAGREB – CENTAR (HEALTH CARE ZAGREB – CENTAR), HL7 INTERNATIONAL FOUNDATION, I~HD (EUROPEAN INSTITUTE FOR INNOVATION THROUGH HEALTH DATA), MDOG (MIJN DATA ONZE GEZONDHEID), SPANISH MINISTRY OF HEALTH – MINISTERIO DE SALUD, OSAKIDETZA (BASQUE HEALTH SERVICE), PCHA (PERSONAL CONNECTED HEALTH ALLIANCE), PROMIS (PROGRAMMA MATTONE INTERNAZIONALE SALUTE), JÄMTLAND HÄRJEDALEN REGION, SPMS (SERVIÇOS PARTILHADOS DO MINISTÉRIO DA SAÚDE, SHARED SERVICES FOR MINISTRY OF HEALTH), UNIVERSITY OF AGDER, and the UNIVERSITY OF APPLIED SCIENCES TECHNIKUM WIEN.

Screenshot 2020-02-18 at 16.31.20abc

Posted in Uncategorized | Leave a comment

mHealth Insight NOT @ GSMA Mobile World Congress 2020

Screenshot 2020-02-12 at 16.22.57

The GSMA is currently lobbying the Spanish Government to have Mobile World Congress cancelled (so that it can claim back insurance). UPDATE: The 2020 Mobile World Congress has been cancelled.

I had no plans to travel to Mobile World Congress as while it used to have dedicated mHealth conference tracks these were stopped a few years back and this year there was going to be no mHealth presentations which is a surprise considering that the senior management of Apple (the world’s most profitable mobile company) has publicly stated that they’re going all in on healthcare and in 2016 their CEO Tim Cook has stated that Apple’s mHealth revenues will dwarf the entire $Trillion smartphone market.

If you’d like to check them out you can click the following links to read my reviews and guides to Mobile World Congress here: Reviews; 2008/2009/2010/2011/2014   Guides; 2012/2013/2014/2015/2016/2019.

I attended the first Mobile World Congress (and even before that when it was the 3GSM Congress held in France) and have been advising the GSMA in various capacities over the years (helping organise meetings, select topics etc) so I thought it would be helpful to host a webinar on Monday 24 February 2020 to talk about the importance of mHealth to the Mobile Industry. The webinar will be live-streamed from a Hospital in Central London.

The webinar will be free to attend and you can find out more and watch the livestream on the dedicated conference website by clicking here.

https://mhealthinsight.com/mwc-2020/

Screenshot 2020-02-12 at 16.23.12

 

Posted in Uncategorized | Leave a comment

What is the clinical value of mHealth for patients?

Screenshot 2020-01-23 at 15.38.28

An interesting paper asking “What is the clinical value of mHealth for patients?” has been published in Nature by Simon P. Rowland (Department of Surgery and Cancer, Imperial College London), J. Edward Fitzgerald (KPMG International), Thomas Holme (Department of trauma and orthopaedic surgery, Epsom and St Helier University Hospitals NHS) and Alison McGregor (Nuffield Department of Primary Care Health Sciences, University of Oxford).

mHealth Insights

“Despite growing interest from both patients and healthcare providers, there is little clinical guidance on how mobile apps should be utilized to add value to patient care”

We saw a paper similar to this back in 2018 and I think it’s a classic case of not being able to see the wood for the trees.

I think this is because medical educators despite the evidence still aren’t teaching students to use the tools of our time.

If you are a medic who needs to modernise your skills please consider taking the “mHealth for Healthcare Professionals” certified programme that I developed to help educate healthcare workers about the opportunities presented by mobile technology for advancing access to and quality of healthcare.

In 2020 you fail the MRCGP exam automatically by having a mobile phone on your person. Examiners should be testing you on how you use your mobile with Patients because when Patients see you uncomfortable using a mobile they may doubt how current your medical knowledge is.

“We categorize apps according to their functionality (e.g. preventative behavior change,digital self-management of a specific condition, diagnostic) and discuss evidence for effectiveness from published systematicreviews and meta-analyses and the relevance to patient care”

This is a common misunderstanding that medics have about mHealth. It’s key to understand that basic features of mobile are often the most valuable apps used for mHealth. We don’t have to have Patients download apps to their smartphones before mHealth can totally transform care eg. it’s as easy as saying ‘here’s my number’.

I wrote all about this over at Mobihealthnews 10 years ago: Successful mHealth applications are already here.

“There are only a small number of clinical scenarios where published evidence suggests that mHealth apps may improve patient outcomes”

This is a classic misunderstanding of the motivations for publishing evidence. 9 years ago a hospital here in Ireland published evidence stating how appointment letters, reminders etc should be replaced by SMS but the HSE ignores it and still wastes millions every year on more expensive and less useful snail mail and missed appointments.

It’s important to appreciate that because mobile first designed care is typically a lot more efficient and less expensive than the services it doesn’t benefit from being published in the same way that a new therapy or drug would (as these innovations come with new growth opportunities for the healthcare businesses eg. increased staffing and/or costs that they can pass onto payers like the government or insurance companies).

If you think mHealth apps aren’t getting adopted without evidence being published in clinical publications study the emergency call business. The entire Irish out of hour Doctor rota is organised using SMS for years. +99% of all calls have been made using mobile phones for 10+ years now in places like UK/USA/Ireland. Very little/anything can be found on pubmed but lots of work has been done behind the scenes by engineers. If they hadn’t figured out things like caller ID, location awareness, mobile phone design etc etc the services we see today would be completely unmanageable.

“The World Health Organization (WHO) Global Observatory for eHealth (GOe) defines mHealth as medical and public healthpractice supported by mobile devices”

When I coined the term mHealth I realised this issue was going to be a problem. It’s incredible that most people still don’t realise that the biggest part of the mobile industry still lies in the $T networks that cover the world… Before you have any hope of appreciating the mHealth opportunity you must understand that the m is for mobile the newest and least understood mass media.

