In reply to the publishing of the Pew Internet Mobile Health 2012 report author Susannah Fox has shared an interesting point of view from Dave Clifford, a strategy consultant in Health IT and Science and Tech Policy, who having read the report challenged the conclusions many readers are making.
Of course this isn’t the first time someone’s suggested there’s too much hype in the mHealth app world but it’s well worth a read and gave me several further thoughts I thought it might be worth expanding on (in addition to my shared thoughts on Pew’s 2010 and 2012 Mobile Health reports):
“Since 2010, Susannah’s reporting has shown that the number of people downloading health apps onto their smartphones has remained roughly constant”
For me this highlights the importance of us understanding what is mHealth. Obviously I disagree with Pew’s definition (eg. that it’s a “health application you download to a smartphone” or a “health related search you make on a mobile browser”) and the speed with which this has run into problems hasn’t surprised me because so many mHealth activities don’t look like healthcare but rather social interactions – which is something I am expecting to see more of eg. when mobile and health truly converge it won’t be called mHealth it will be referred to as Mobile (something I’ve tried to explain in this post: Why we’re more likely to drop the “Health” than the “m” in mHealth).
To give you an example of what I mean consider a healthy citizen looking up “Alzheimer” on their mobile phone because they heard an Auntie or colleague at work has developed this. Now ask yourself do you think it’s likely that they’d even recognise that this was a health related search when called up by a researcher a few weeks later?
In 9 out of 10 instances they probably won’t even recall that they did it, and if reminded that they did they’d probably respond that they “just wanted to know what it might be so it was hardly a health search as they’re not their aunties carer or anything”.
If however you look at in from a Healthcare point of view you’ve managed to achieve access in moments to data that only a few years ago you would of had to go to a Medical School library to discover. Perhaps I’m just too sensitive to the impact of this because I remember how hard it used to be for citizens to get information in those good old days (eg. in 1995 I vividly recall the day an anxious parent begged me at the door of my medical school to help them access our medical library and research a condition that her child was being treated for in the adjacent hospital).
To give you an idea of the impact that I see from low health literacy I recently shared a long haul flight next to a group of non-medical professionals who were travelling with a close friend that they told me had been diagnosed with dementia – and yet they had so little idea what this meant that they had taken to thinking it was funny to tease him about his increasingly frequent memory lapses.
If you want to take the counter argument (that Health searching behaviour isn’t increasing) consider how quickly mobile web search activity is growing and the increasing growth of smartphone ownership amongst seniors (eg. more than half – 53% – of Apple iPhone customers in the USA are aged 35+) as I can’t think of one good reason why health searches would be an exception on a device that’s unshared and always with us.
"Since 2010, Susannah’s reporting has shown that the vast majority of what are considered “health apps” are diet, exercise, and weight loss apps. Of the remainder, there are limited cases of disease management apps, drug adherence apps, or personal health record apps being used. We’re talking about handfuls of people out of thousands of people”
This probably explains the confusion. The vast majority of health apps that are used by patients are native apps not ones they have to discover and download. To get an idea of these think of things like SMS appointment reminders (eg. your Doctor or Hospital implements a SMS service and 100% of their patients start using it), pill reminders (eg. you program your calendar/alarm to tell you to take a pill at 8am everyday), a mobile phone you bought for your grandmother to help her stay in touch (please consider doing this – connectivity not only has a massive direct relation to health but it’s key to mHealth reaching it’s potential), etc.
If you must have data to show that the smartphone is being used by patients to find healthcare information look to Kaiser who have taken a mobile first strategy that is setting new benchmarks for patient engagement (is it any surprise they’re already talking with the Pew Research report’s author?).
“And that’s without touching things like “frequency of app use.” I can only speak from my inclinations, but the most used “Health App” on my phone is called “Zombies, Run” and it’s a fantastic app that says “Oh no, zombies! Run!” when I’m listening to music on my phone while I’m running. It’s great and it’s the best thing that I use on my phone when I’m running and I think I’ve used it six times. Six times is a lot of times for a user of any given health app, since most people download a “health” app and don’t use it, and very few people use “health” apps more than once. This is even in the broadest category”
When it comes to mobile we have to realise that “use” doesn’t mean actively doing something. Most people don’t actually use their mobile any more than a few hours a week but the rest of the time they benefit from being reachable. Being reachable is key to mobile adoption but it’s value is hard to appreciate because we quickly forget we’ve got it (something Tomi Ahonen explained in his “3G Marketing: Communities and Strategic Partnerships” book way back in 2005) and in the healthcare world it is often even more valuable than 2 way communication eg. I can walk to the landline to place a call but I can’t find out my mum’s fallen or even just needs something from the stores if I’m not reachable.
