Telenor publishes “The socio-economic impact of mHealth” a report by the Boston Consulting Group

In a very positive move Telenor Group, the Norwegian telco with mobile operations in more than a dozen international markets and 200 million customers, are promoting their first mHealth report on their corporate homepage. Download the PDF here.

Titled “The socio-economic impact of mHealth” the report is a 49 page document produced by BCG‘s Dag Bjornland, Eugene Goh, Knut Haanæs, Tommi Kainu, and Simon Kennedy.

Companies and concepts profiled/mentioned in the report include:

Ca:sh, DoCoMo MD+, EatRight, eMPOWERx, EpiHandy, FrontlineSMS, GlowCaps, HealthLine, Horizon Mobile Care, iBodyMo+, iSmoke Break
Masiluleke, MD Consult Mobile, MEDgle, mQure Med Reminders, Nacer, SIMpill, Text4Baby, Text to Change and Voxiva Health Watch

I had the following thoughts on the paper:

mHealth—the provision of health services enabled by mobile communications

I think the report has started with a definition of mHealth that is flawed – see here for a more accurate definition that explains the m as mobile the newest mass media.

The flaws in the definition being used by BCG become quite obvious if you look to a few basic mHealth use cases that don’t require “mobile communications” eg. a Doctor looking up medical text book content on the micro memory stick in his smartphone, a cardiologist looking at the ECG on the screen of her Alivecor encased smartphone, etc.

However, a number of barriers need to be broken down before mHealth can begin to transform health systems and service delivery. Moreover, a diverse range of stakeholders must collaborate in order for mHealth applications to be adopted on a wide scale

I think it’s counterproductive for mHealth proponents to perpetuate this naive point of view as it’s so obviously flawed. In this 2009 MobiHealthNews article I expand on this but here’s it in a nutshell:

> The Healthcare industry practically seed funded the build out of mobile networks – find me a Doctor who wasn’t sporting a pager in the 80’s and 90’s.

> Look at the impact the Nokia camera phone has had on the pharma industry by killing the photo development cornerstone of their high street business model

> Look at the how medical emergency calls are now handled and compare it to what we had just a few years ago (when most calls used to originate from fixed lines).

For this reason, Telenor Group commissioned The Boston Consulting Group to study the potential impact of mobile services on healthcare over the coming years. This report summarizes the findings of the study, which focused on 12 markets that Telenor serves

For me this is a classic example of Mobile Operators not seeing the wood for the trees. Instead of asking someone else they should have simply applied analytics to their own data.

In my opinion releasing data showing how many and how frequently their customers are already calling health advice lines would have been more valuable than this entire report. From my analysis of their competitors I think it’s highly likely that Telenor is already generating millions in profit from such activities eg. way back in 2005 Vodafone reported that in the UK alone they billed their customers more than £1 million from a single health advice line.

New solutions urgently needed In the face of the mounting pressures on healthcare systems in all countries, new solutions are urgently needed. Governments will be unable to continue to deliver quality services to all of their citizens with existing resources and traditional methods. Not only will they find budgets stretched as demands for healthcare services increase, but, in addition, large numbers of new medical professionals and support staff will need to be added to the sector’s workforce, putting further cost pressures on the healthcare ecosystem. In mature economies, there is a growing awareness of the potential crisis that could hit welfare systems if nothing is done to change the status quo

I’m always personnally confused by this focus on new. What’s wrong with eliminating waste, improving workflow efficiency and improving access to information at the point of care? There is no point me explaining this as Heidi Wilson has done such a great job of it in this post.

Another aspect of the challenge developing countries face is their need to meet the health-related targets of the Millennium Development Goals (MDGs) by 2015

I love the way MDG’s are referred to by analysts as though these are themselves somehow driving change. History has consistently shown that these lofty ambitions are only in exception being achieved. If Bangladesh can achieve a reduction in TB by 60% by 2015 because of a SMS based adherence service have no doubt about it Matti Makkonen is going to be hailed as this century’s Alexander Fleming.

