MIT Review article warns that Mobile Video Calls may encourage Patients to spend too much time talking with Doctors

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In this MIT Review post Christina Farr expresses concerns that mobile access to Doctors could amplify health anxieties.

mHealth Insights

“Your Doctor App Could Amplify Your Health Anxieties…   …People with the kind of health anxiety formerly referred to as hypochondriasis used to have to go to the doctor’s office to quell their concerns. Thanks to a new crop of apps, they can now just take out a smartphone and reach a health professional anytime, from anywhere.”

The start of this article annoyed me as I really hate the idea of calling people hypochondriacs because they have a health anxiety – they’re Patients/Carers first and the most anxious I’ve ever met are normally Doctors or Medical students!

Today I think things are completely different because we can all look things up but I find this is a fascinating point of view as when we launched 3G Doctor in 2006 a Doctor in the audience at the Royal Society of Medicine asked me in front of the whole audience why Patients would ever want to video call a Doctor as though consulting an independent impartial Doctor was something there would never be a demand for.

It reminds me of the classic concept of what happens as a new idea goes through the stages of adoption in Medicine: “First they ignore you, then they laugh at you, then they fight you, then they scream look at what this is doing to the Patients whose needs we had been ignoring all along”…

As we hear technologists hyping the potential of Big Data to transform healthcare outcomes the reality for most Patients with anxiety issues is that they must suffer because their interactions with Doctors follow more of a Zero Data model in which they break down in a Doctors office and try and communicate while being emotionally drained and the Doctor tries to guess why they’re there and what they might need.

“So-called super users might not be a good thing when it comes to on-demand consultations with doctors. People with the kind of health anxiety formerly referred to as hypochondriasis used to have to go to the doctor’s office to quell their concerns. Thanks to a new crop of apps, they can now just take out a smartphone and reach a health professional anytime, from anywhere”

I think it’s quite amusing that in 2017 Doctors who have moved beyond the office visit only model are getting the finger pointed at them for milking Patients. For decades I’ve been listening to Doctors who offer Office Visits Only complaining that Patients are wasting their time but today I can walk into their waiting rooms and either load up the Instant Medical History questionnaire (that we have integrated into the 3G Doctor site since 2006) onto their Patients mobile phone web browser and it has been proven that I will be able to improve the quality of the care and reduce the need for at least 25% of the Patients  to have a consultation with the GP they’re waiting forand yes this could obviously be done before the Patient waited for the appointment and in complex organisations like the NHS where GPs use complex EHRs and workflow tools.

Perhaps Christina Farr has been confused by the work of some VC funded startups that have arrived on the market offering undocumented video chats with random Doctors who prescribe drugs and I agree these are daft, dangerous and hopefully won’t be around long (in my talk at Doctors 2.0 in 2014 I explained how we need to ensure Video Consults with Patients are all supported by tools that help Patients share information before a consult and get documentation of what was said/shared during the consult).

“Studies suggest that health anxiety—more recently termed somatic symptom disorder and illness anxiety disorder—affects anywhere from less than 1 percent to as much as nearly 12 percent of the population. For some of these people, a new array of telemedicine apps like MDLive and Doctor on Demand are appealing because they take insurance and also let you pay up front at cost of about $40 to $50 for a short video or phone consult”

I can’t believe that less than 12% of the population are affected by Health Anxiety and it’s odd that anyone thinks such a group of Patients might be in some way less deserving of high quality care.

The growing numbers of unvaccinated children in the US are a good example to use to make this point as they have Parents who are typically wealthier, have had more formal education, are more likely to have health insurance and the latest iPhone. To change these trends it’s critically important Doctors appreciate that online video (even that produce by quacks) provides such a powerful means of telling a story (eg. a celebrity talking about how his beautiful kid was diagnosed with autism straight after getting vaccinated) and this will very often be more compelling than any statistics that can be produced to support even an area of medicine that has an abundance of high quality evidence (eg. child vaccinations). Ignoring this group because we consider them to be health anxious is not only unethical but it’s putting children’s lives at risk and driving overall trust issues with evidence based medicine (as in order to really believe the story the Parent has to actually be convinced that Healthcare Professionals are all in on an elaborate conspiracy to harm children with harmful medicines) which is in turn fuelling the growing Quack industry.

