Going beyond killer apps: building a better mHealth evidence base

mHealth Insights


“mHealth relates to the provision of health-related services via a mobile device. It comprises multidimensional elements including provider, patient and administrative applications. Applications include consumer education and behaviour change, wearable sensors and point-of-care diagnostics, disease and population registries, electronic health records, decision support, provider tools (communication, workflow management, professional education) and healthcare management (human resources, financial monitoring, supply chain logistics)”

I see a lot of shortcomings in this definition and think the authors would’ve done better if they’d gone with the definition I proposed when I coined the term eg. in 2010.

“Although mHealth has potential to strengthen health systems worldwide, the evidence base is immature, and consequently, the opportunities to advance knowledge remain limited. Mobile devices and apps have become essential tools for disruptive change in many industries, but thus far, this has not happened in healthcare. Here, we discuss five interrelated reasons as to why mHealth has under delivered and highlight challenges and opportunities for mHealth researchers”

I think this is a popular myth held by researchers. In the real world (as I wrote here in 2009) successful mHealth applications are already commonplace across the world.

“The myth of the ‘killer app’. Disruptors often rely on a ‘killer app’—a highly popular application that users will consider indispensable for their needs. At last count, there were nearly 260 000 health apps on the market, but most downloads are never opened and consistent use is extremely rare. Further, these apps are often disease siloed, focus mainly on behaviour change, gloss over privacy issues and are not integrated into any overarching healthcare structure. Such apps struggle to achieve large-scale adoption because of their failure to address the needs of diverse stakeholders”

We’ve noted this happening time and again before (eg. “Majority of mHealth apps fail to engage patients”, NIH funded researchers spend $270 on misleadingly labelled iPhone apps & conclude that apps offered for ‘EDUCATIONAL USE ONLY’ can’t be relied on for ‘PROPER MEDICAL ADVICE’The Impact of mHealth Interventions: Systematic Review of Systematic Reviews, etc) and it’s a classic case of the researchers being failed by their imaginations. The reality should be obvious: it’s now cheaper to distribute high quality life saving medical information than it is to distribute water to most of the citizens living on this planet. The killer app is probably the baked in life saving potential that mobile connectivity offers.

“Most apps are consumer facing, whereas healthcare systems tend to be provider facing. This important distinction may explain why the ‘killer app’ approach is not the correct mindset. The diversity of users and the inability to address their varied problems results in user fickleness and ready abandonment of new technologies”

It’s odd to think that a group of researchers in 2018 feel their audiences need to be made aware that ‘most apps are consumer facing’. I know lots of researchers still get confused by all this but I’d of thought anyone reading the BMJ in 2018 is aware that the app stores have created an unprecedentedly low barrier to entry and that this means there are millions of cookie cutter apps some made by students having fun trying something out and posting it for it to be downloaded a few times (and probably never for real world use by an actual Patient/Carer).

The neat distinction between ‘consumer’ and ‘healthcare provider’ facing is also fast disappearing eg. see Apple Health Record.

“When tools are not connected to systems and human support, they are unlikely to be effective. Consequently, moving beyond a single solution focus towards a ‘health ecosystem’ approach is needed”

This hope of joining everything up before joining anything up is why in 2018 your dog has more joined up care than that provided by £multibillion teaching Hospitals to your sick child.

“Neglecting user perspectives and preferences. Related to the killer app mythology is the tendency to over engineer solutions before having an opportunity to fully understand user needs, contextual factors and the size and specifics of the problem that needs addressing. The Greentree consensus outlines nine principles for digital development, emphasising frequent and in-depth user engagement in all phases of the development process. It stresses the importance of understanding the ecosystem, designing for scale and sustainability, addressing privacy, using open standards and taking a data-driven approach”

This is such a dated concept and is only held by people who haven’t yet learnt how to use an app store. Who is making smartphone apps and neglects user perspectives and preferences??? Don’t the authors realise that apps all have public ratings posted by actual users and that developers are prioritising this feedback or getting fired in quick order?

“It also emphasises the need for multidisciplinary collaborations. Although researchers are often the subject matter experts, non-health specialists such as human factors engineers, human computer interaction specialists, anthropologists and ethicists can provide strong methodological frameworks for understanding user perspectives at all stages of the development, implementation, evaluation cycle”

This is  a classic misconception. In my opinion researchers are far from the subject matter experts and the basic flaws in this paper stand testament to that. The real subject matter experts are carers who just intrinsically know that ‘here’s my number’ is one of the most caring things you can say to a Patient.

“By not taking a user-centred approach, we risk over engineering solutions. The most promising use of mHealth to date has not been smartphone apps, but basic functions such as short messaging service or voice calls to address specific issues such as medication adherence and promoting smoking cessation”

This could only ever be written by someone who has never been involved in producing a mHealth app/service.

How are sms and voice calls to ‘address specific issues such as medication adherence and promoting smoking cessation’ still considered ‘promising’? Aren’t these already common and widespread eg. in 2012 Walgreens were generating more than $300M a month in revenue from their medication adherence/reordering app.

I think it’s important to realise native functions of mobiles now all start first as features/apps and the mobile brands get to enormous data sets that show their popularity/use/value in order to make the decision to make them native ‘basic functions’. A good example of how futuristic smartphone apps can quickly become ‘basic functions’ can be seen by studying Apple Health Record. Only weeks ago that wasn’t even imaginable to most and many very senior Doctors still can’t believe it!