In the process, the healthcare system is undergoing a cultural shift—from the traditional paternalistic approach, in which doctors talked and patients listened, to a more patient-centered approach in which individuals equipped with knowledge and information can play a much more active role in prevention and care

This highlights a concern I have about viewpoints on the future of healthcare. 99.9% of care today the world over is self care (eg most of us aren’t washed or fed by Doctors) and while I see mobile as supporting the moves to connect patients, their data, devices so that they can work more effectively with their carers. In my opinion it’s only in theory (or before we try to actually manage an illness ourselves) that we hear techies claim there is a DIY future for healthcare.

Always good to be mindful of the old rule of thumb: “only a fool is his own Doctor”.

Mobile technology is also transforming the way doctors do their work…. …Mobile devices will allow them to access medical reference material, training content, and professional journals

I think the “will allow them” should be “are being used”. If I’m wrong tell me which leading medical reference or professional journals aren’t available on the iPhone today already.

And many companies, seeing the commercial potential of these trends, are developing professional apps exclusively for healthcare professionals

I also think this is also in the incorrent future tense. There are thousands of such apps. MobiHealthNews sell research reports on this area and one glance at the headlines will inform you this these apps are already widely available in the market and being used.

For governments trying to cut the costs associated with operating a healthcare system, mHealth will help hospitals and health centers reduce paperwork. By speeding up processes, reducing the possibility for human error, and avoiding duplication, remote access to centralized electronic health records can reduce administrative burdens by 20 to 30 percent

Once again if you know where to look you can find multiple examples of success stories where even greater gains are being achieved. The BlackBerry/PaperIQ paperless solution that is now being used by hundreds of midwives in the NHS is a good example of this as it’s exceeding these 20-30% estimates.

I think it’s critical that mHealth proponents move beyond sharing guesstimates now that there are services have been successful in the market for so long eg. I first shared news of it here in 2009. In my opinion Telenor’s objectives with this report would have been much better served by talking of what is already having success (even if it’s being done by other telcos/competitors) than trying to muster enthusiasm for an uncertain future.

Moreover, the apps enable patients to take a more active role in their own healthcare—managing appointments, updating prescriptions, and accessing their health records. And when patients take on more responsibility for their own care, their health improves

This is typical of the sweeping unsupported generalisms the paper is full of. For me it overlooks the reality, most citizens in the world already have responsibility for their own care yet they’re smoking, making poor diet choices, etc.

Evidence shows that 86 percent of women taking this approach undergo breast cancer screening (compared to the average of 57 percent)

Another example of a sweeping statement that adds little value – especially when you consider that there is increasing evidence that suggests breast screening campaigns may now have resulted in over diagnosis of breast cancer. On a positive I can imagine the potential if Telenor included mHealth video content on the mobiles they sold that could help patients for example a “know your breasts” video like this one.

In countries where resources are under increasing pressure, mHealth has the potential not only to cut costs but also to free up badly needed capacity. In Sweden, for example, remote consultation and support could save $65 million a year in hospital nights for patients with chronic obstructive pulmonary disease (COPD), as patients would be able to use remote monitoring and video-enabled smartphones to rehabilitate at home. Patients with conditions such as heart disease, diabetes, and asthma could also be treated in this way. Trials in Nordic countries show that mHealth could generate a 50 to 60 percent reduction in hospital nights and re-hospitalizations for patients with COPD. Taking data collected from pilots and projects in Scotland and Norway, it is estimated that mHealth could reduce overall elderly care expenditure by 25 percent

I cannot imagine why the report doesn’t share links to any of this published work. Unfortunately no amount of “Could”, “would”, “might” is likely to inspire much confidence or create behaviour change. Denial of service provision is a garunteed way of reducing care expenditure by 25% so I think it’s also critical that proponents of mHealth don’t quote financials without reporting on patient experience and quality of life improvements.