“In total, 2.5 billion peopleworldwide own a mobile phone and there is huge potential for mHealth to facilitate unprecedented access to specialist clinicaldiagnostics and treatment advice. In the US 56% of physicians have discussed mHealth with patients and 26% have been asked about mHealth by a patient (PWC Provider Survey)”

I would doubt the value of a ‘Provider survey’ as most ‘providers’ still use fax machines. The vast majority (+99%) of Patients in the US have used their phone to call someone for medical advice or to look something up. Note: Facebook is very much a mHealth app.

“Despite growing interest from both patients and healthcare providers, there is little clinical guidance on how mHealth apps should be utilized to add value to patient care, where value might include improvements in speed and accuracy of diagnosis, personalized treatment regimes, behavioral change advice, patient education or improved access to established therapies such as cognitive behavioral therapy (CBT)”

It’s mostly about training. The Internet and Mobile has totally transformed education but the Universities have for the most part not yet realised:

Please be patient im still learning

“This article discusses the potential valueof mHealth apps for patients and the challenges that cliniciansface in discussing mHealth apps in clinic”

I see this is a major hurdle to the value of this paper. It’s focused on how mHealth apps can support the 2000 year old office visit model but the biggest opportunity is clearly for the newest mass media to take us beyond that model.

The Doctor office visit only model no longer works because we can look it up.

It’s like thinking a paper on how mobile will transform the post office will be interesting whereas the real opportunity lies in how mobile has transformed (and continues to transform) communication.

“Despite the citations of diagnostic mHealth appsthere is huge potential and evidence is starting to emerge todemonstrate clinically significant improvements in morbidity andmortality outcomes in specific scenarios”

I think we’re long past talking about ‘Current limitations’. Check out the Smartphone Medical from 2013. I think it’s clear none of the papers authors have ever seen an experienced medic using a quality mHealth diagnostic app like that developed by Alivecor and unfortunately I think this substantially undermines the value of this paper.

Posted in Uncategorized | Leave a comment

mHealth Events to attend in 2020

mHealth Events 2015

In 2019 there were just 22 mHealth events held around the world (in the USA, Israel, UK, Spain, Dublin, France and India). You can click here to view the events that were held in 201920182017, 2016, 2015, 2014, 2013, 2012, 2011 and 2010.

If you know of any events please add them as a comment below and I’ll update this listing to make this another definitive listing:

“How would the BornMobile generation redesign Medicine?” & “The Future role of the Doctor“ Lectures
UCD Medical School, Ireland
5 February 2020

The European mHealth Knowledge and Innovation Hub Launch Event
Geneva, Switzerland
18 Feb 2020

mHealth in times of Crisis: the Coronavirus
London, UK (& Free Livestream)
24 February 2020

mHealth App Developer Workshop
London, UK
26 February 2020

Are you an innovator working in mHealth?
Birmingham, UK
4 March 2020

WHO Symposium on the Future of Digital Health Systems 2.0
Copenhagen, Denmark
4-5 March 2020

HIMSS 2020 Global Health Conference & Exhibition
Orlando, USA
9-13 March 2020

Apps in Healthcare
Berlin, Germany
19 March 2020

High Street Clinic Conference 2020
Royal Pharmaceutical Society HQ London, UK
19 March 2020

IMPACCT: mHealth in Clinical Trials 2020
Boston, USA
July 2020

Posted in Uncategorized | Leave a comment

Amazon launch Amazon Care service offering Mobile Video Consults with Primary Care Physicians & Nurses

Screenshot 2019-09-25 at 17.27.12.png

It’s of course a great validation of the value of the 3G Doctor service that we launched in 2006 that Amazon have put a similar service at the heart of their new Amazon Care service for employees in the Seattle area.

Founded by Jeff Bezos in 1994 Amazon is the world’s largest internet company by revenue (they generated $232Billion in 2018) and the second largest private employer in the USA (with some +470,000 employees it has more staff than Malta has citizens!). This isn’t the first experience they have of trying to run a healthcare service for employees as in 2013 at Zappos.com (a subsidiary since it was acquired in 2009) they launched TurnTable Health as a ‘next generation primary care clinic’ for staff next door to their huge office in downtown Las Vegas. Although Turntable Health was closed after 3 years I have no doubt from my own tour of the clinic that they built that it will have been in an invaluable contributor to helping Amazon get Amazon Care right and it’s positive that this new approach has very much evolved from being clinic centred to taking a Mobile First approach.

Turntable Helath Founder Dr Zubin Damania (@ZDoggMD) gave an interesting round up of the experience earlier this year for the AMA that you can watch here:

mHealth Insights

Screenshot 2019-09-26 at 14.53.48

It’s great to see the shift to a mobile first strategy. I was given a personal tour of the TurnTable Health clinic and while it was incredible to see what the team were trying to create it struck me that they were obviously missing this transformational component because the clinic was being built next door to the Zappos office and was part of an urban regeneration project. In 2019 a Mobile First approach puts Amazon in prime position to disrupt the entire healthcare industry.

Amazon Care is being billed as “Your first stop for healthcare” but I think the listing of  “urgent issues like colds, allergies, infections and minor injuries” is making a common misunderstanding about the mobile consulting opportunity and making the common  presumption that complex issues aren’t suited to remote consulting. This presents lots of challenges because giving people easy and free access to undocumented video chats with random Doctors creates lots of repetitive work but doesn’t save anyone much in the way of time or money. 

I think this is a predictable issue when a service isn’t well designed because if you’re just having undocumented video chats with random Doctors who know nothing about you and your needs before the chat starts you are pretty much limited to ‘general health questions’ (that you could probably just find the answer to by looking online if you’re someone who works in the tech industry). I’m confident that Amazon Care will soon evolve from the 2000 year old office consult model as they clearly extensively use data to enhance the relationships they have with all their customers.