“On the flip side, Susannah showed that a large number of people use their smartphone in their healthcare. The majority of smartphone users indicated that they have used their smartphone to search for health information. To me, this seems totally logical. My smartphone has become a secondary brain for me that I can offload factual memory into. It tells me what streets connect where if I’m in a different city, or who that guy was that sang that song that I like, or what time the football game starts and what time the proper football (soccer) game starts. For the most part, it answers these questions via Google, although some people might use Siri to accomplish the same tasks. I use a very, very powerful app for this called ‘Browser’”
Great point, after the Nokia Decade most people just uses native apps without thinking. In many cases we don’t even consider them to be software as when an App is native and simply works out of the box we quickly presume it to be “just something a mobile phone does”.
In my opinion it is wrong to discount an app that is used for a health purpose because it is a native app and here are a few examples of this to give you the general idea: the camera you snapped your screensaver image with (remember this is the one that shows you wearing your skinny jeans!), the calender/alarm that reminds you to take your pills, the SMS you send to your daughter on a night out (reminding her to stay safe and let you know if running late), the GPS details that you share with a 911 operator when you make a distress call in an emergency, the Navigation app that you use to find the quickest/safest way home or to map a jog, etc… …these are ALL now native software apps and they are ALL being used routinely for healthcare uses.
“On the other side, there are hundreds of health and medical apps that seek to use things that only a smartphone could do in order to advance care. For example, there are a set of apps that claim to cure disease via sound, light, or vibration from a cell phone. These have not been demonstrated to have any benefit at all. There’s also some health apps that tell you if you’re ready for exercise by counting the number of squats a user can do in a minute via the phone’s accelerometer and then asking the user to measure a resting health rate. These are slightly ambitious in their functional claims”
Isn’t it obvious this is what happens? Have we forgotten already that when the online health revolution started over a decade ago that it was all very spammy and low value? (largely because the business model back then was created by millions of illegal adverts that do-no-evil capitalised on).
Fast forward to today and no one’s going around saying “stay off the interwebs is full of misleading information”, instead we’ve got well known patient leaders explaining why we need to have the right to access our health information and highlighting the importance that we can turn whoever we want to in order to share and discuss this information.
In 5 years time it will be laughable to suggest that we should have hesitated with mHealth strategies because of the existence of obscure Health Apps on app stores that are practically impossible to find or generate a livelihood from. Instead we’ll see that the creative early adopters will be some of the major victors as the cannibal of cannibals takes chunks out of major medical device, pharma and healthcare brands (just like the carnage we saw the camera phone and Facebook inflict on Kodak).
“One of the other interesting findings is the number of users with chronic disease that used a health app on their smartphone. This was only slightly higher among those with chronic disease than those without (21 percent v. 19 percent), but the number of people with chronic disease that went online to look for medical information was lower than those with no chronic conditions (26 percent v. 34 percent.) My guess, if I had to venture one (and without seeing the cross-tabs) is that people with chronic conditions are less likely to have a smart phone to be able to look up health information online (thus the 8 percent gap) but more likely to use a smart phone to manage their wellness (thus the increased use of apps.)”
First up I think these stats are likely to be so off the mark it’s hardly worth commenting on them. Unfortunately you can’t determine the existence of a chronic disease by calling a patient up and asking them if they do.
Let’s ignore the statistical reasons why someone with a chronic disease is less likely to be answering the phone in the first place, or to tell an interviewer, and instead look to the clear fact that there are tens of millions of people in the USA who have chronic conditions who don’t think they have got a chronic condition – the sources of good stats for this claim would include the CDC’s National Diabetes Education Program (these indicate that about 10 million citizens in the USA have Diabetes and don’t know it).