Dr Roy Benaroch posted an interesting view on these video chat services but it fascinates me that US Patients are using the insurance paid option for talking about a mental health issue when just paying out of pocket for the consult is so inexpensive.  Perhaps the T&Cs aren’t made clear but I can’t think of a quicker way of increasing your insurance premiums. Surely it’s better to pay the $40 for such an interaction and keep this personal information private or perhaps the Patients know the data will get to the insurer anyway?

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“Because they are so easy to use, some medical experts wonder whether, over time, telemedicine apps will encounter a disproportionate number of users with health anxiety disorders. Already, app makers are encountering the ethical question of whether they should encourage such users to seek mental help”

So clearly I’ve got a vested interest in that I developed a course for medics seeking to move beyond the office visit only model of healthcare but why is anyone surprised that office visit only model Doctors really don’t like the idea that care can be made convenient for Patients?

Now that your iPhone has a faster CPU than the computer in a £10Million Surgical Robot I think it’s time we realised it’s unethical for the big mobile device manufacturers to not encourage their customers to seek help from a registered Healthcare Professional  considering the quantity and quality of data they are gathering on us (eg. tracking our eyeballs with high quality cameras).

“MDLive’s chief medical affairs officer, Deborah Mulligan, says that the company’s app has 28 million registered users, and it’s likely that about 6 percent have this condition, which mirrors the proportion found in the general population. What makes matters more complex is that with any other type of mobile technology, these people would be considered “super users” who drive revenue—the kinds of folks you want to stick around and keep using the app all the time”

I think this is another reason why Doctor Video Consulting services should be owned and operated by Doctors and Patients/Carers should be wary of those that aren’t – especially those who are heavily debt funded (eg. MDLive has raised $73.6M from Venture investors who in all likelihood are expecting a 10X return on their investment and has a T&C page that clearly states ‘MDLIVE does not provide any physicians’ or other providers’ services itself’ disclaiming the company from providing and being responsible for Patient Care)  as unlike registered Physicians they could be forced to exploit Patients mental health needs to get more revenue, trade Patient data, etc, etc.

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“Mulligan spent much of her career working in emergency rooms and was trained to recognize the symptoms of health-related anxiety disorders, which include worrying about a disease when there are no symptoms, experiencing high anxiety about minor aches and pains, and not feeling reassured by negative test results. She recalls one MDLive patient who exhibited all of these symptoms, and who suggested setting up regular consults to discuss a specific health condition that the patient didn’t have. After several sessions to build up trust, Mulligan recommended that the patient try MDLive’s cognitive behavioral therapy service. “They contacted me to thank me,” she says. “It was like a weight off their shoulders.”

I wonder what’s going to happen when this unfortunate Patient tries to renew their Health Insurance?

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I think the idea of using Video Chats to establish trust with a Doctor is quite odd. Perhaps MDLive should also copy the phrase we use at 3G Doctor where we inform Patients that the best place they can get care is with a Family Doctor. We would on the first Consult inform a Patient reporting concerns like this with us to go and register with a Family Doctor and provide them with a written consult report so that their first consult with that Family Doctor would be a productive one.

“Doctor on Demand board member Bob Kocher says that the majority of people who use the app are calling up about routine symptoms, like colds and the flu. He isn’t aware of patients with health-related anxiety regularly using the app to discuss their symptoms. However, he thinks it’s possible that more such patients will discover the app as it gains mainstream recognition. “Frankly, I think there are some of these patients in the health system who haven’t found us yet,” he says. “I’m sure we’ll have board meetings someday about a patient who used us 20 times that week.” Kocher says that app makers might make a “lot of money” through these interactions but will have a responsibility to investigate whether the cases were handled well”

I think this is an important distinction between how a business (that disclaims itself from providing the Care of a registered Healthcare Professional) and an actual Doctor can operate. Every single Doctor deals with this on a day to day basis and there are organisations like the GMC who work to protect Patients from Doctors who might want to abuse Patient trust to make a lot of money by repeatedly seeing them for no reason but to take their money.