“Apps are not pills. Researchers tend to lack a good understanding of how developers operate. Two commonly used industry standards include Waterfall and Agile development. Waterfall is a stepwise process whereby developers iteratively revise their software at each stage of the product development cycle based on target audience feedback. It may be particularly appropriate for large-scale system development. Agile design takes an incremental rather than sequential approach. Initial prototypes are usually simple and each development effort is completed in short sprint cycles with increasing maturity at each cycle. It is particularly useful when there is not a clear idea what might work. Whichever approach is used, initial deployments are unlikely to work perfectly. The interim goal should be a ‘good enough’ prototype, known in industry as the minimum viable product. These approaches highlight differing developer and researcher perspectives. The developer’s outlook is plastic, continually updating and refining a product to create novel solutions and stay ahead of the competition. By contrast, a researcher’s outlook is more static where interventions are viewed as pills—specific agents that are developed and tested in isolation of other factors. These differences in perspective are often disregarded. Understanding the developer’s approach can help research teams to get apps in front of users quickly, fail early and build from the lessons learnt. This approach can also avoid expensive ‘scope creep’ later in the development cycle when the app is more mature and user testing reveals a major redesign is needed”

I find this quite a bizarre piece of editorial. Why would anyone think developers must choose between 2 completely different approaches? Isn’t everyone aware that all the major pharma brands now have beyond the pill strategies?

“Rigid approaches to evaluate evolving technologies. While we strongly support the need for evaluations with randomised controlled trials (RCTs), there are several considerations in applying this design in mHealth. First, traditional RCT designs reflect ‘the static view’ described above—assuming an intervention is ‘fixed’ and external factors are standardised or adjusted for to avoid introducing a bias. This is anathema to software development where iteration, bug fixes and new releases as user experience grows are the norm—‘the perpetual beta’. The key consideration here is that we test principles rather than fixed apps”

I agree with this but sadly a lot of key decision makers in the Healthcare industry don’t even understand it eg. until recently the EU and major pharma brands were actually sponsoring a printed directory of mHealth apps!

MyHealthApps Directory

“A third and unexplored area is postmarketing surveillance mechanisms to safeguard against unintended consequences derived from mHealth-related activities”

I don’t think this is unexplored at all. What’s unexplored greatly is the potential for mHealth apps to support post marketing surveillance of medicines (something I’m currently working on with a leading vaccine brand).

“What are the priorities of those who pay for mHealth technologies? Public and commercial payers of health services play a central role in determining whether mHealth can be adopted at scale. Innovation in the business model is just as important as the apps themselves in promoting disruption. Greater attention to business model specifics may stimulate different research questions. From a researcher’s perspective, the priority is to demonstrate clinical effectiveness. This contrasts with the payer’s perspective which is broader and includes factors such as reduced administrative burden, improved workflows, greater patient and provider engagement and improved quality of care and outcomes at lower costs. The macroeconomic environment is also key to driving particular business models. While profits may be greater in high-income countries, the largest mHealth market in terms of user numbers will be in emerging economies. Just as the pharmaceutical industry tends to be segmented into low volume, high margin products for rich countries and high volume, cheaper products for poorer countries, mHealth markets are likely to evolve differently depending on the payer, provider and consumer environment. It is therefore important that the research community generate evidence on effective business models as much as effective apps”

This is why I think Apple is taking such a positive direction in it’s unique approach as a tech company to not be focused on what helps the Patient rather than what gets you reimbursement. I really hope Apple can make a product that’s great for Patients and can earn their trust because if they achieve that ambition they will once again change the world and I have every confidence that the business model will take care of itself (and will indeed dwarf their current annual revenues of ++$200B).

“Conclusion. Although some may be disillusioned by the lack of ‘blockbuster’ mHealth trials, we are optimistic that the evidence base for mHealth will grow substantially in coming years. Particular challenges remain, especially in low-income and middle-income country settings where literacy, health literacy, unavailability of smartphones and limited access to reliable data connectivity all pose adoption challenges. However, these factors are improving rapidly, and the opportunities for future growth are substantial. With increasing knowledge of what works and what the challenges are, we will arrive at a more nuanced understanding of the role of mHealth in improving health and healthcare”

Last week I presented to the medical students at UCD Medical School in Dublin. At this world leading medical school the future Doctors were being trained for a career that no longer exists using tools that are relics of a by gone era.

No doubt we could research every avenue (‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials’?) but we really don’t need to wish for ‘blockbuster’ mHealth trials we need to move beyond the 2,000 year old office visit only model of care and stop expecting medics to do the impossible because the Born Mobile generation wouldn’t actually believe that a Doctor would be allowed to work without at least a connected smartphone loaded with quality medical content.

“Competing interests: None declared”

I understand this is a challenging area but even a cursory appreciation of the George Institute’s work and it’s clear the organisation has several heavily vested commercial interests in this area eg. the George Institute has a ‘China Centre of mHealth Innovation’ that was set up with corporate sponsorship from Qualcomm to “improve community health care in China through the study of affordable, sustainable mHealth interventions, which target the nation’s leading causes of premature death and disability, while supporting the central government’s deepened commitment to health care reform” and it clearly benefits from a paper that in summary calls for more need for the work of researchers.

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About David Doherty

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