PwC Report “Emerging mHealth: Paths for Growth”

PwC, the world’s biggest Professional Services company, have recognised that “mHealth is dropping into a ‘perfect storm’, enabling and accelerating three major global trends already in play in healthcare… …regulatory reform driven by demographic changes …industrialisation of the healthcare sector …personalised medicine” and produced a report examining the “current state and potential of mHealth, barriers to adoption, and opportunities for companies seeking growth in the mHealth space“.

The report is free to access/download here.

I’ve had a quick read through and it’s a very worthwhile read and a vast improvement on the report they produced in February for the GSMA.

Here’s a few thoughts I had while reading it:

PwC is very serious about mHealth

PwC is the world’s largest professional services firm so this more formal recognition of mHealth and creation of a dedicated landing page for the speciaility ( is a very positive development.

For one thing now that PwC have assembled a 32 executive global mHealth team to work with clients it’s going to make it quite difficult to have any credibility if you’re simply claiming mHealth is some little subset of eHealth (for one thing the URL doesn’t exist).

Surveys with key subject matter experts

It’s a little disappointing that the researchers only interviewed 20 execs and so few of these had any patient care backgrounds as you really don’t have to go far to find experts who are passionate in this industry. All the same it’s an interesting cross section from around the globe:

Ozgur Turgay, Acibadem Mobile, Dan Brostek, Aetna, Sangita Reddy, Apollo Hospitals, George Poste, Arizona State University, Jason Mann, Barclays Capital, Claudio Giulliano Alves da Costa, Brazilian Health Informatics Association, Ian Leslie, Cambridge University, Peter Benjamin, Cell-Life, Bakul Patel, FDA, Eric Dishman, Intel, Patricia Mechael, mHealth Alliance, Dr Jennifer Dixon, Nuffield Trust, Thierry Zylberberg, Orange Healthcare, Martin Kopp, SAP, Claudius Metze, SAP, Misha Chellam, Scanadu, Sunderrajan Jagannathan, Siemens Healthcare India, Steinar Pedersen, Tromso Telemedicine Consult, Chris Taylor, University of Manchester and Axel Nemetz, Vodafone mHealth.

Mobile is the newest mass media not a different form of communication

Unlike many other forms of communication, such as the internet, mobile health (mHealth) will likely have a greater effect on how care is delivered for three reasons:

> Mobile Devices are ubiquitous and personal;

> Competition will continue to drive lower pricing and increase functionality; and

> Mobility by its very nature implies that users are always part of a network, which radically increases the variety, velocity, volume and value of information they send and receive

I think here we see a limitation of Dr Levy’s understanding of Mobile. Rather than consider it to be a “different” form of communication from the internet (since 2010 more people have actually accessed the internet from a mobile phone than from a PC), it’s best to appreciate mobile as the newest mass media. Tomi Ahonen is the best selling Mobile Analyst who gets credit for identifying this, be sure to read more here, this is critical knowledge if you want to pursue any mHealth opportunities.

Once it’s appreciated as the newest mass media the opportunity for it to have a greater impact than previous mass media (eg. Print, Cinema, Radio, TV, PC) then becomes obvious that rather than something that’s “likely” to happen particularly as it’s already happening.

The 3 “reasons” Dr Levy has given aren’t all that precise/correct either, for example:

> “Mobile devices are ubiquitous and personal

With an appreciation of mobile as the newest mass media you can be a lot more specific than this eg. mobile is the only mass media that is “Personal, permanently carried, always on, has a built-in payment channel, is available at the point of creative impulse, is most accurate at measuring its audience, can capture the social context of consumption and can offer augmented reality”.

> “Competition will continue to drive lower pricing

This used to be the case in mobile until the biggest new entrant to the market changed that particular trend. mHealth sensory capabilities are likely to drive higher pricing (eg. higher ARPU) for mobile device makers as they add mHealth sensory capabilities. I personally think this is going to be very pronounced as we see massive increases in the ownership of smartphones and adoption of mobile services by the senior audiences that are currently dismissed or ignored by telcos and device makers as a low value consumer group.

> “Mobility by it’s very nature implies that users are always part of a network

To me this isn’t accurate and misses the much larger opportunity that arises from being a mass media that is “always carried”. To appreciate this better consider a Doctor who can now carry an entire medical library on her mobile phone for use whilst on the London Underground, in a plane, out at sea, in a remote African village or in a region that has been struck by natural disaster and is still waiting to get it’s mobile networks back up.

