“mHealth itself might be a transitory period that lasts only another year or two”

The phrase “mHealth Benefits: No Evidence – Yet” is pretty much guaranteed to be interesting to me but this “Mobile Thinking” article by Cathy Boyle featuring an interview with Peter Benjamin, General Manager of South Africa based Cell-Life, does a fabulous job of highlighting the short term perspective and straight line thinking that some people are applying to the newest and least understood new media and the opportunity it presents the healthcare industry (AKA mHealth).

With the ink barely dry on a contract with the South African National Department of Health, Peter and his team of programmers, network engineers, business analysts, and trainers are already elbow deep in planning a National mHealth System that will enable facilities across the country to test 15 million people for HIV by June of this year. Peter took an hour away from his Gantt Charts to explain how Cell-Life grew from a probing question among colleagues to a non-profit organization equipped to build the nation’s first mHealth system

As someone who’s just participated in the submission of an incredibly detailed EU Application to launch a “Mobile First” Public Healthcare system with a European Ministry of Health the lack of integration of Cell Life’s work amazes me. Testing patients for a particular disease might be a start but it’s a long way from being regarded as a healthcare system.

There is also a lack of evidence that rapidly scaled testing capacity is going to find it difficult to be anything more than another short term fire fighting tactic. It is highly unlikely that it will solve the core problem that faces South Africa a country in which as many as 6 million people are already infected with HIV.

If we can turn this electronic, always-on device, in the hands of 90% of all youth and adults into a way to access healthcare, we have the potential to make a very significant change to the way the health system works in South Africa

This is a classic case of ignorance of the countless successful examples of mHealth that are already all around us. Remember to leave your sense of self importance at the door: We don’t need to turn a mobile phone into anything because even without “us” mobile phones are already a means of accessing healthcare. If it’s got access to the internet there is nothing stopping someone in Africa googling for information on HIV or accessing OVI LifeTools. Even if it hasn’t got internet access there’s nothing stopping a citizen calling or texting a relative/friend/clinic to ask a question.

It’s developed a lot in the past decade or so and the acronym we have for this project today is EMIT, Evaluation and Monitoring Information Tool.  It’s mainly used by NGO’s reporting on their different HIV activity, particularly community training where you report saying today I trained 30 people in how to use condoms at this particular clinic, etc

What an incredible example of Straight Line Thinking applied to the idea of health education in an emerging market. I can almost imagine the NGO strategy meeting that came to the conclusion that NGO’s are the best people to train citizens about how to use condoms because that’s got to work, doesn’t it?

It amazes me that Cell-Life have been able to get governments and mobile operators (who contributed 15,000 devices) on board with this project because isn’t there a better, cheaper, more disruptive way of getting this information out? Mandating that mobile phones or SIM cards sold in South Africa are preinstalled with a video file containing approved advisory information on condom use would probably be much cheaper and more effective. Likewise operator portals could be uploaded with this content and browsing costs could be made free of charge drive eyeballs to this important information and encourage discovery and adoption of the mobile internet.

Asides from that there are also preventative strategies that mobile operators in the region could effectively help with eg. by enforcing regulations on the “adult” sexual content distributed within their operator decks. The positive reinforcement of the safe sex message could have a very important impact on the young impressionable minds who are paying for access to this multimedia content.

In December we were given the first big mHealth project led by the National Department of Health in South Africa and the plan is to use cell phones for monitoring their HIV Counseling and Testing campaign (HCT).  After receiving 15,000 cell phones from the biggest operators in the country, this project became the flagship project of the Dept of Health.  They want a cell-phone-based system that will allow them to meet their goal of testing 15 million people for HIV by June of 2011 and enable all clinics and other HIV testing sites to report regularly

More straight line thinking. Because of course more testing = management of this pandemic. Except it doesn’t. Evidence is now emerging that suggests the rapid jump in testing targets (from less than a million a few years ago to 15 million in 2011) has led to a situation of hitting numerical targets that is misdirecting resources and encouraging patients to participate in regular retesting rather than behavior change. It’s likely that this may even lead to a more dangerous situation than before as the availability of free testing is encouraging citizens to take poorly calculated risks eg. not everyone understands the risks of unprotected sex/needle sharing and even fewer appreciate the window period issues (eg time from infection until change is detected) of diagnostic tests. This can result in an individual wrongly assuming it is a low risk strategy if they take a free test in between unprotected sexual encounters.

We’re a small non-for-profit NGO in data and we’re now being asked to set up a National mHealth System and have it working in 7000 health facilities.  My desk is full of plans, Gantt Charts of how we’re going to train 14,000 people in 7,000 health facilities between now and Easter.  So it’s doable but it’s more than we’ve done and, to my knowledge, more than anyone else has done in South Africa and probably anywhere in Africa

I’m getting the sense that Peter’s counting his chickens before they’ve hatched. The money and intention to do something is one thing, being able to carry it off is another completely different story. Instead of criticising the mHealth Alliance’s objectives (eg. “they’re actively trying to hype this stuff”) I wonder why he’s not engaging with them?