Smartphone most popular technology among Doctors since the stethoscope

This paper highlights a statement I’m increasingly hearing but find confusing and massively miscommunicates the importance of smartphones.

Smartphones are the only devices that Doctors have EVER permanently carried (yes it’s only 1st year medical students who go out and sleep with their stethoscopes!), had a built in payment channel (you could never use your stethoscope to buy your latest medical text books!), etc.

mHealth also helps these countries combat communicable diseases. Because they can be used to send reminders to patients with tuberculosis (TB) to take their pills, mobile phones improve TB treatment compliance by between 30 and 70 percent, saving lives, since with effective medication compliance some 90 percent of those infected with TB can be cured. Pill boxes with integrated mobile capabilities can deliver similar benefits to those without mobile phones

I wonder if the authors have much experience with TB? 90% of those with TB may be curable but you still have the expense of the meds to consider. Not every patient with TB can afford their meds, has a healthcare service that will pay for them, or will continue to pay for them when their symptoms have subsided. This is particularly important when you consider the objective stated here to reach those who are not yet connected with mobile phones, a point that’s quite obvious when you appreciate that the mobile connected pill box being referred to here is much more expensive than a mobile phone.

As for a mobile connected pill box offering similar benefits to those without a mobile phone, I can find no reason for this to be true. My basic instinct on these things suggests it’s probably nonsense.

By delivering advice via SMS to pregnant mothers and health information to nurses and community health workers, these deaths can be reduced 30 percent

Why? Is it because Boston Consulting say so? For a tip on how to communicate this type of information check out this image created using data shared by the John Hopkins Bloomberg School of Public Health.

For governments, mHealth has the potential to reduce the per capita cost of healthcare while maintaining or increasing care quality. And as governments around the world start to explore different measures of human progress, wellbeing is increasingly being treated as an indicator. In this respect, mHealth has a role to play in improving new “gross national happiness” indicators by producing a happier, healthier populace, and has the potential to transform health service delivery

In many ways I see the opposite happening – that’s why 3G Doctor operates with a model where the patient is the consumer. I think it’s more likely that governments are going to find that patients use their mobiles to report and expose gross failure and mismanagement.

Fortunately this is something that we’ve seen can be a much more dynamic change agent than a “gross national happiness” indicator.

This single image from the report captures the complete lack of awareness that exists amongst the authors of the pharma, mobile and medical device industries. This is a massive oversight of the entire report.

mHealth transforms lives. Take the case of a 26-year-old pregnant mother living in India. Without the assistance of technology, the mother, whose home is in a remote rural village far from health centers and hospitals, has no doctors to consult about her pregnancy. She does not recognize or understand warning signals and therefore risks dying during labor. With the assistance of a mobile phone, she can receive timely birth-related information and advice and become aware of any signs of danger during her pregnancy. Thanks to this information, she has a successful delivery and both mother and child go on to lead healthy lives

I think it’s important to be aware of the massive potential downside. mHealth researchers seem to think it’s all just a win win but I wonder if they’ve ever thought what their healthcare services might look like today if 50 years ago there had been a technology that undermined the development of their local primary care services.

Perhaps it’s just me but I’m seeing mHealth as a massive threat to the creation of local primary care services. If big players (like international telcos, hospital groups, pharma brands, etc) run services over the top of local community healthcare services you could have a situation where there is have even more unsupported care environments being created as the viability of local care providers is threatened and they either wind up or move on.