At Doctors2.0 in 2014 I explained the value of enabling Patients to share the product of clinically validated interactive Medical History Taking Questionnaires with Doctors BEFORE they meet (so the Doctor can get a chance to do her research before connecting with their Patient):

I feel that without tools (like Instant Medical History from Primetime Medical Inc) to prepare Doctors and Patients for the Video Consults that this will also buy a lot of beachside properties for lawyers to retire to while the Doctors involved are forced into bankruptcy as Amazon’s lawyers won’t miss a trick in ensuring they are liable for malpractice if they miss something and there is a bad outcome or didn’t practice defensive medicine and refer their patient onto a specialist. Hopefully Amazon is already onto this as the potential for Alexa to be used to gather a clinically validated medical history (via Instant Medical History) would be a step change in medicine that would deserve a Novel Prize for Medicine…

Over-prescribing and excessive referring issues will no doubt abound with the model Amazon Care are showing here and it’s even obvious to the team creating the website eg. they’ve shown on their website how they prescribed antibiotics for acute sinusitis which is a viral illness!

Screenshot 2019-09-27 at 14.03.27

Privacy and your employer: If this service is enthusiastically adopted by employees it will be a break through that we’ll need to study extensively. We’ve never seen it work before at scale and there are loads of examples of how challenging it can be as employers have a long history of tripping workers up with small print eg. the US telco Sprint (who had 25,000 employees) couldn’t find any employees who would accept a monthly $100 bonus to share their blood glucose monitor readings as part of a study.

Amazon staff are acutely aware of how data is used to derive value for third parties so it’ll be very interesting to see what take up of their “Sexual health services like contraception and sexually transmitted infection (STI) testing” will be like.

Screenshot 2019-09-26 at 15.03.05

The biggest beneficiary of corporate wellness and preventative health programs is the worker and their family so I’m surprised by the restricted eligibility criteria that Amazon have used here. Surely they have the resources to build and validate a completely new care model so why not offer a basic service for all employees that doesn’t require insurer partners snd their third party healthcare provider companies that are invested in old models. Where we’ve seen  wellness incentive programs developed by insurers it’s all too often that the employees feel forced to partake in what feels like intrusive bureaucracy or face financial additions to their premiums if they refuse to participate which is not a great way to help people feel generous with sharing information especially as most Americans have heard about job applicants being routinely rejected when they apply for a job based on the data from a personality test, credit score, etc. 

I wonder how many Amazon employees are enrolled in an Amazon-sponsored Health Plan that isn’t with Kaiser Permanente and if this additional service is going to be used to entice them across to a different insurer. In the UK major companies have been offering mobile video chat services for years and staff have more often than not been unhappy with how it was implemented so devil is always in the detail eg. at corporations like VISA staff were very annoyed to find that they lost their weekly free cinema ticket perk and had it swapped with a 24×7 mobile video Doctor call service that they didn’t want to use.

It’s interesting that Amazon employees who are enrolled in Kaiser Permanente insurance plans are not eligible. I presume this is because Kaiser Permante were the first major healthcare brand to go Mobile First (back in 2012) and have been offering their own mobile video consulting services to their customers for 6+ years now.

Surely this friction is going to be a huge nightmare for health insurers. Amazon is quickly coming for your business and it has huge troves of data (they even have recording devices in their rivals boardrooms!) that are going to make it a rival that you probably don’t stand a chance competing with unless you’re prepared to disrupt your own business model.

Screenshot 2019-09-26 at 15.34.49

The lack of 24hr coverage is a great surprise. Maybe its just until the service gets up and running but sinking the cost to have a Doctor on call overnight has got to be more cost effective than having staff hit the insurance for a visit to an urgent care clinic and the time off work that could be completely avoided by the advice of an experienced medic on a video call.

Surely they shouldn’t be cheap skating things at the beginning and should’ve sunk some funds into even an under-utilised night shift working staff until demand materialised as 8-6pm opening hours aren’t going to make healthier, happier and more loyal employees especially when they work for a corporation that is a master of the consumer experience at scale.

Presumably it’s going to make it challenging to genuinely present the service as “Your first stop for healthcare” as all the Patients are all Amazon staff who are more than familiar with Chat Right Now messaging assistants etc that they provide to customers.

Screenshot 2019-09-26 at 15.36.12

Will this offer cost savings for Amazon or does it actually need to? I get a feeling that Amazon are going to launch this on the public after trialing it on staff as when the Patients aren’t their employees although it’s not great medicine they’ll have a gold mine on their hands. Most people don’t care a jot about small print so if they bundle this with Amazon Prime subscriptions all the extra data they’ll get will make it incredibly profitable.

I still strikes me as a weird decision to start this service in the USA where the massive sickcare business isn’t aligned with the interests of primary and preventative care, drug companies advertise on TV, and the market is dominated by employer sponsored insurance (that bring a whole host of issues arising from the most profitable use of data being it’s use to detect pre-existing conditions and deny coverage). Surely they could’ve had much more success developing this in a market like the UK or Ireland (where employers aren’t made responsible for employee health insurance and employees don’t have to change insurance every time they change employer etc) and instead of trying to fix an upside down healthcare model they could’ve better focused on leveraging their existing businesses and ignored the complexity of the health insurance market completely (eg. selling products through Prime, WholeFoods, rapid deliveries, etc).

Future

With Amazon Care launching Healthcare providers had better put their best people to work trying to disrupt themselves or preparing to get be disrupted. Medical Schools and professional membership bodies for family doctors (like the RCGP) should be gearing up to develop training courses for these emerging new roles that society expects of Doctors. They are welcome to copy ideas from the mHealth for Healthcare Professionals course that I produced for the Healthcare Informatics Society but they need a ground up revision as the type of medicine that Doctors can now practice cannot be done with the Doctor not using a properly provisioned smartphone (in the UK Doctors aren’t even tested on their use of the internet and still fail their membership exam of the RCGP if they have a mobile on their person).