The fun part is that the infrastructure needed to get this HCT monitoring system working, is more or less the exactly the same infrastructure you need for any clinical and mHealth application you can think of, from information management to stock ordering to lab results, tending to remote diagnosis to training health professionals to epidemic outbreaks and other epidemiology.  If it goes well, it could start convincing the Dept of Health that mHealth actually can work

Let’s get this straight there is no “actually can” about it: mHealth does work. My Doctor colleagues here in the UK and Ireland have been using mobiles for over a decade and the speed and efficiency with which they work has been transformed as as result of these devices and the increasing quality of the networks that support them. There are countless examples where patients using mobile phones have made the difference between life and death.

All the same I love the wide eyed optimism Peter shares here as it disregards the countless issues of theft, fraud, patient privacy, ignorance that act as barriers to adoption, Unfortunately just because we’re using mobile phones doesn’t mean we safely side step these. It reminds me of all those “geeks with a cause” at the NHS that I used to meet at the outset of the UK’s National Programme for IT. Unfortunately it took more than $20 Billion until they realised the ability to build IT infrastructure does not give you all the answers to every healthcare problem.

When Peter expands on the services reliance on a mobile IM service to deliver Patient-Provider communication it becomes abundantly clear that he hasn’t come off the starter blocks yet when it comes to clinical communication efficiencies or the issues of patient privacy:

Have you heard of MiXit? MXit is an absolute phenomenon in South Africa. It enables users to send an instant message over a cell phone system.  To use it, you have to download a little applet and then you can connect to the MXit server and communicate immediately with anyone else on MXit. Effectively it sends SMS-type messages through GPRS, which makes the cost of a text message of let’s say 100 characters, less than 1 South African cent (or 1 tenth of a US cent).  It makes text messaging effectively free. We have created a sort of website within MXit.  The MXit jargon is calling it a BOT.  In this space we provide all the usual HIV content, information, interactive quizzes and things like that. Probably the cutest thing we’ve done with MXit is linked it to the National AIDS Help Line.  The National AIDS Help Line call center is free for people calling from a landline but its normal price from a cell phone — which means it’s often too expensive for most people to call it

Peter seems confused about costs here. Mobile IM services are only really available and cheap if the customer has a programmable phone (AKA as a smartphone) and a data plan. Otherwise they can’t download the application or use data to send/receive messages. Of course this functionality is coming to cheap feature phones but so too is Skype – and that would make the National AIDS Help Line call centre call cost cost “FREE” too.

Maybe instead of taking on 15,000 cellphones, Cell-Life would have done better to negiotiate for a free SMS shortcode or telephone number from the mobile operators?

Now that we’ve linked MXit to the National AIDS Help line, someone can be texting away on MXit and it goes through to the computer screen of professional HIV counselors at The National AIDS Helpline.  Those counselors type back and it goes back to the users cell phone screen.  It’s, if you like, text counseling.  I can’t remember the exact number but somewhere around 22,000 text counseling conversations have been done over the last year and half

From a quick check of the MXit Terms and Conditions:

MXit may…
…monitor and/or intercept any communication sent and received by yourself using the MXit Application, MXit Websites and the Services.
…use your information to contact you about promotions and special offers and you hereby consent thereto.
…reserve the right to disclose aggregated information regarding its Users and usage of the MXit Application and MXit Websites (such as member demographics and traffic patterns) to, amongst others, advertisers and suppliers, and you hereby expressly consent thereto.
…make use of “cookies”… ….the only personal information a cookie can contain is information you supply yourself

So I guess it’s more than fair to say that the National AIDS Help Line and Cell-Life have enabled MXit (and their advertisers) to get a list of thousands of patients with HIV. Doesn’t sound too scaleable to me particularly once story gets out that some scammer has decided to make an advertising campaign targeting these specific citizens with some dubious offer.

We also do a small amount of stuff on Cell Book, which is basically a downloadable Java app over GPRS that allows you to download a reasonable amount of information, like a hundred A4 pages of information to a GPRS phone.  That’s a way to disseminate large volumes of HIV information, treatment guidelines and that’s sort of thing

More of that straight line thinking. I’m sure it won’t be long before they realise that the mHealth opportunity is bigger than sending A4 pages to a 2 inch mobile phone screen.

Basically mHealth seems to be overwhelmingly about the “m.”  It’s ‘look at how we can do things with cool little add-on devices to the iPhone,’ or a hundred other tech things and not that much to do with health

As a mHealth company that leverages the native apps (Secure Mobile Web and 3G Video Call) on millions of feature and smart phones to remove the barriers of time and distance between Patients and Doctors I’m amazed that Peter has come to this shortsighted conclusion. Check out the rest of this blog for countless examples of mHealth that rely on nothing more than the mobile web, SMS, MMS, Caller ID etc. I think the reason Peter has come to this conclusion is because he’s been reading the buzz being generated by entreprenuers that are promoting stuff eg. Dr Dave Albert who wowed the CES in Las Vegas at the start of 2011.