On the other side of the world, a 69-year-old widower living in Stockholm has been diagnosed with dementia. Forced to rely on traditional face-to-face health services, he is unable to call for help when he finds himself in need. Unused to dealing with a complex medical regime, he frequently forgets to take his pills. He even gets lost when he goes out, unable to find his way home. He is a constant source of worry to his family, who question whether it is safe for him to continue living in his own home… …But when equipped with a range of mobile technology devices, the patient is able to manage his condition and continue to live at home, should he so desire. Automatic alarms alert healthcare professionals of anything unusual in his behavior and his family can track his whereabouts whenever he ventures outside the home. With easy-to-understand medical reminders sent to his phone, he remembers to take his pills on time, while wireless check-ups and electronic communications with his doctor mean he has to visit his health center less frequently. With the help of technology, he can remain in his own home for many years, living independently

I think this example fails to pay attention to several important knock on effects. From experience of remote monitoring projects I’ve noted that all this data can place lots more duty of care on providers such that the wireless monitoring route is actually going to get this widower into a long term care environment much quicker than they might have without it.

This just seems like a pointless and uninspiring exercise in guesswork. With the insights that could of been attained from a simple analysis of Telenor customer calling, texting and web browsing data this is inexcusable.

Telecoms play a critical role… …while split incentives and divided business models could serve as a barrier to the integration of mobile technology in healthcare, there is one industry that could play a powerful role in bringing together the diverse stakeholders in the mHealth system—the telecommunication sector

When people ask me why we need to have an understanding of mHealth (eg. “can’t we just call it healthcare”) I always explain that a big opportunity exists when we don’t have such confusion. Once you understand we’re talking about the newest and least understood mass media I think it becomes obvious why it’s nonsensical to be stating that the telecommunications sector could “play a powerful role”. It already plays a fundamental role, most Doctors couldn’t do the jobs they do in 2012 were it not for mobile technology.

Mobile penetration is high among the citizens of these countries, which means acceptance of mHealth is likely to be high. Increasing bandwidth also enables them to use advanced services, including video, and the most advanced smartphones can double as medical devices

These are very typical misintreptations of the emerging market mHealth opportunity. I think there are 2 important things to note here:

1) video doesn’t always need bandwidth. Healthcare is still typically local and last year hundreds of millions of phones shipped with onboard memory, bluetooth and micro memory stick slots. These enable P2P content sharing without the need for a mobile network.

2) The big opportunity for medical device technologies is not in “the most advanced smartphones” doubling up as “medical devices”. In the next few years as we see technology like Alivecor’s ECG incorporated into low cost feature phones from firms like Samsung, Nokia, Huawei, ZTE and Doro I think this will become obvious.

The experience of mHealth so far has also demonstrated its effectiveness in combating diseases such as tuberculosis. With effective medication compliance, something technology will support, some 90 percent of those infected with TB could be cured. In South Africa the SIMpill system has achieved a 94 percent compliance rate for a TB trial, resulting in a 92 percent cure rate… …Similarly, in Thailand, phoned pill reminders have achieved dramatic improvements in the success rate of TB treatment, by leading to 90 percent compliance rate among patients (compared with a 22 to 60 percent compliance rate without the use of such systems)

These comments highlight for me a massive underestimation of audiences. Doctors reading this will know it’s fictitious as it’s not the adherence that got the results but the drugs and it’s things like new infection rates, access to quality drugs and the side effects of medications that lie at the heart of the problem.

It’s also worth pointing out that the cost of the SIMPill device is going to be more than the cost of a basic mobile per patient (I use the word “going” because the SIMPill isn’t for sale commercially and hasn’t published any retail prices) and a standard medication course for TB is about $20 (multidrug resistance TB drugs can cost up to $5000).

Perhaps it’s the quoted “The Nation, Phoned pill makes inroads against TB” news article from 2007 that is being taken as evidence that this is a workable solution?

In Russia, where the WHO estimates that in 2008, 132 people per 100,000 were infected with TB, it is estimated that a full-scale mHealth rollout could cure 50,000 sufferers, helping the country exceed target number six in its Millennium Development Goals (a TB prevalence of 53 people per 100,000) by reducing prevalence to about 40 people per 100,000

This is what you often see when accountants apply themselves to healthcare problems. What is clear is that Telenor has had the opportunity for several years now to distribute content preloaded on devices they sell or contained within their free to access mobile web deck that could educate people about the risks of contracting or infecting others with TB. My completely ungrounded (why not?) guesstimates are that this will eradicate TB by stopping citizens from spitting, sneezing/coughing without the use of tissues, having close contact with others who have active TB, etc.

