mHealth Insights from the 2014 GetHealth Summit

On the 13-14 November the GetHealth Summit convened by iHeed (the Irish social enterprise that produces digital training content for health workers, and also seeks to bring together policymakers, leaders and implementers in the health worker training space, to scale up creation of content, and help mitigate global shortages of trained health personnel) and the John Hopkins Center for Clinical Global Health Education (A center of excellence leveraging innovations in information technology to support clinical care and research training in resource-limited settings) to bring together stakeholders from different sectors, levels and geographies, including Governments, NGOs, Education and the digital and IT sectors to generate fresh knowledge, partnerships and ideas that can address the global health worker shortage, through the use of digital media and ICTs.

The World Health Organization (WHO) estimates that the world faces a global shortage of almost 4.3 million doctors, midwives, nurses, and other healthcare professionals, as well as a shortage of faculty that can provide high-quality training and mentorship for current training programmes.

The list of international speakers included:

> Zahid Maleque, State Minister of Health and Family Welfare, Bangladesh
> Dr Leo Varadkar TD, Irish Minister for Health
> Denis O’Brien, Chairman, Digicel Group
> Hamadoun I Touré, Secretary General, ITU
> Mwendwa Mwenesi, mHealth National Coordinator, Department of Policy and Planning, Ministry of Health and Social Welfare, Tanzania
> Uju Ofomata-Aderemi, Programme Director, OneWorld UK
> Coumba Touré, Founder and President, Advanced Development for Africa (ADA) Foundation
> Firdaus Kharas, Social innovator Director and Global humanitarian.
> Robert Bollinger MD MPH, Professor and Director, Johns Hopkins Center for Clinical Global Health Education
> Tom Arnold, Director, General Institute of International and European Affairs
> Dr Tom O’Callaghan, Founder and CEO, iheed Institute
> Vincent Richardson, Chief Information Officer, Concern Worldwide
> Smitha Mundasad, Journalist, BBC news and BBC Media Action
> David Weakliam, Programme Lead, Global Health Programme, Irish Health Service Executive
> Julie Sinnamon, CEO, Enterprise Ireland
> Chiwoza Bandawe, Professor, Dept of Mental Health, College of Medicine, University of Malawi.
> Lauren Woodman, Chief Executive Officer, NetHope
> Catherine McCarthy, Incoming Chief Executive, Medical Aid Films
> Dr Craig Friderichs, Programme Director, mHealth Mobile for Development, GSMA
> Graham Love, Chief Executive, Health Research Board
> Lesley-Anne Long, Global Director, mPowering Frontline Health Workers
> Patricia Mechael, Senior Advisor; Principal at mHELP United Nations; mHelp
> Dr Marc D Mitchell, Founder and President, Lecturer at D-tree International; Harvard School of Public Health
> Doreen Bogdan-Martin, Chief of Strategic Planning, ITU
> Dykki Settle, Director, Health Workforce Informatics at IntraHealth International
> Reza Jafari, Chairman and CEO, e-Development International
> Alain B Labrique, Associate Professor, Johns Hopkins University Global mHealth Initiative
> Marion McNabb, Senior Project Manager for mHealth, Pathfinder International
> Nathan Pienkowski, Co-Founder & Partner, Bull City Learning Systems Inc
> Neelley Hicks, Director, ICT4d Church Initiatives at United Methodist Communications
> Pamela Riley JD MS, Senior mHealthEd Advisor, Abt Associates
> Sharon Jiae Kim, Program Manager, One Million Community Health Workers
> Shoba Arun, Senior lecturer, Manchester Metropolitan University
> Guillaume Deflaux, Software Engineer, Terre des hommes Foundation
> Linda O’Sullivan, Creative Manager, School in a Box, IADT
> Ken Banks, Founder of kiwanja.net & FrontlineSMS
> Dr Anne Geniets, Post-doctoral researcher, mCHW project, London Knowledge Lab
> Florence Gaudry- Perkins, International Director for Global Government Sector, Alcatel- Lucent
> Lisa Robinson, Senior Advisor, BBC Media Action
> Sheri Lewis MPH, Global Health Surveillance Program Manager at Johns Hopkins University Applied Physics Laboratory
> Dr Paolo G. Miotti, National Institutes of Health, Office of AIDS Research
> Dr Kunal D Patel, Medical Director, iheed
> Dr Niall Winters, Reader in Learning Technologies; Deputy Head at London Knowledge Lab; Department of Culture, Communication and Media
> Kieran Ryan, CEO, Irish College of General Practitioners
> Alex Little, Co-Founder, Digital Campus
> Anna Frellsen, CEO, Maternity Foundation
> Estelle Quain, Senior Technical Advisor and Leader for Health Workforce in the Office of HIV/AIDS, USAID
> Peter Cardellichio, Associate Director, Global Health Media Project
> Trip Allport, Africa Lead, Accenture Development Partnerships
> Blake The, Manager, Qualcomm Wireless Reach
> Sabina Beatrice-Matter, Manager of Health Project, Novartis Foundation for Sustainable Development
> Miriam Yiannakis, Nutrition Policy and Partnership Advisor, World Vision
> Stephen Redding, VP Country and Regional Operations, Pathfinder
> Samara Hammond, AMREF UK
> Jane McKenzie-White, Director & Senior Program Officer, Johns Hopkins Center for Clinical Global Health Education
> Phillippa Biggs, Economist, ITU