What do you think? Click here to join me for a discussion of this development over in the +8000 member Linkedin mHealth group.

UPDATE: Sat 28th September 2019 

Screenshot 2019-09-28 at 16.05.14

After sharing this post on Linkedin Dr George Margelis informed me that Amazon are cutting the insurance for many of part time employees at the same time as launching Amazon Care which I presume isn’t going to boost feelings amongst staff that this is something that’s going to be great for them. 

Screenshot 2019-09-28 at 16.28.09

UPDATE: Monday 7th October 2019 

AWS (Amazon Web Services) will be hosting a “Healthcare & Life Sciences Web Day” on Wednesday 13th November 2019. This completely free virtual event will explore how the transformation of healthcare and life science companies is being fueled by cloud technology and will bring together industry leaders to explore how they expedite therapy development, incorporate digital therapeutics at scale, support population health, and improve patient outcomes.

Register here to receive your login link.

Screenshot 2019-10-07 at 13.52.26

Screenshot 2019-10-07 at 13.55.35

Screenshot 2019-10-07 at 13.55.46

Presenters include:

Dr Shez Partovi, Director Healthcare, Life Sciences & Genomics, Amazon Web Services
Ryan Hamilton, Sr. Vice President Population Health, Cerner
Marcello Damiani, Chief Digital and Operational Excellence Officer, Moderna Inc.
Venkat Jegadeesan, CTO, Beth Israel Deaconess Medical Center
Arun Ravi- Sr. Program Manager, AWS
John Brownstein, Chief Innovation Officer, Boston Children’s Hospital
John Axerio-Cilies PhD, Cofounder and COO, Arterys
John Schneider, CTO, Apixio
Chris McCurdy, Lead Solutions Architect, AWS
Bill Nordmark, CEO, Aver.io
Morris Panner, CEO, Ambra Health
Drew Schiller, CEO, Validic
Patrick Combes, Healthcare Technical Lead, AWS Jim Harper, Cofounder and COO, Sonde Health
Nick Hatt, Director of Developer Relations, Redox
Ali Zaman, VP Marketing, Health Gorilla
Patrick Leonard, Founder and CEO, Sopris
Kevin Weinstein, Chief Growth Officer, Apervita
Russell Granzow, Head of Pharma Solutions, Philips
Mikki Nasch, Co-founder, Evidation Health
Aaron Friedman, Solutions Architect, AWS
Kyle Johnson, Data Science Practice Manager, ML Labs
Sivan Bercovici PhD, CTO, Karius
Nigel Beard PhD, SVP of R&D, Mission Bio
Ainslie Hatch, Digital Therapeutics Director, Otsuka America Pharmaceutical
Joris Van Dam, Head of Digital Therapeutics, Novartis
Corey McCann, CEO, PEAR Therapeutics
Yvonne Chen, Director for Digital Health, Icahn School of Medicine at Mount Sinai
Nigel Beard PhD, SVP of R&D, Mission Bio

Posted in Uncategorized | Leave a comment

Review of Mobile Devices and Health by Ida Sim in the NEJM

Mobile Devices and Health

Mobile Devices and Health was published yesterday in the New England Journal of Medicine. Authored by Ida Sim, M.D., Ph.D who is a Primary Care Physician, Professor at UCSF & coFounder at Open mHealth (follow her on Twitter @IdaSim).

It’s exactly the type of papers we need to see more of so please read it at the NEJM website and share that link with your colleagues and social networks:

https://www.nejm.org/doi/full/10.1056/NEJMra1806949

mHealth Insights

“Mobile health — the application of sensors, mobile apps, social media, and location-tracking technology to obtain data pertinent to wellness and disease diagnosis, prevention, and management — makes it theoretically possible to monitor and intervene whenever and wherever acute and chronic medical conditions occur. With 81% of North American adults owning a smartphone,1 this frontier could be reached in the foreseeable future in the United States and is particularly relevant to the management of chronic diseases. More than 40% of U.S. adults have two or more chronic conditions2 and chronic conditions now account for 71% of all U.S. health care spending,3 so the promise of mobile health is especially attractive.”

While I clearly have a conflict of interest (I coined the term mHealth more than a decade ago and define it as ‘the leverage of mobile – the newest mass media – for health’) I think it’s rather obvious that this is not what Mobile Health means and by thinking it does you limit your capacity to understand the scale of opportunity that comes from taking a Mobile First approach to healthcare.

An obvious example of how such limited thinking comprises your ability to see the opportunity is demonstrated by how Dr Sim has presented the concept that mHealth is somehow limited by adoption of smartphones. We all should know by now that the most kind thing a carer can say to a Patient in 2019 with a chronic condition is “Here’s my mobile number” and that obviously doesn’t require anyone to have a smartphone as you can benefit from this if you just both have even the most basic mobile phones.

I realise that not everyone is like me and had a smartphone BEFORE they had a camera phone but it’s well worth medics appreciating that in 2019 even the most basic feature phones are more powerful and smarter than the latest smartphones from just a few years ago.

“Mobile health is at the swirling confluence of remote sensing, consumer-facing personal technologies, and artificial intelligence (AI). Data from smartphone applications (colloquially known as “apps”) and an ever-growing range of wearable and environmental sensors can be processed with the use of machine learning and other AI techniques to support medical decision making. Here, I review the current state of sensing, digital biomarkers, and digital therapeutics (the use of online technologies in the treatment of behavioral and medical conditions); discuss the challenges of integrating mobile health into clinical care; and describe regulatory, business, and ethical issues confronting mobile health. I do not discuss sensors and apps intended solely for use by health care professionals in health care settings. Because mobile health is a nascent technology and rigorous evidence of clinical validity is generally lacking, rather than presenting a review of existing systems, I present an overview for practitioners and policy makers to understand key aspects of this rapidly evolving field (see video)”

We live in a strange time when even popular tech journalists still think “we have no idea if Mobile Healthcare apps work’ but it surprises me that a lot of frontline medics still seem to think that ‘Mobile health is a nascent technology and rigorous evidence of clinical validity is generally lacking” because it’s not like these same medics would want to live their own lives without mobile technology.