Maybe not networked but you can bet there’s value from having this information so readily at hand. Of course this value will rapidly increase in line with the diagnostic potential of mobile phones (read here about how my mobile can record and display an ECG) and the capability of this as a tool for the medically unqualified.

“Kathleen Sebelius + few proven business models”

mHealth is the biggest technology breakthrough of our time [being used] to address our greatest national challenge’ said US Health and Human Services Secretary, Kathleen Sebelius in her key address at the 2011 annual mHealth Summit… …However, such effervescence in a field with few proven business models suggests that, yet again, technology-driven hype may lead to expensive failures

It’s interesting to see the US Health and Human Services Secretary’s presentation being used to support a claim that we’re looking at a field with few proven business models or technology-driven hype.

First up and very importantly Kathleen Sebelius didn’t actually talk about Technology in this talk, I know this because I was there. Instead Kathleen spoke of the enormous possibilities we have through mHealth of attaining the patient centric healthcare system we all want.

Rather than speaking about the mHealth sensor technology of the future that so many other presenters at the mHealth Summit optimistically looked forward to, Kathleen’s talk pointed to the opportunity to consign the basic “information deficit” that exists today to the place it belongs in tomorrows history books eg. Doctors having incomplete info on patients, Patients not knowing where to find something, Patients not knowing the side effects of a med, etc.

Obviously I also think anyone trying to perpetuate the idea that there are “few proven business models” in mHealth hasn’t appreciated what’s already happened. The use of mobile by the healthcare industry practically seed funded the creation of the newest trillion dollar industry and if you think about it for even a minute it’s quite obvious that our modern day healthcare system wouldn’t simply work without mobile networks and that’s before you even start to consider the wider impact this industry has on the health of society.

Going forward and trying to attain that patient centric care experience we all want the impact of mobile is profound as it’s our best chance of documenting the undocumented (eg. through use of interactive mobile tools like patient history taking questionnaires) and introducing modern effective replacements for inaccessbile and paper based alternatives eg. the mobile first strategy that’s paying dividends at Kaiser Permanente, replacing appointment letters with SMS reminders, etc.

Survey says: “Expectations are high for mHealth”

I don’t hold much confidence in patient/provider surveys about mHealth. Most of this stuff is such a no brainer that it’s not up for debate and won’t even need to be considered.

The “quanitified self” concept might currently appear to be all about top flight atheletes vying for incremental performance gains but in a few years it will be an obligation for the smoke and CO alarm in a seniors home to be connected to the Fire Brigade’s CRM system. Similarly it will be compulsory for care providers to provide patients with mobile web access to their healthcare records.

The report concludes that it’s positive that 50% of patients surveyed feel that “mHealth will improve the convenience, cost and quality of their healthcare in the next 3 years“. ONLY 50%?!?! The majority of these 1027 patients were based in the markets that already offers a service that enables a free of charge connection from anywhere with mobile network coverage to an EMS call handler. You’ve ALREADY GOT convenience and improvements are being made in by these service providers without patients needing to do anything at all.

“Emerging markets are the trailblazers in mHealth”

I’m quite certain that the real trailblazers in mHealth are working in veterinary markets but I’m seeing a lot of claims about emerging markets that seem to be based on the fact that regulations aren’t in place to prevent services being rolled out. This report attempts to perpetuate this widely held myth but offers little solid evidence to support the claim and a some unbalanced focus eg. a full page profile of Apollo Hospital Group’s “triaged health information and advice” service versus a fleeting mention of the NHS Direct.

I’m not too confident that the achievements in emerging markets are going to be quite as straightforward or achieveable as the report is trying to suggest. Without adequate legislation and advertising controls mHealth initiatives in emerging markets will often be undermined and countered by the NEGATIVE health impact of so many other mobile services.