Try this wheeze as a business that specifically disclaims itself from providing Patient Care (by calling the Doctors providing the advice ‘third party contractors’ and having bizarre disclaimers on your T&C page that the service is ‘limited to providing a information for entertainment purposes’, ‘not for medical care’, ‘is to be used solely at your own risk’, etc.) and your investors are going to be happy with the financial returns you give them until there’s a class action. But try the same as a Doctor and your career is over quicker than it started.

“One of the challenges of finding these kinds of users, experts say, is the lack of information transparency, particularly as the apps don’t share data with each other. “We don’t really know who the frequent users are,” says John Torous, co-director of the digital psychiatry program at Beth Israel Deaconess Medical Center. “It’s a population that is not well characterized.”

This is a typical reactionary comment about apps. The problem I see with Apps is the opposite eg. that they share data too widely with third parties etc unlike Doctors who rarely get to share at all with colleagues a few miles up the road.

“And Doctor on Demand’s chief medical officer, Ian Tong, points out that excessive health anxiety might be challenging to monitor if patients use an array of different apps. “You might not be able to tell unless the person was being prescribed a lot of medications,” he admits”

Perhaps Cheltenham Week has gripped me but isn’t this a classic case of trying to bolt the shed door once the horse has bolted?

Surely Doctors who are trying to help care for Patients who have excessive health anxieties AFTER they’ve helped to prescribe them too many medications should be struck off the register and retrained?

Key Takeaway

Blaming convenient Doctors for causing Patient Anxiety is like blaming ABS braking systems for causing tailgating motorists…

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Mount Sinai Hospital publishes early findings from a Mobile First Asthma Mobile Health Study

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“After it’s Apple App Store release on March 9th 2015, the Asthma Health App was downloaded 49,963 times over the first 6 months, 40,683 of which were from United States…   …a total of 7,593 users, out of 8,524 completed the enrolment process (89%)”

When you realise that most Clinical Trials in Europe fail because they can’t even recruit Patients it should be obvious the only reason organisations that are involved in designing Clinical Trials to prove the value of medicines aren’t releasing Mobile First ResearchKit trials is because they have a different agenda/something to hide…

Related posts/videos:

How Mobile First Clinical Trials & Ratings will transform the $100B Clinical Research Industry

Imagine if we took a Mobile First approach to designing Clinical Trials

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Your iPhone has a faster CPU than that used by a £10Million Surgical Robot

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Robots don’t challenge surgeons such as me – they challenge dogmatic practice 

This was a fascinating read for me as I’ve experienced this Da Vinci Robot as well as the latest models in UCSD’s brand new state of the art lab where they teach Doctors from all over the world on how to use these robots.

The big takeaway though has to be that this super expensive robot was always accompanied by a large trolley containing it’s computer and the central processing unit (the CPU or brains of a computer where all the calculations take place) was equivalent to 5 Pentium 300MHz processors. Today’s iPhone has a CPU speed in the region of 2.34 Ghz.

Imagine if 10s of millions of NHS Patients permanently carried a £10Million computer and  we refused to let them use it to engage with their GP and didn’t even encourage them to use it to look things up?

Imagine if every GP in the country was permanently carrying a £10Million computer that was networked to the world yet when we trained them and examined their skills we categorically banned them from even using it?

It should be clear:  Mobiles are no longer toys and it’s about time for Healthcare brands and Carers go #MobileFirst when our iPhones have faster CPUs than £10Million Surgical Robots…

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Introducing Apple Healthcare #mHealth

On a serious note check out and share anything you think should be added to the Smartphone Physical.

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On International Women’s Day 2017 let’s make a #BeBoldForChange call for Patients to have access to a means of independently sharing their Medical History

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Incredibly tragic news from Australia breaking on International Womens Day but I think it’s time to #BeBoldForChange and start demanding that Patients are provided with the means to independently share their medical history in the way that we know will illicit more honest information because it’s one of the best hopes we have of deterring and bringing successful prosecutions against abusive partners.

interactive sexual violence questionnaire

Related Posts: 

Perhaps it’s time we stopped saying “go and get help”?

I’d never admit that to my Doctor but to a computer? Sure (2014)

Are you more honest with your Phone than your Doctor?