Click here to watch videos of the keynote talks.

Source more take aways from the event via the twitter hashtag #GetHealth14.

mHealth Insights from the GetHealth Summit 2014

The event was held in a great venue (Dublin Castle!), had a super talented speaker line up and was really well attended and organised to ensure plenty of opportunities for networking.

Too much Here’s a few of my key take aways:

The Irish Minister for Health Leo Varadkar is a very accomplished speaker and his keynote opening the conference was spot on acknowledging the mHealth opportunity:

“…Perhaps the most exciting and most promising development in communications technology in recent years has been the dramatic growth of the mobile industry and the emergence of ever faster mobile devices. The growth of mobile technology in countries that do not have fixed line infrastructure offers real opportunities for healthcare. In 2011 the WHO reported that the use of mobile and wireless technologies has the potential to transform healthcare delivery and one of the factors driving this potential is the continued growth in coverage of mobile cellular networks. Over 70% of them are in low and middle income countries covering 85% of the world’s population and extending far beyond the reach of the electrical grid. In many ways developments in mobile technologies probably hold more promise for africa than they do for developed countries like Ireland and I’m delighted that Denis O’Brien of Digicel is going to address you on this topic a little bit later on and those of you who have travelled to Africa will know the extent to which mobile phone credit has become a currency and the extent to which some developing countries can leapfrog old landline technologies and go straight to mobile and I think there are some parallels to that in Ireland. In Ireland General Practice Primary Care has embraced IT but in our hospital systems they are still very much paper based. There are still people walking around wheeling trolleys of charts behind them and while in some ways that’s a big problem I think it’s also an opportunity as it does allow us to skip a generation of technology by proper investment in secondary care IT which is intended in the future and indeed in the next week or so we’ll be appointing a new Cheif Information Officer for the Health Service whose job will be to make a reality of that. All things going to plan next year we’ll start work on our new childrens Hospital and that will recieve a huge IT investment and will be virtually paperless. It will be the first public hospital in Ireland to be in that space. So I think this is a very exciting time for telecommunications, for mobile technology and for medicine and I think what we should try to do is leverage as much as we can from each other…”

As a rule of thumb if your minister of healthcare doesn’t use a smartphone mHealth innovations will have trouble getting traction in your public healthcare system so it’s a very positive development for mHealth in Ireland to have Dr Leo Varadkar replace Dr James Reilly in July as I personally found James to be very far from his comfort zone when we talked about the mHealth opportunity in the Irish Healthcare System (see the mHealth course that I developed for healthcare professionals with the Irish Computer Society/Healthcare Informatics Society for more on this opportunity).

Although this is very common amongst healthcare leaders it surprises me that with Leo’s personal experience of the bloated paper based healthcare administrative systems in Ireland that he thinks that mHealth will help other healthcare systems more than our their own: Yes Mobiles are more distributed in emerging countries than more developed ones but it should be very clear from the success at KP in the USA (see their future vision video here) that the very same smart devices that will bring modern healthcare to regions like Africa are going to provide the backbone required to save €billions that we waste every year propping up the undocumented and wasteful paper based healthcare services in more affluent regions of the world that continue to fail Patients.