Citizens and public health doesn’t exist in some idyllic bubble. The same techniques you can imagine being used to market health are already being used to push and facilitate the consumption of fast foods, sugary drinks, alcohol, tobacco, gambling, etc and that’s all before you even start to consider the impact of counterfeit meds, “fake” Doctors, unrepresented patients (eg. enabling the possibility for foreign medics to dangerously experiment on them), poor awareness of basic health risk factors, etc. Similarly the same efforts you can imagine will be applied to public mHealth initiatives will also be abused by the powers that be to enforce human rights abuses, birth control legislation, creating criminals of patients (eg. in markets like India 90% of ALL crimes are already solved through the use of mobile phone records), etc

I also wonder if the authors are aware that there are plenty of Doctors in Western Europe who advertise their mobile telephone numbers only? That send and receive SMS from their patients? That there are specialist clinics in Harley Street and NHS Hospital Consultants who are sending Mobile Video content to their patients mobile phones? That you can consult with an informed registered Doctor in the UK and Ireland on a Video Mobile since 2006? That a NHS GP is conducting 70% of all his patient consults over the phone and 90% of these calls are made to their mobiles? That more than a million of Kaiser Permanente patients engage with their care providers using the mobile internet? That Doctors in the west aren’t buying physical text books anymore and are consulting with patients using content on their iPads which they are then sending to their patients mobiles?

“Patients are highly sensitive to price and will provide little income”

widespread mHealth adoption requires services and products that appeal to current payers because patients, highly sensitive to price, will provide little income. Consumer’ sense of entitlement with regard to healthcare aggravates this price sensitivity. Accordingly, vendors must concentrate on solving payer’s problems

Mobile device makers used to think this when they had consigned themselves to the idea that VAS revenues belonged to mobile operators and every year the selling price of a device would go down or stay the same if they crammed in more tech. The billion’s of dollars that the App Store now generates and the inflated prices Apple demands telcos pay for it’s hardware have quickly turned around analyst opinions on that cosy status quo but it originated from a disregard of the idea that the mobile operator was the customer.

Apple focused on the end user and ignored the belief that there was price sensitivity. Yes it was only those who were rich or had lots of expendable income that lined up to be initial customers but the transformational mobile experience that this approach enabled Apple to offer (at the time shortsighted telcos were dictating that mobile manufacturers should disable the WiFi, provision devices with their telco branded content/browser/services, use their greedy payment processes, etc) was what enabled it to achieve this turnaround. Of course eventually the telcos woke up to the disruption but not until Apple had launched it’s own billing relationship, messaging service, assigned SIP addresses to their customers and banked a cash pile expected to hit $200 Billion by next year.

I find the phrase “consumer’ sense of entitlement with regard to healthcare” is something that is only ever used by people who cannot see the patient as a customer. Fortunately there are others who can see this is the disruption that’s about to take place in the healthcare market.

To my mind the future of the “payer as the customer” becomes ever more uncertain every time a patient goes to a Doctor with information they have researched on the internet, an ECG from an Alivecor Sensor, a consult report from 3G Doctor, or a patient finds themselves sat before a Doctor who doesn’t have access to their Healthcare Records, or gets told they can’t have access to their records, or they get a SMS from their taxi driver or hairdresser BUT not their Doctor…

“Riding on the back of an incredible amount of investment”

Page 10/40 of the report features a great quote from Misha Chellam, COO, Scanadu:

the value of ubiquitous infrastructure for innovators.. ..building attachments for the phone.. .. they are riding on the back of an incredible amount of investment; there is a billing model, connectivity and a user interface people are trained on

Doctors think mHealth will have about as much impact as the Internet

The impact of mHealth on relationships with patients will be about as big as that of the Internet, doctors say

I quote this line only because it will be so funny to read in 3 years time when these Doctors begin to realise that their patients have been using their mobile phones to Google them in their waiting rooms, record them in their consult rooms and to post reviews about them as they ride the bus home.

Healthcare IT Consultants suggest change isn’t simple

Expectations are high that mobile technology will help… …most experts interviewed for this study however, are much more cautious… …such words of caution suggest that change while certainly desirable and likely, is not simple

Except that these words of caution come from Healthcare IT consultants. If you want to be told something is complex ask a consultant on the subject. I’d suggest a bit of balance would be achieved if the authors asked a family Doctor, a midwife and a practice nurse if they would be prepared to leave their mobiles at home for a day. Even better ask a senior citizen who lives independently in a mobile only home.

The reasons that they’ll list for you will give you a much better idea of the value of mobile technology in healthcare today and going forward.

Is SMS boring and simple? Does it fail to change the way medicine is delivered?