I think this is largely because they think mobile health is synonymous with ‘healthcare apps on smartphones’ but also because even the most technical young medics have very little concept that there is anything inherently wrong in the outdated administrivia heavy IT systems they use everyday. Remember: even if no one is paying to publish papers in expensive journals stating this it is a fact that if Patients see you’re uncomfortable using mobile technology they may lose confidence in how current you are with your medical knowledge.

“Of passive sensors, the smartphone is the most ubiquitous. It has a nine-axis inertial motion sensor that tracks motion and position in three-dimensional space. A three-axis accelerometer measures acceleration in the x, y, and z axes; a three-axis gyroscope senses rotation around each axis; and a three-axis magnetometer compensates for magnetic drift to maintain position accuracy. These sensors enable physics-based capabilities, such as detecting the number of steps that a person takes during a day. Most smartphones can also sense geographic position, atmospheric pressure, ambient light, voice, and touchscreen pressure. Creative uses of these sensors and a built-in camera can turn the smartphone into a fall detector,4 spirometer5 (by sensing air pressure on the microphone), or heart-rate sensor.6″

I love made for mobile medical sensors and the smartphone medical is still an ever fascinating opportunity that’s still surprising me every week but it’s important to realise that the mobile has a personal secure browser and that is probably THE best way to collect a medical history from a Patient.

“Active Sensing. Passive sensors collect observable data. Subjectively perceived states of health (e.g., pain and other symptoms) are equally important for informing patient-centered care and, at this time, can be captured only by asking the patient. Until recently, information about such outcomes has been obtained from questionnaires administered at intervals of weeks to months that ask patients to integrate their experiences during some past interval of time (e.g., “in the past 7 days, how often … ?”). The ubiquity of personal devices makes possible an alternative approach called ecologic momentary assessment (EMA) that is well suited to capturing some types of patient-reported outcomes. EMA involves “repeated sampling of subjects’ current behaviors and experiences in real time, in subjects’ natural environments.”18 EMAs are less subject to recall bias than infrequently administered questionnaires and can be administered multiple times a day to capture short-term variations in responses. EMAs range from simple text-message prompts to short one- or two-item app-based questions and have been used to collect information on chronic pain,19 anxiety,20substance-use disorders,21 and many other conditions. Widely used in the social and behavioral sciences, EMA is an emerging method for outcomes assessment in both clinical care and clinical research. Newer image-based EMAs, if designed with cultural sensitivity, offer intriguing opportunities for bridging language, literacy, and numeracy barriers”

To say that mHealth is something that is only just emerging is nonsensical. Back in 2008 at 3GDoctor we started offering the ability for Patients to use their mobiles to provide their own history to Doctors prior to a documented video consult:

https://www.youtube.com/watch?v=z4JoJnRbsbI

Eleven years on to describe this as emerging is plain denial of what’s happening in the USA (where Kaiser were the first big healthcare brand to go Mobile First in 2012 and Walgreens were generating $375Million a month in revenue from their smartphone app back in 2014) other parts of the world that don’t have healthcare systems designed around the needs of insurers eg. in the NHS where honest practical GPs are just doing innovative things and sharing news of what they’re doing (instead of paying to have a paper published in a journal).

“Digital Therapeutics and Diagnostics. Simply monitoring patient outcomes remotely generally does not by itself improve clinical outcomes”

I think this isn’t true. Of course it’s possible to anything the wrong way but Mobile devices can now be embedded inside medical devices that Patients are already reliant on and we’ve seen that with popular FDA cleared medical devices like glucometers for years now and having accurate information on the use is invaluable for Clinicians who can work more effectively when they have more informed, timely, useful and honest consultations with their Patients.

“A major challenge of mobile health is the high drop-off rate in sensor and app usage.40 In one survey, more than half of users of activity trackers stopped using their device, and a third did so in the first 6 months.41Strategies to improve engagement include discussion between patient and provider of goals for tracking and clear plans for attaining them. Joint goal-setting followed by joint review of the data appears to motivate continued tracking and therapeutic engagement.42 However, it is not clear, at present, whether enhanced patient–provider communication and shared decision making improves clinical outcomes”

I’m suprised people are still talking about the reluctance of Patients to use sensors and apps given to them by their carers because for the most part Patients still don’t get to even see their medical record and notes.

Also worth noting: this usability issue with trackers was a simple challenge that they managed to deal with in Japan 10+ years ago when the Raku-Raku (simple to use) mobiles used by seniors began featuring activity monitors (doing away with the need to wear separate motion tracking devices) and displaying the user activity as an icon on the idle screen. For more on this please read “Mobile Health Devices: Will Patients actually use them”.

Integration with Clinical Care. At the front lines of care, two challenges dominate the implementation of mobile health. The first is the vast quantity of data. Ancillary staff can help review and triage data, and visualization tools can mitigate the cognitive burden of interpreting the data. However, the most effective response is to develop and show to clinicians only those digital biomarkers that inform clinical action or clinical understanding (e.g., temporal and severity profiles of patient symptoms). Simultaneously, these biomarkers must be of sufficient direct value to patients to justify their participation in the data-collection effort. None of this is easy. Greater investment in the science of digital biomarkers is needed to evaluate the value of mobile health data for clinical use.

Let’s just start by letting Patients use the tools of our time to share their information with their Doctors, and let Doctors use these tools to move beyond the 2000 year old office visit only model of care.