An interview of Irish telecom Billionaire Denis O’Brien by Reza Jafari, Chairman and CEO, E-Development International was fascinating and gave some insights into telco perspectives on network neutrality and mHealth in rapidly developing mobile markets. My highlights:

“…we started our business (Digicel) in 2001 and we went into Jamaica and at the time in Jamaica they had very high prices, it was about $2 per minute for long distance and about 70-80 cents to make a call, so only the very wealthy people in Jamaica had a mobile phone and over a couple of years we changed that and now in Jamaica, a country with about 2.78 million people, there’s 100% mobile penetration and we’ve just launched a LTE network so we’re building better networks than you’d experience in the United States in countries that would be seen to be countries that are emerging and the same in Papua New Guniea a country on the other side of the world with a population of 7 or 8 million people where again we’re bringing the most modern technologies. So Broadband I think is a human right and I’m hoping in the MDGs next year it will be put into words as such because if you really want to have an economic development and movement of globalisation to the developing world you have to have umbilical cords going into these countries and the most modern technologies…

…the biggest challenge now is in the world today there are about two and a half billion people with access to broadband but those people are living in very developed countries. The challenge is in parts of Asia and also Africa where broadband access is probably less than ten percent. It’s over the next five years that we’re going to see that develop so the plans that you’ll be talking at over the next 48 hours (at the GetHealth Summit) are heavily dependent on networks and we have this situation where telephone companies or mobile companies are investing very heavily but they just do not, I mean if you’re putting 25% of your revenues in terms of capital expenditure every year, your investors you know are beating a drum and saying we want a dividend and we want you to be more conservative so there’s this situation where on our own mobile phone operators in Africa or Asia will not be able to do it and there needs to be a contribution from what’s known as these OTT (over the top) operators so people like Facebook, Google, WhatsApp, all of these people who ride on top of the networks but don’t do any revenue with the telcos and I suppose the most disappointing thing this week was this whole question of net neutrality where President Obama has put his two feet in it again, now like almost everybody in Ireland we are wildly enthusiastic because they’re Democrats but you know he’s just got this issue wrong because net neutrality is great if you’re in the United States but awful if you’re in Africa because effectively it means these silicon valley (companies) can ride across the networks and not give any contribution to the construction of the networks and that is actually going to hold back the development of eHealth. It’s a massive challenge and if you take Google, Google will probably have 200 lobbyists in Brussels rattling the cage of the European Commissioner. So there’s challenges everywhere, the FCC got four to fve million hits to their website over the net neutrality issue so it’s unfortunate because normally America leads in a lot of these advances but because of the lobbying power of silicon valley and these companies who have been major contributors in the most recent elections of ten days ago and Presidential elections, they are actually ruling the roost…

…there’s a balancing act because it’s a matter of regulators in the African countries saying look we really want to have everyone in the country having access to broadband and once you have broadband then you can have all the other eHealth services but there has to be a contribution even if it’s modest from Google and all these people because you know Google’s profit margins are 80%, mobile phone operators have traditionally had margins of 40% but they are going towards 25% so there has to be some sort of contribution and then if you look at technology there is also the work that is being done in low orbit satellites where if you take Bunkino Faso for example it’s unrealistic to say that 90% of the geographic size of that country is ever going to be covered by LTE or 4G so using access to low orbit satellites could also be a very economic way for health workers to actually upload and download data and I actually think if you look in Africa there’s one million new health workers needed and Jeffrey Sachs has a really interesting project and there will be people who say well I don’t agree with his project, but I’m always a believer if someone’s out there trying to do something out of that fallout there will be a way or a system that will develop that will make another leap forward as such…

(Reza Jafari) …when Jeffrey Sachs came to our UN Broadband commission and asked for help nobody offered to help. 12 months passes by he comes back and says “I Need your help” and the only person on the UN Broadband Commission who held his hand up and said I will help you is Denis O’Brien, I was the second guy behind him who said yes we would love to help you Jeffrey to be able to do it. How is that partnership going and what would you say about creating a public private partnership where it is not only the private sector making the investment for the OTT’s to come in and use it because they are all going to be participants in our ecosystem we just need to create that win win opportunity for all of us?

(Denis O’Brien) …I think he’s a big thinker. He’s a big brain and he has some fairly wild ideas but as a social entrepreneur he’s worth backing. The problem is a lot of people on the broadband commission would be representing very big companies and they can’t really make a decision in terms of doing something so it’s easier if you don’t have share holders, much easier. So if you take his plan, he’s looking for startup capital which he’s now got and now he’s obviously trying to implement. And we said we’d do it with him in Haiti and it’s my belief that a project like that particularly in eHealth where it’s very very undeveloped countries I think the operators should actually give the capacity for free because when you look at the totality of the capacity on the networks that are needed by a health worker it’s very very modest. You know it could be 10 GB per month so it’s not an expensive thing to you and also it’s not a cash payment by the operator so it’s not going to effect their margins. They have the capacity it’s perisable you know it’s like an airline seat that goes empty from New York to Dublin…”

While it’s great news that Ireland has a self made billionaire investing in mHealth startups who is now calling for healthcare workers to get free mobile data access and broadband access to be a human right, I couldn’t help but see how the objectives of the GetHealth Summit to help ‘scale up creation of content‘ won’t struggle to be aided by these efforts.