(there are) some quick wins to be had, that will almost certainly come from the simpler, more boring things. for example, the increasingly common practice of texting appointment reminders to patients substantially reduces costs form miss attendance. These innovations have value but they do not change the way medicine is delivered

A bit inside me groaned when I read this comment attributed to Prof Chris Taylor, Director of the University of Manchester’s mHealth Innovation Centre.

Chris should visit a GP clinic and get to see what an effective SMS appointment reminder service means for a medical practice. A patient cancelling an appointment doesn’t just mean the Doctor saves costs associated with a missed attendence. It also saves money because it’s automated so there isn’t the need for a receptionist to be managing this administrative task (they can spend more time with other patients offering good customer care), it’s automated so that the clinic isn’t tasked with calling round to find another patient to fill that appointment, it enables that appointment to be filled by another patient who has made themselves available so that they can be seen quicker, it also enables Doctors to survey their patients for feedback AFTER their consultation, etc, etc

Who knows once Chris has had a chance to see some of what’s actually being done already he might even realise that these systems aren’t so boring after all?

Network Security

Only around half of Doctors believe that the mobile Internet facilities at their workplace are reasonably secure

I think this highlights a huge opportunity for the mobile industry. A lot of Doctors I meet with believe perceive big branded 3G networks to be much more secure than alternatives such as fixed lines, WiFi, etc and this is a big marketing advantage that could help them stave off threat of MVNOs and off network alternatives. It’s also probable that this perception could be extended to patients.

SMS Drug Authentication

(a) widely praised (mHealth) programme (that uses SMS codes to verify authenticity of medications) benefits a broad variety of stakeholders – including pharmaceutical firms, pharmacies, purchasers and mobile phone companies that carry the data traffic. Nevertheless (it’s) not found a commercially viable model

My sniff test for mHealth fails to appreciate why counterfeit meds should be any different to counterfeit branded car parts, perfumes, trainers or handbags. Surely if this was robust and ready for market with meds costing a few pence (rather than just yet another loop hole the counterfeiters would step through) it would already be adopted by premium brands seeking to assure customers that they’re buying the genuine posh bottles of fragrance (eg Chanel), autoparts (eg Mercedes), handbags (eg LVMH) etc?

What if everybody isn’t a winner?

‘With many mHealth solutions you need to understand what is in it for the person who pays your bill and, even more important, you need to understand whose toes you are stepping on, and how to turn it into a situation where everybody wins’

I commented before about this concept Vodafone has that mHealth will make winners out of everyone. In the same way the mobile hurt the high street pharmacy photo development business it’s unlikely there’s not going to be losers in the bloated healthcare industry. Surely the trick for a telco in this is to make sure they (and their partners) are on the winning side?

Instead of sitting on the fence trying to make everyone happy I think Vodafone should be trailblazing a lead by zero rating healthcare content and using this to create valuable forward looking relationships that reassure patients and providers and ensure they’re looked to for all the wonderful technical features that will inevitably follow this demand eg. “do not track” secure browsing, prioritised connectivity, etc.

How hard can it be for Vodafone UK to have IBM make the .nhs domain free to browse by subscribers to their network? They could cache the entire website on their new masts in the next hour and it wouldn’t even cost them any backhaul. How hard for Verizon in the USA to do something similar for Kaiser’s MyHealth Manager?

Why not compare Emerging Markets?

The report makes a bold claim that:

The lack of healthcare infrastructure means that emerging markets do not face the challenge of entrenched interests that can impede mHealth in developed countries… …”why waste time in the West”

In this section the report offers up a variety of metrics for emerging market mHealth adoption. The reliability of these is uncertain and I know for a fact (from talking to trusted individuals who worked on at least one of these projects) that some of this data is false. To make the case that “overwhelming necessity helps explain the more rapid adoption of mHealth in emerging markets” it’s worth noting that they still don’t get anywhere near the numbers put out by the NHS in the UK (eg. the NHS Direct handles 6 million calls a year and the proportion of mobile initiated calls is high eg. 7 years ago Vodafone subscribers alone placed more than 1/4 million calls at ~30p per minute call rates) and that’s before you even start to look to medical emergency calls in a market like the USA (with a population 6 times bigger than the UK).