“Integration of Sensor, Smartphone, and Electronic Health Record (EHR) Data for Patients and Clinicians. The second (and related) challenge is how the inclusion and presentation of data will fit into an already complicated and overstretched workflow. Clinicians cannot be expected to log in to separate websites for every sensor or app their patients are using. That said, integration with the electronic health record (EHR) is currently extremely challenging and costly. A recent development may offer hope: the federal government’s “meaningful use” requirements for EHR certification are calling for greater interoperability through an emerging data-exchange standard called Fast Healthcare Interoperability Resources (FHIR). FHIR allows external third-party apps to integrate into the EHR workflow. For example, Apple enables data to flow from FHIR-enabled EHRs to the Apple Health app on iPhones and from there to other apps in the Apple ecosystem (). With this new ability to combine EHR and mobile health data, iOS mobile health apps may become more useful and effective. Absent an Android equivalent for EHR access, Android apps may over time become systematically less effective than iOS apps, which raises deep ethical concerns, as discussed below. A recently started open-source project called CommonHealth (https://commonhealth.org) aims to mitigate this concern by bringing EHR data integration to Android smartphones”

I notice Apple gets a lot of criticism for this but the reality needs to be appreciated by medics that Android smartphones really aren’t technically equivalent to Apple iPhones.

Apple is structured in a way that it owns the whole ecosystem and so can reassure the regulators, hospitals, insurers, Medics (who are putting their careers on the line entrusting these devices) and Patients (who are entrusting Apple with keeping their information private/secure) that the customer is using a specific device with the latest up to date software. In sharp contrast even brand new Android devices vary considerably in terms of their performance, specs, operating system, etc. On top of that they can install apps from a variety of app stores, have native software on them placed there by the mobile operators and manufacturers and Google. This makes it much more challenging environment in which to innovate and assure partners to have trust because there are many ways that data can be compromised if you don’t have a means of trusting the devices in Patients/Clinicians hands.

“FHIR also supports integrating the output of third-party digital health tools directly into the EHR workflow without requiring that the output be written into the database of the EHR, since such a requirement would trigger often prohibitive legal and security concerns. With this SMART-on-FHIR integration approach (SMART stands for Substitutable Medical Applications and Reusable Technologies), a clinician who is signed into the patient’s record can view that patient’s third-party app or sensor data in an embedded window without the need for a separate log-in. This approach opens up the workflow and “screen real estate” of the EHR to essentially unlimited innovation. However, SMART-on-FHIR integration is currently very limited”

Sometimes while these innovations seem great and easy to work, the reality is they often fail because they’re an attempt to run before you can walk.

We must be mindful that Doctors have a responsibility to stay current with technology. The Royal College of General Practitioners is a world leader in championing tech and yet in 2019 a Doctor is still failed for bringing a mobile into an exam room for the entrance exams despite the fact that many of the consultations they provide wouldn’t need to happen if they just used the tools of our time and they’ll probably not ever consult with a Patient who hasn’t already used their mobile to research their symptoms, diagnosis and medications.

“Health care organizations that wish to implement mobile health cannot overlook the logistics and legal implications of providing patients with sensors and apps. Additional staffing must be considered for assisting patients with technology setup, providing technical support, and responding to patients’ questions and concerns. For example, the Ochsner Health System has assigned dedicated staff to act as “geniuses” in their O Bar, a retail-like space modeled after Apple’s Genius Bar that carries Ochsner-approved apps and devices that patients can “test drive.” As patients independently bring mobile health data to clinicians (e.g., Apple Watch and Fitbit data) and as digital health vendors try to sell to health care organizations, health care leaders will need to grapple with how best to support mobile health and the use of patient-generated health data.

I think that you’re taking the wrong approach in wanting to be implementing mHealth innovations that require ‘Additional staffing’ needs. Instead of always trying to expand the healthcare workforce we should be trying to use technology to better utilise the teams we already have. Around the world healthcare professionals waste their lives doing arduous administrivia and we have the opportunity with mHealth to consign this to the history bin. Let’s seize that opportunity not try and build genius bars so that we can do even more complex things that we’ve no experience of ever having actually done before.

“Other Challenges: Validation and Regulation. Higher-risk mobile health technologies are considered medical devices under the Food, Drug, and Cosmetic Act. The FDA regulates medical devices under processes that were designed for medical-grade hardware devices, such as hip implants, with known physical properties that change little after market release. Mobile health technologies, in contrast, often combine hardware (e.g., a glucometer) with software (e.g., algorithms for the management of type 1 diabetes) and can be extremely dynamic, with frequent hardware and software updates. A different regulatory approach is needed. The FDA proposes to regulate these technologies (now termed “software as a medical device”) through a new Digital Health Software Precertification Program.”

I think this paragraph makes a statement that is factually inaccurate. Everyone and their dog knows that the FDA does a terrible job of regulating medical devices and we’ve seen that with countless examples eg. the collossal failure of their regulation of the hip implants from JnJ DePuy.

It is more than ambitious to think they will be able to effectively manage the enormous complexity of the mHealth app market without killing innovation through their bureaucracy and overreach (but I’ve written more than enough about that back in 2012!).

“This “Pre-Cert” program, currently under pilot, proposes to precertify companies that demonstrate a “culture of quality and organizational excellence” for streamlined review of their applications. Products of precertified companies do not have to be associated with improved clinical outcomes before market release but will instead be subject to postmarketing performance monitoring to support the claims of safety and effectiveness by the company.

Many details of the program remain to be determined, including how companies can gain or lose precertification status, how different levels of risk of harm will be determined and handled, and how real-world performance will be assessed through postmarketing monitoring and with what consequences. Trust in mobile health technologies and the extent of their adoption will depend on how these and other details are resolved. Thus, the stakes for success of the Pre-Cert program are very high. The desire to support innovation must be balanced against grave concerns about insufficient or delayed oversight”

How is the pre-cert program any different from a situation in which the FDA gets paid by mHealth innovators to learn how to do its job and introduce more regulation and administration?