It’s hard to see how the content needed for public health advances wouldn’t find it even more challenging to reach audiences eg. brands promoting the consumption of junk food and soda are going to be helped by efforts to tip the balance towards a content provider pays model because they can indiscriminately adhere their brand to any youtube video content etc.

When you realise the disruptive impact that Digicel made to the Jamaican telco industry and the benefits this has provided to families and businesses in the region I’m surprised Denis is now calling for tighter regulation. Perhaps it’s just a sign of the rate of change that’s seen within the newest trillion dollar industry that it is capable of turning disruptive foreign startups into incumbent businesses in just 13 years.

I think it’s interesting to note that many of the disruptive mobile strategies that are the focus of brands like Coca Cola and Starbucks don’t really care about the future role of the mobile operator and anyone who thinks that telcos are short on political influence isn’t keeping up with the world.

The success of Apple in rebranding the smartphone (from a device that appealed to male geeks who thought it was called a smartphone because you had to be smart to be able to use it) and the enormous draw this has had on telco profits (Apple is getting practically all the profits out of the most affluent top end of the mobile industry) highlights that the telcos are just being blindsided by partners that work harder than they do.

Obviously it’s a chicken and egg situation because much of the reason for wanting to pay Mobile Operators for mobile data in Africa derives from the great ad sponsored content that companies like Google offer (gmail, google docs, youtube, etc) so perhaps it’s time for telcos to either become a commodity with lower profit levels OR accept their evolving role as a communications company and partner up to bring customers innovative new services and continue with the cannibalising of outdated industries.

I personally won’t lose a tear as Apple Pay and Google Checkout cannibalise the massive card and cash transaction markets because it’s only happening because telcos have sat on their hands and haven’t coordinated themselves to work to spare their customers from the pain of outdated approaches to transactions that are held onto so dearly by banks and governments.

Denis O’Brien is one of the smartest thinkers in Ireland so perhaps for next year the GetHealth Summit should try and organise for him to take part in a proper debate with someone who thinks disruptively about the future of content on the internet. I’m sure Kim Dotcom would have audiences on the edges of their seats…

I found a lot of common misconceptions about the mHealth market being expressed by speakers at the event and that was very disappointing because although this is not a new phenomenum it could discourage or at least distract audiences from the mHealth opportunities that Patients and Carers want and society needs to get the most from the budgets it commits to healthcare budgets.

The “mHealth Tools and Point of Care Devices” plenary in which Dr Alain Labrique, the lead of John Hopkin’s Global mHealth Initiative, used some nonsensical arguments to suggest mHealth devices that he doesn’t understand aren’t useful:

“…I put my hat on as a Hopkins faculty and what we do at the Global mHealth initiative is really the research around mHealth technologies to understand the efficacy the sensitivities the specificities of these tools
in accomplishing the clinical goal or public health aims that they claim to do. It’s why one of the first successes in mHealth point of care tools has really been the information look up tools the reference tools.
The transition from paper based pocket guides to now digital pocket guides because the content and quality of that information is easy to port into a digital arena. When you look at how mobiles have been used to enhance diagnostic tests the first slew of innovation out there was to use the mobile camera to interpret lateral flow assays to be able to read the bands on things like malaria tests in order to ascertain whether a patient has or does not have malaria in a semi quantitative way. but we’ve tried in the field to use, and I’m to not going to name which company, but mobile ultrasound units. After about three weeks the field nurses came back to us and said “we want to go back to our larger format laptop based Ultrasound because the screen is too small, we can’t discern the various artefacts in the image because of the footprint”. So that’s a design issue where the innovation wasn’t compatible with the need of the specific work cadre. 2 lead EKG it’s something that we’ve seen plastered across a lot of the mHealth landscape where we’ve it’s a very cool thing to whip out of your pocket and i’ve done it myself to show people look I’m taking your EKG right here using my mobile phone but you talk to Cardiologists and tell them about the ability to do 2 lead EKGs and compared to a 12 lead the diagnostic landscape that you can capture with 2 leads is very different and so you know there’s a credibility leap between what the technology can do and what the clinical world are looking for. So evidence is not sufficient, design is also very important when we looked at, in the last Wireless Health meeting in Baltimore we had a group from University of Maryland report on point of care tests for Diabetes management and so looking at the glucometers that were available off the shelf. They took 25 of the top most popular, most purchased glucometers and only found that one of the 25 met the design criteria or design requirements for elderly adults who would be using these technologies. So there’s a lack of fit there that needs to be overcome. But then the other issue of tolerances. there is a lot of technology out there that simply cannot survive the very very challenging environments of rural uganda or tropical bangladesh when we are using these day in and day out under high humidity, high dust environments. Those are points of failure that we need to address. So i would say these two things of improving the evidence base so that we have greater clinical reliability and improving the designs so that the technology fits with the end user and are going to be critical to rapid adoption…”