Emerging solutions and other uncertainties

This section on page 30/44 highlights a certain naivety exists with the reports authors as they’ve clearly just buying into anything they’ve ever read in a press release:

Emerging markets are likely to be the seedbed of innovation – an advantage they can leverage in the global market. Two of the best-known American mHealth services follow emerging-market examples. Glowcaps, a tool that warns patients and their caregivers when the former fail to take prescribed drugs, is very similar in concept to SIMpill, a South African product that appeared several years before

Best known for what? Where can I buy this SIMpill or Glowcap? While the report enthuses about how “western healthcare may be developing in emerging markets today” it seems to me the examples given are exactly the type of “hype” the report suggested it was attempting to counter.

To the best of my knowledge (and I made one more check again today) these are both still prototype devices and neither is available for sale to buy anywhere despite the sometimes misleading claims that researchers (like the report authors) seem to keep falling for eg. sales for AT&T’s Vitality GlowCaps began more than a year ago on Amazon for $10 each (except they didn’t and still aren’t).

Orange Healthcare digitising all medical imaging from Paris Hospitals

Similarly, Orange Healthcare’s project to digitise and store all medical imaging from Paris hospitals in the cloud addresses the problem of the huge storage costs that these institutions face

This is another classic case of the researcher believing everything they are told and the telco being only too happy to hype and accept credit for inventing and making the world. As so often before talk of this Cloud PACS and Archive services project “by Orange” fails to mention the important healthcare partner in all this (GE Medical).

I fail to understand this, collaboration with a brand like GE is something that Orange Healthcare should be very proud of especially as it’s a change from some of the big failures they’ve already reported in this sector. It also comes at a time when anyone who’s familiar with what a modern mobile operator does is going to be left confused about how they can hope to differentiate and expand this further across the Orange network (eg back in 2009 Orange UK outsourced their network infrastructure to NSN).

Ingredients for successful mHealth models

The pervasiveness of technology is enabling the emergence of a new, more patient-centric healthcare value chain. As a result, conventional business models, which typically place consumers at the periphery, may soon no longer apply. To lead, all stakeholders… …will likely shift their practices toward patient/consumer models that will focus on clinicla outcomes, value, and patient satisfaction

This bit of the report on page 38/44 has quite clearly been authored by someone else as it presents a completely different (and in my opinion more accurate) perspective on the opportunity to that which went before this point in the report eg. “vendors must concentrate on solving payer’s problems

Does it work? Does that matter?

Perhaps the most visible element of mHealth is the profusion of phone apps, especially ones related to fitness and wellness

I can’t think how any healthcare analyst could get the impression that this is the most visible opportunity. I wonder why they can’t see the opportunity in a device that’s already in the hands of billions of citizens already loaded with native apps like calendar/alarm, SMS, MMS, mobile web, calling, video calling?

mHealth is probably going to happen anyway

On page 34/44 there’s an interesting quote of Jennifer Dixon, Director, Nuffield Trust:

there’s an inevitability about it, so people aren’t looking carefully. In itself this may not be bad… …even if banks did not do cost/benefit analyses when introducing online banking, this technology has allowed the restructuring of numberous processes that would have been impossible otherwise. Society may, then, simply expect such change in healthcare, and the issue will be how to use it most effectively

I think this is increasingly going to become obvious and we’re already noticing it with children eg. “this isn’t new it’s just like Skype mum I do this with Grandma already”

I think the most exciting part about the analogy used here is that the bank leading in the UK for customer service is First Direct – the only bank that has no face to face/office business model. Perhaps this will be something we’ll also see with the mHealth service providers who will lead?


Ultimately, mHealth will probably become so commonplace as to fade from notice… …in several years… …mHealth will have reached its full potential when it becomes ordinary

I think this closing line fits well with Amara’s law (“that we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run”). In my opinion this change will never happen in several years it’s going to be a lot longer and even the most forward looking sentence in this 44 page report doesn’t go near to what we’re going to be getting. The power of having access to a Doctor in your Pocket is going to do for healthcare what the internet did for access to information.

However before any of this becomes “normal” we’re going to have to see a massive transformation of what it means to be a Doctor, the way we train Doctors and the responsibility we take for our actions. The confluence of individuals, information and communities is the fire that’s changing society, to my mind the newest mass media is just a very powerful accelerant.

About David Doherty
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5 Responses to PwC Report “Emerging mHealth: Paths for Growth”

  1. Pingback: PwC Report “Emerging mHealth: Paths for Growth” « mHealth … | Universal Health Care Advice

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