Surely Dr Sim is aware of the mess the FDA have made with it’s efforts to regulate the ‘e-cigerette/vaping’ market?

In addition to these technologies, the accuracy of digital biomarkers also requires validation. For example, commercial sensors are relatively consistent with each other on step count but not on sleep duration or sleep cycles or duration of physical activity. Because most commercial devices restrict access to their raw data and algorithms, independent verification and validation of the majority of current digital biomarkers is not possible. Greater transparency and accountability, the setting of metadata standards (standards on how to describe data, such as their provenance), and external validation will facilitate evaluation of digital biomarkers proposed for use in clinical care. This can be achieved by making available reference data sets and through publication of tests of validation. An illustrative example is Sage BioNetwork’s Parkinson’s Disease Digital Biomarker DREAM Challenge that made available data from studies of digital biomarkers of tremor and dyskinesia.

These are all desirable things but isn’t it obvious that this is where innovative startups are being motivated to innovate and build their value? For example innovators like SleepTracker help coach you to better sleep without the need for medications for a price that is insignificant compared to sleeping medications – all without side effects. But they wouldn’t be interested in this market if it wasn’t financially viable because regulations made them have to help everyone understand and potentially make a copy of the tech that they use to enable you to do that for yourself. 

“Clinicians, patients, and payers would benefit from digital health formularies that list sensors and apps that are vetted for clinical use, much like medication formularies for drugs. The latest of several attempts to launch such a digital health formulary is by Express Scripts. Other efforts include the establishment of principles and guidelines for app development and rigorous evaluation, but best practices for screening, integrating, and appraising apps remain to be established.”

Amazing that after calling for a need for more “independent verification and validation… Greater transparency and accountability” it’s seen to be a good thing for the USA’s largest pharmacy benefit management organisation (with 26000 employees and revenues of +$100B that is itself a subsidy of the health insurer Cigna) to provide the resource for Doctors to work with Patients that could be all about better control of and more appropriate clinical use of the medications that drive profits in the parent companies. 

While I think it’s obvious that everyone would like the lucrative gate keeper role when it comes to mHealth app quality the reality is it’s a very challenging area and vested interests often detract from a corporations ability to do a good job eg. remember how the American Medical Association CEO called out mHealth as Snake Oil and told us they were going to be the arbitrator of what’s good and what’s not?

“Market Growth and Clinical Value: Despite the regulatory flux, the digital health sector saw a record $8.1 billion in investments in 2018. A recent change in the Medicare Physician Fee Schedule that allows physician billing for time spent managing and interpreting data from remote monitoring (e.g., electrocardiographic, blood-pressure, and glucose monitoring) for management of chronic conditions provides an incentive for the use of mobile health data in the clinic. However, no standard models exist for who should pay for mobile health technology that is recommended or prescribed to patients. In clinical research, decentralized clinical trials (see Glossary) are using digital biomarkers as end points and replacing in-person study procedures with virtual and mobile procedures. ResearchKit by Apple and ResearchStack by Android — mobile research platforms that facilitate large-scale virtual recruitment and outcomes assessment — are expanding the reach of clinical studies, analogous to the effect of mobile health on clinical care”

I think it’s important to put VC investments into perspective. In the USA alone $350 Billion was spent on prescription drugs in 2018 and the federal government spent nearly $1.1 trillion. Surely it’s obvious that when the financial incentives are this stark in comparison you shouldn’t be optimistic that the US sick care system wants to drive the adoption of mHealth.

“Mechanisms of Mobile Health and Potential Benefits and Harms. Underlying these market developments is a persistent question: to what end is mobile health? Tracking and reporting data are means to an end, not the end itself. Achieving clinical value, the ultimate goal, may occur through the use of mobile health data as cognitive aids to patients and clinicians (helping people understand or think through an issue), decision aids to patients and clinicians (helping people decide on an action), or motivational aids for patient engagement and activation (). More collaboration is needed among clinicians, patients, and technologists to drive the development of clinically useful mobile health technology and to imagine clinically useful applications of novel sensors, while remaining cognizant of potential harms”
I don’t agree that the ‘ultimate goal’ of mHealth should be to achieve “clinical value”. Yes that’s desirable for the healthcare industry but societally we should be looking for much more. Mobiles are already having a huge impact on the psychology of young people. Most are learning about sex and developing their personal lives through watching ‘porn’ (AKA videos of sexual abuse) and becoming addicted to mobile content and struggling to concentrate, mature or develop with their lives. Instead of looking for clinical value maybe the much bigger opportunity is for mHealth to help these young people and their families to avoid the need for clinical intervention altogether. With Dr Sim’s focus I fear we’re just going to be  trying to fight fires with (eg. manage the obesity, anxieties, narcissism, sexual abuse, depression, stress, disease, etc, etc) rather than prevent them happening.
“Clinical researchers need to develop new evaluation approaches because years-long studies are poorly suited to the pace of change of mobile health technology. Finally, clearer demonstrations of the clinical and business value of mobile health will come when factors far beyond technology itself, such as integration into clinical workflow, payment model, and validation methods, are addressed in tandem with sensor and software development”

Somewhat unusual for me I know but I agree with these great points!

“Ethics. The tremendous promise of mobile health for transforming clinical care and research is tempered by deep concerns about the effect of these technologies on equity, privacy, and patient autonomy. Although there is essentially no digital divide according to race in the United States, Internet and smartphone adoption is lower in lower-income, disabled, elderly, and rural populations. Moreover, Android users, who account for more than half of U.S. smartphone users, have lower average income than iOS users. If iOS mobile health apps are systematically more effective than Android apps at improving health outcomes (e.g., owing to differential access to EHR data, as discussed above), health disparities will worsen. As health institutions increasingly develop a mobile presence with branded apps and other initiatives regarding digital patient experience (see Glossary), they must be careful not to increase health disparities — for example, by offering unequal services to iOS users and Android users”.