Remote monitoring and video consultations could be conducted with specialists using devices such as a video-enabled smartphone or a “COPD briefcase” equipped with built-in video capabilities, monitoring sensors, and a connection to the patient’s hospital or health center

Obviously once again video consultations over a “video-enabled smartphone” isn’t some future possibility (we’ve been offering it direct to the public since 2006) but whenever I hear about “COPD briefcases” I can’t help but think about the unfortunate teams at Ericsoon who have been tasked with selling this engineer conceived solution looking for a problem. So much potential, such a disappointing waste of engineering talent and all it probably needed was a proficient designer:

Trials have shown that a 50 to 60 percent reduction in hospital nights and re-hospitalizations can be made using such technologies. This has important implications for countries such as Thailand, where approximately 5 percent of the population has COPD and 10 percent of these individuals need annual rehabilitation treatment. Here mHealth could both save governments money and improve quality of care and outcomes for patients

Throughout the report there is a lack of appreciation of preventative care and the focus identified in this paragraph really highlights this for me. For the record: governments who want to save money and improve quality of life for patients need to work on effective efforts to control advertising and use of Tobacco products.

Take the example of a tuberculosis patient in Malaysia. As a husband and father, he needs to continue to provide for his family. He leads a busy life and has many questions about his condition. Without technology, he must make an effort to remember to take his pills. But he frequently forgets and eventually stops altogether. Without treatment, he dies, leaving the family without a provider and forcing his children to work to make up the difference

I can only imagine this patient journey was written by someone with zero experience of patients in Maylaysia affected by TB.

I wonder what they think is happening in wealthy countries where the obesity problem could so simply be solved by a simple combination of 2 SMS messages: “Don’t eat” and “Go out and exercise”.

I would recommend people with such naiveity to volunteer to work in a hospital as a porter for a day. I’m sure those rose tinted perspectives will begin to fade as you push another COPD patient outside for a cigarette break (with all the Doctors & Nurses!).

When it comes to the regulatory environment, lack of common standards is a major barrier to the widespread deployment of mHealth

For some reason the report highlights one of the biggest advantages of mHealth as a major barrier, Perhaps authors need to appreciate that you can reach over half the people on this planet with SMS and more than 3 billion deivces via MMS.

My takeaways

This is great news. The list of mobile operators committing themselves to mHealth continues to grow.

Don’t try and invent, instead build on the work of others. Sadly there is nothing in this report that moves thinking forward from the China Mobile sponsored mHealth report by Cambridge University that came out in 2011.

Share. The report highlights how “Payers lack incentives to push for mHealth services” because the “mHealth relative cost/benefit” is “not clear”. So why not help with these challenges? Why not share the data on market traction of the Telenor doctor service in Pakistan? Why not share patient opinions and complaints of these services? The ROI they are generating?

Once again this boils down to a nod to a future where everything works out. I’m not sure it’s going to be so simple. For one thing the growth of over the top (OTT) mHealth services is going to make winners and losers of Telcos so the opportunity to innovate is immediate and should start with an appreciation that mHealth isn’t for someone else. Telcos need to start offering mHealth to their thousands of employees and they should share the lessons of this wide and far.

If they fail to innovate I think it’s obvious that in a couple of years it’s going to be game over when a firm like Apple, Nokia or Samsung announces to the world that it’s been doing this internally for the last few years and they’ve managed to reduce healthcare costs by X%, attained the lowest Healthcare costs per employee in the USA, improved staff attendance by X% and morale by X%… and last year collectively their employees lost X tonnes of ugly fat.

What a mHealth headline that’ll be!

About David Doherty
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