25% of men visiting their NHS GP clinic revealed via a questionnaire that they’d experienced domestic violence/abuse

If you are a GP who thinks the product you produce is ‘office visits’ it’s time you were retrained

Do we need AllTrials or AllConsultations? (2013)

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It’s no longer sales as usual for medical device firms when Patients shop in the Apple Store for devices that are better & less expensive than what Hospitals are prescribing…

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I originally shared this as an update on Linkedin and it generated some interesting discussion but as discovery and retention of content on Linkedin is a bit hit and miss since Microsoft  acquired the company in June, I thought it might be worth cutting and pasting the comments thread in a blog post for posterity and to share with those who don’t use Linkedin:

Joel Selanikio: And this is just getting started.

David Doherty: oh yes but the fear of becoming little more than an iPhone accessory brand is real even in the boards of the biggest global Medical Imaging firms:

https://mhealthinsight.com/2017/01/11/medicaldevicemakersbecomeiphoneaccessorybrands/

Johan Goris: think again https://theskepticalcardiologist.com/2017/02/15/sustained-atrial-fibrillation-or-not-the-vagaries-and-inaccuracies-of-alivecorkardia-and-computer-interpretation-of-ecg-rhythm/ also

David Doherty: Think again? There’s nothing stopping Kaiser Permanente San Diego having their own Cardiologists reading the ECGs that their own Patients record/share. You know you don’t have to use Alivecors read services?

Johan Goris:It was a generalistic reply on a generalistic statement.

Johan Gorisnot to mention the many “put your finger on the camera” Afib detection apps. PPG based Afib actualy only sustainable for follow-up of AFib diagnosed patients, not for screening and only when clinically validated …

David DohertyI think you know it’s unfair to compare either the medicomp or alivecor to these unreliable apps that lack evidence of their effectiveness despite the claims. Perhaps you’re inventing a problem that doesn’t exist in the hope that we’ll stay distracted and keep the life support going for the broken medical device sales model in which the Patient never knows the price and never has a choice. The real threat isn’t cookie cutter me too apps that promise a lot and offer very little but it is that medical device companies need to turn around their business model if they’re going to survive being redesigned by mHealth. The question we should be trying to answer is how would the Born Mobile Generation sell that medical device? https://mhealthinsight.com/2015/09/22/bornmobile/

Johan Goris: Just like it’s unfair to compare validated ECG machines offering extended arrithmia detection with Kardia from Alivecor… The link you included refers a.o. to the Aura Activity Monitoring Ring ( I guess they mean the OURA ring) … clearly an unvalidated device for sleep monitoring, as they themselves conclude in their pre-compliance study : https://support.ouraring.com/helpdesk/attachments/6027900621 … “the variability in individual accuracy in some parameters informed the ŌURA team of clear opportunities for improvements” There is no technological chicken & egg situation with mobile biomonitoring, it’s the just the chicken often reluctant to deliver the real egg (not just empty shell). Some mHealth devices manufacturers (± 15% in my +3000 # database) do perform and will probably make it, if only they keep their claims realistic. Its a funding/adoption chicken & egg situation suffering from hyperbolic inflation/distrust from people with skin in the game.

Johan Goris: But I disagree … the system is not broken … it was built this way … and needs a restore (but not without a clever backup)