I think this is very controversial and it ignores the fact that Android devices are CHEAPER for a reason and that reason is that the software on these devices and the Google Play app store is made for device makers (like Samsung, Motorola, Nokia, Huawei, Xiaomi, etc, etc) so that Google/Alphabet (Android’s parent company) can essentially collect more data on customers and subsequently sell more effective means for advertisers to reach them. To think that you’re going to reduce health disparities by sharing more information with a company that makes its money from  advertising is overly optimistic and somewhat naive.

Android is a product of Googles. For all the positives and negatives it is the same company that makes billions from serving unhealthy junk food ads to customers. It’s the same company that is selling ads from the highest bidder next to the results when Patients search for healthcare information or get a gmail message from their Doctor etc.

Google has been very effective at ensuring you don’t read bad news about it’s brand as they have a great legal team so if you’re a normal medic and have no idea about this read here about how they are collecting NHS Hospital Records without consent or go further back to their founding story and you’ll realise they were [practically seed funded by illegal drug ads.

In my opinion health institutions should not preoccupy themselves with how unequal the iOS and Android platforms are. Google should be taking on the responsibility of investing in this space just like Apple have been with Apple Health, HealthKit, ResearchKit, etc, etc and hospitals should opt for the best platform for them and their Patients (as clearly the cost differential between an iPhone and Android Smartphone is an insignificantly inexpensive cost compared to the cost of healthcare services

“There is an even more profound digital divide. Use of mobile health and Internet of Things technologies requires digital literacy skills. Patients are essentially being asked to install and maintain their own medical devices and to be adept at managing their own data deluge, a tall order when the majority of U.S. adults are in the lowest three of six proficiency levels for literacy and numeracy and more than 60% are in the lowest two of four proficiency levels for problem solving in technology-rich environments (defined as “using digital technology, communication tools, and networks to acquire and evaluate information, communicate with others, and perform practical tasks”). This gap is further compounded by the paucity of mobile health technologies in languages other than English.”

I see a lot of insurance companies taking advantage of this and craftily pushing apps in their marketing messages to help them resonate with younger smartphone users who would have more profitable insurance needs but I think it’s important to realise what mobile SMS has done for literacy rates and that mobile services in public systems (like the NHS etc) are helping save resources when they aren’t needed because Patients can look up their own healthcare information, results, watch videos, organise and collect their own prescriptions, etc.

If you need a really obvious example think about the benefits of SMS appointment reminders (from 2011).

“Actions for Stakeholders in Mobile Health. With respect to privacy and autonomy, the potential threats are particularly worrisome. Mobile health technologies will increasingly connect to the Internet of Things, in which, like a “one-way mirror,” our virtual bodies and behavior will be visible on a grand scale for purposes to which we have not directly consented. When personal health and nonhealth data comingle in the cloud, companies and governments may access physiological biomarkers to monitor employee stress in the workplace, or marketers may offer us only certain products at differential prices based on our health history. Coupled with algorithms that are not in the public domain, these approaches could deliberately or inadvertently reinforce and entrench existing biases against disadvantaged groups, and incautious deployment of mobile health technology could potentially result in loss of privacy and autonomy amounting to net harm to patients. lists actions that patients, practitioners, researchers, and policymakers can take to guide the evolution of mobile health”

To be fair I think these potential risks are already materialised. Google already has your full search/viewing history and if you gave that information to a good psychiatrist they could probably tell more about you than you know about yourself and that’s before you go into the myriad of incredibly sensitive personal data that’s being collected just through normal use of a smartphone (think eye scans, fingerprints being used to unlock/lock a phone, etc, etc.)

“Conclusions. Mobile health technologies are evolving from descriptive monitoring tools to digital diagnostics and therapeutics that synergize tracking with behavioral and other interventions to directly affect health outcomes. Major challenges include the discovery and validation of meaningful digital biomarkers, regulation of and payment for mobile health technologies, and their integration into frontline care. Clearer articulations are needed of how mobile health technology can concretely affect clinical outcomes, along with more rigorous evaluations of clinical effectiveness”

Interesting ideas but I prefer the idea of mHealth being used to create a new frontline of care rather than just trying to integrate it into today’s frontline of care.

“Networked mobile health technologies have the potential to harm. Concerns about digital surveillance are not unique to mobile health, but health-related risks can be reduced through improved digital literacy among patients, ethical codes of conduct for developers and regulators of mobile health, and transparency and accountability in how health care organizations adopt mobile health technology. The transformative potential of mobile health compels clinicians to take an active role in ensuring that this new frontier will be safe, fair, and just for all patients”

Another very important message in this excellent paper.

 

*** Update 8 September 2019 ***

Please click here to join a discussion of this NEJM paper over in the Linkedin mHealth group:

Screenshot 2019-09-08 at 10.46.06

Screenshot 2019-09-08 at 10.46.27

Posted in Uncategorized | Leave a comment

European Parliament approves #Article11 & #Article13

Kim Jong Un

The European Parliament has approved copyright legislation including Article 11 (a “link tax,” that requires web platform to obtain a license to link to or use snippets of news articles) and Article 13 (that will require a web platform to make their “best efforts” to obtain licenses to copyrighted material before uploading it to their platforms which is a change to the current standard practice whereby platforms would simply comply with copyright takedown requests).
This is the end of the open internet in the EU and it will do great harm to innovative thinkers and all the startups and internet companies based in the European Union. Medics and Patients will suffer because it will make it harder for them to make and share content. 
Please write to your parliamentary representative and ask them to fight this. 
Screen Shot 2019-03-26 at 15.51.30
Posted in Uncategorized | Leave a comment