“Before you make an app, ask yourself “Is the app I want to make essentially a mobile web page? Is the purpose of it to serve information to a consumer on the go?” If yes, there are ways to code your landing page(s) so that they detect the sort of browser being used and provide an optimized experience for a mobile user”
I agree that mobile web design is critically important – click here for a good source of information on this. If you really need an app I think you should also think of some ways you can leverage the 8 already discovered attributes of mobile as the newest mass media – as the more of these you can incorporate the richer experience it could offer.
“What side of the “Digital Divide” do the consumers you want to target live on? The gap is narrowing but it’s still there. Many individuals with chronic disease are older and have lower incomes, both of which are unfortunately correlated with lower digital literacy and lower smartphone adoption”
There is no technology on the planet that’s getting anywhere close to the capacity the mobile has shown itself to have to cross the digital divide. The fact that the world’s biggest mobile brand is going to be bringing mHealth Apps to us as native out-of-the-box experiences should assure anyone that there is no longer a contest – especially when you look back at the history of basic mobile hardware being extended and popular apps going native.
If you want to be the partner for them I’d suggest you get out there and work out how you can create an app and get paid for it because it’s these successful developers who’ll be getting their doors knocked on by Apple and Samsung… (here are some solid stats that support the fact that the most successful smartphone brands are talent scouting in exactly this way).
“Does your app take advantage of a feature of the smartphone in a compelling way? Does it use the camera or the microphone or GPS? Could your app be an API that runs off a separate, common media (Twitter, email, SMS)? Would it be simpler to integrate it with a separate “workstream” of day-to-day life than force a separate “workstream” on to a consumer?”
Instead of “twitter, email” I’d suggest HealthVault, Patientsknowbest, a bricks and mortar healthcare provider, or remote consulting healthcare professionals (like the service we offer here in the UK/Ireland at 3GDoctor or you can find in the US market through firms like ConsultaDr.com or TelaDoc).
“Last, if you’re selling an app that cures a disease or diagnoses a condition from user-entered data that is a very difficult thing to do and seldom supported by rigorous science and the FDA is probably going to scrutinize what it is that you say your app does”
I find it odd to hear IT consultants sound paternalistic when they talk of patients incapacity to differentiate the good from the bad so that they come to harm because of some obscure information that you could find on the interwebs, but it’s particularly surprising when you realise that Dave works with PatientsLikeMe – a firm that pledges to patients that it’s a community made up of patients just like them despite it’s full and frank acceptance that many of the patients …aren’t even human.
I don’t personally think low quality content is actually the big challenge as people are more likely to believe/take the advice of a friend (who has no medical training) than that of an obscure health app that has poor/zero ratings and no affiliations with registered Doctors or healthcare brands.
I also think many people underestimate the work the app stores are doing to ensure quality control, the fear developers have of being banned (eg. the AppStore is not like the world wide web you’ve got to play by Apple’s rules), and must be unaware of the many much more significant challenges patients are encountering already as a result of digital advertising techniques that are being used to covertly profile them so they can be set up for some other -seemingly unlinked – scam.
My take away
If you’re concerned about the fact that some 12 year old hackers might be creating bizarre mHealth apps for smartphones that can “tell you if you’re ready for exercise by counting the number of squats a user can do in a minute via the phone’s accelerometer” take comfort in the fact that this is what digital innovation often looks like eg. it’s not totally incomparable to the clumsy FaceMash website made by a Harvard sophomore in 2003.
Instead of worrying get yourself networked with the key leaders in this industry, partner with talent so that you can help them fill gaps (eg. you might find that the kid who has an app monitoring squats has worked out how to accurately identify when a user falls) and learn by doing (launch, measure, improve, rinse, repeat…) and if you’re in any doubt about the direction this is heading reflect on how:
> Seniors are the future of smartphones and the mobile industry and despite their affluence (citizens aged 50+ in western markets own 80% of global wealth) they still represent one of the lowest spending mobile user groups.
> Just as we saw camera technology converge with the Mobile (thanks of course to the mHealth genius that is Philippe Kahn), mHealth apps are going to increasingly converge medical technology and services with the cannibal of cannibals. If you need to see where this is happening read Digital Korea or take a trip to Japan where the majority of senior citizens have smartphones, use mobile data services and millions use native pedometer apps.