It’s worth being mindful that while these may serve very different markets they are absolutely related. It’s worth remembering that the low cost 15 million antigen tests that Peter is involved in distributing in South Africa derive from expensive Immunology research done in leading centres of excellence. At some point I bet analysts couldn’t even imagine the impact these initially very expensive technologies could have in emerging markets.

Time will inevitably tell but maybe the connected ECG solution developed by Dr Albert will be a huge commercial success AND will help to create an environment where even lower cost new solutions that perhaps even remove the need for expensive medications by helping diagnose and treat cardiovascular disease in completely new ways.

From my experience I find most of the entrepreneurs behind these companies know about the potential for the mobile web to deliver information but also realise it may not be a sustainable business model for them because information is being quickly commoditised by free and advertiser paid for sites such as Wikipedia, Google Health and WebMD. This contrasts with Peters perspective in which he appears to be suggesting that the future of health education is in delivering advertiser sponsored SMS/mobileIM with a system that is sustainable as a result of government/NGO donor funding.

On top of that, there are very few systems that have gone to any scale.  Almost all the systems that I’ve read about or heard about, are basically at the level of one clinic or a handful of clinics testing a particular intervention or service.  The only two that I’ve known that have gone through a bigger national scale are TrackNet Data Reporting in Rwanda and various Text4Baby things in the US and other countries.  Those are massive projects but neither has proven health benefits. That is why the HCT project with the 7000+ health facilities we’re doing in South Africa could be quite interesting this year

Incredible to think that Peter is so confident that neither of these projects have proven any health benefits.

I’m absolutely NOT saying there isn’t a benefit to this stuff but I think this is an empirical point rather than principle point.   We have yet to see any clear evidence to demonstrate a tactical and monetary benefit of mobile healthcare. I can say dozens of things about how I think it can, or it’s reasonable to suspect, or there’s a coherent hypothesis that this can be a benefit, but we haven’t proven it yet

I think Peter can’t see the wood for the splinter in his eye. He’s already stated in this article that twice as many people have access to the Internet on the mobile phone them through a PC. It’s long been the case that access to healthcare information has been a breakthrough for patients and carers the world over. I say this as someone who recently revisited his medical school to see that the library has now been developed into a computer room.

To my mind it is inconceivable that the unshared, much more pervasive, personal access that the mobile Internet provides will not have an even bigger impact on access to information, advice and patient communities.

Separately, there’s the GSMA, which see mHealth as potentially the next big thing that the operators can make money on. There’s a big conference in June in South Africa in which they’re going to bring together 100 governments and 150 different operators to build an industry around this stuff.  They’re desperately searching around to find a few examples that a) have medical benefit; b) can go to scale c) show a business case

Forget searching, just read through my blog: Students training in the worlds best medical schools are using mobile phones to collaborate more effectively and improve their understanding of healthcare and disease. Collaborations between publishers and mobile handset manufacturers have already made educational powerhouses and there is no reason this will not continue to scale globally e.g. Pearson and Nokia are already the worlds number 1 provider of English language education.

So yes, there are lots of people trying to find this stuff but no one has cracked it yet

Lesson here: sometimes it’s not apparent who has cracked what and sometimes people who have cracked things just get on with doing them. But here’s one tip: it’s unlikely that advertiser-paid-for SMS counselling will crack the problem of HIV in Africa.

I think mHealth as an area doesn’t have much more than 1 or 2 years in it. What I mean by that is if it is shown to be effective then it won’t be called mHealth anymore.  It will just be the obvious way to do healthcare

Peter confirms in this statement his ignorance of the emerging opportunity. With Moores law onside the opportunity for mHealth in 2 years time will continue to be transformational e.g. dual core processors running in low-cost smart phones will begin to enable the emergence of natural language support for patients. Technologies such as speech recognition might still remain primitive on shared PCs but the opportunity to run it on personal mobile phones is transformational. In 2 years time this will just be starting to gain mass market adoption.

Before mHealth loses it’s shine patients will be talking to mobile phones, accessory medical devices will be talking to mobile phones and mobile phones will be listening, talking back and reporting this with a community that respects an individuals right to privacy.

Let’s just hope that all of this chatter is like the Mozquito Ringtone and takes place outside of the normal acoustic spectrum!

The only thing that it’s safe to say is that the future is not just more of the same…

About David Doherty

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2 Responses to “mHealth itself might be a transitory period that lasts only another year or two”

  1. Pingback: Tweets that mention “mHealth itself might be a transitory period that lasts only another year or two” « 3G Doctor Blog -- Topsy.com

  2. Pingback: The Lancet “Mobile health-care information for all: a global challenge” | mHealth Insight: the blog of 3G Doctor

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