A few tweets I posted listening to Alain led to Alivecor coFounder and American Cardiologist Dr Dave Albert making a contribution:

LINKS.

I’m astounded that a Medical Professional from an institution like John Hopkins who is supposedly working to try and drive the understanding and adoption of mHealth has such a poor grasp of ECG technology and not the vaguest understanding of the Alivecor ECG or the new opportunities for self care that it represents.

I think it’s an interesting thing to comment on as it’s a great example of how the low cost, ease of use and wow factor in mHealth tech can contribute to driving it’s use by those who simply don’t understand it’s clinical relevance. There is an abundance of information on the clinical evidence supporting the use of Alivecor’s ECG sensor on their excellent website but as someone who has been using ECG tech for 20+ years and who was invited to explain, demonstrate and sell this medical device to Ireland’s leading cardiologists at their annual scientific symposium last year I can probably explain some of the reasons why it’s very unprofessional of Alan to have tried to denigrate the value of this clinically validated medical device.

Firstly it could be considered by audiences that Alan is casting aspersions on some of the world’s most pre-eminent Cardiologists (see Leslie Saxon, Eric Topol, Prof John Camm, etc) who are carrying and using Alivecors in their clinical practice (and in-flight!) and advocating for it’s use by their Patients.

Alan’s issues with the Alivecor arise not from a failure of mHealth design but from the failure of this particular medical professional to understand what the technology is/isn’t and how and where it needs to be applied. The Alivecor has proven itself to be extraordinarily useful for detection of disabling and life threatening arrhythmias. You can click here to read about the experience of a Patient that I helped who had a completely asymptomatic arrhythmia back in 2011 with my own Alivecor device.

It’s key that commentators with influence all appreciate that even though research is being published that demonstrates the feasibility of using the Alivecor tech to create a 12 lead ECG the Alivecor is not being marketed or sold as a replacement for a highly diagnostic 12 lead ECG (which can give significantly more information on ischaemia, infarction, accessory pathways, anatomical position of the arrhythmia, etc, etc). Instead it provides an incredibly convenient and easy to use method of recording a high quality heart rhythm and this can be used in ways that are similar to and can extend beyond how healthcare professionals today use expensive equipment like Holter monitors, monitors in ambulances or implantable loop recorders.

It’s important to appreciate that these rhythm strips are very useful for diagnosing paroxysmal rhythm disturbances and it’s for this reason that all Cardiologists utilise them extensively in their work detecting arrhythmias and planning treatment for their Patients.

I would also recommend that Alan is more careful about how he judges the quality of information. A blog review (authored by a group of junior medics who don’t understand the value of BP monitoring) does not constitute ‘expert’ opinion – for that look to some of these papers that have been published by Cardiologists leading departments within the world’s top medical research institutes.

As Dr Dave Albert says “Change creates Opportunity so embrace it!“:

The breakout discussion panels were an event highlight for me and I’m very surprised they weren’t recorded so that the points of view could be shared more widely. The above one should give you a feel for some of the conversations eg. it highlights the naivety that academics have in their approach to judging the quality of sources of information – which was enough to get me to chip in with a bit on the Trust Economy.

“…it’s very concerning if content gets out there and is not quality reviewed and quality checked and again there are clinicians and others who could speak more credibly about this but there are ones that don’t have true ministry of health approval and or clinical level review. I mean there are a lot of great applications you know I won’t go into that but I think we all really need to be careful because this is not like agriculture which is a sector I worked in a little bit, where you know if you get the soil pH wrong your tree dies where as in this case it’s lives so you have to be extremely careful…”

What do you think: does Africa not have an evolving trust economy?

Posters

The poster area was very interesting but reminded me of how we used to share information back when I was at medical school before most of us had even heard of the internet or used a mobile phone- I’m sure delegates could take lessons from Africans on this.