Denis KhitrovI would agree with almost the whole statement if the word “better” is skipped. While quality/value of professional medical devices in comparison them with consumer products is overrated, these are still different worlds that can’t be compared directly. If patient could really switch from using of continious monitoring Holter system to another simpler solution it’s not about “better” in terms of medical data collection. It’s about usability and real needs of the patient.
Johan GorisUnfortunately there is no trade-off possible between better usability and minimal accuracy performance in function of the health or medical data purpose. The citizen-patient needs sufficiently accurate measurements to get correct actionable feedback information, whether for prevention, (early) diagnosis or monitoring health. The same applies to data used for clinical decision support, clinical research, payers risk evaluation or regulatory evidence …
Denis Khitrov: I agree with you. What I meant is that there many basic but meaningful things that could be done with much simplier (and cheaper) devices. For example in some cases patient don’t need to have a multi lead Holter monitor, but can collect data with a simple one lead ECG by applying fingers or using a smartwatch with HR/RR sensor. All that doesnt mean that one lead ECG or HR Monitor is “better” than a Holter, but could bring a lot of value for Healthcare and surely a lot of speculations too =)
Johan Goris: OK, I fully agree that there is more grey between the single black and white claims from both sides of the spectrum, so according to the application (intended use) we will have to fix the expected accuracy and exclude what does not comply for it. Today only 10-15% in my evaluated database of +3000 mHealth devices and associated apps shows (validated) specifications to backup their claims.
Denis Khitrov: I do not wonder. There are many Software Vendors that even have no idea of the “Intended Use” meaning. No culture of Risk Analysis at all. And to be honest even regulatory bodies are still not experienced enought with mobile software clearing and seems to loosing controling position in general. That’s why stories like “Theranos” or “PIP” are happening … But from other side overregulation would simply kill the industry or terribly slow it down. I think your point is correct – new simplier devices should be very cureful with Intended Use claims.
Johan Goris: Today disruptive industry is slowing itself down (killing itself) by regulatory avoidance … sometimes one just can’t be ‘carefull’with claims, as some parameters are regulated by default (and that’s a good thing for their expected accuracy !) I believe we might need an extra ‘lighter’ regulatory level for health devices & software, to bridge between existing “medical” and “consumer” whilst product & manufacturer registration remains essential towards market vigilance

 

Denis Khitrov: Surely it’s still a sign of changes. RPM and personal health tracking solutions bringing a lot of disruption and gives more freedom to the end users. A lot of shifts will happen in direction to simplier consumer devices, because regular dynamic changes monitoring may be more valuable than precision of measurement. But that would hardly replace “what doctor is prescribing”

Emmanuele Angione: “90% of strokes can be prevented” is a big – BIG statement. Where will clinical liability fall if things go wrong for the patient? On the patient using that device? On the clinician interpreting the data from that device? On the developer of the algorithm? On the ISP?

David Doherty: Emmanuele Angione Correct, read up on the BIG opportunity to prevent strokes:

https://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2016-07-18-nine-out-of-10-strokes-preventable-claims-study/

Alivecor is also doing great work to support researchers (including colleagues of mine using their tech in leading European Medical Institutions) and publish evidence on their technology:

https://www.alivecor.com/en/research/

Also check out this brilliant interview with Alivecor’s CEO Vic Gundotra to get a feel for how the tech is enable machine learning that is transforming how we practice medicine:

http://www.recode.net/2016/12/5/13837908/machine-learning-doctors-vic-gundotra-recode-podcast

Seamus Flood: Promotes owning your health not leaving to the medical professionals to wave magic wands

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The biggest challenge facing Mobile Operator’s 5G Plans: Apple might get to decide what 5G is.

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At Mobile World Congress 2017 the telcos have wasted a fortune and disillusioned the media talking about 5G with demos that actually made little/no sense and distracted everyone from the really big opportunities to add value to society with mobile networks.

Here’s a few examples from what the world’s biggest Mobile equipment brands promoted at mwc17 to help make the point:

Huawei Technologies

Huawei Technologies is the world’s largest telecommunications equipment company (not including mobile device sales) and centre of their booth was a Virtual Reality Goggles demo.

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Now I can understand an Augmented Reality angle to 5G but what’s the demand for using VR Goggles outside of somewhere that has Fibre connected WiFi? Has anyone at Huawei asked do VR Goggles present us with a computing problem or a network problem as in tandem with the 360 degree Honor smartphone camera I think the answer is pretty obvious.

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You have to doubt the ability Huawei has to market 5G when you realise it’s current marketing team thinks that #MWC17 audiences were going to be spellbound by promises that their new flagship device (arguably one of the best mobile devices in the world right now) is going to be available in a “Mystic Silver Cool and Sleek” color?

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Ericsson

Ericsson is the world’s 2nd largest telecommunications equipment company (not including mobile device sales) and their 5G Robotic Surgery Demo was a disgrace to Kings College Hospital in London. I just hope the hospital got a load of money for it as this made a mockery of how surgeons are using technology in this globally recognised centre of surgical excellence.

The demo was just nonsensical – a guy wearing a “Internet of Skills” was waving his  arm about wearing a glove and this was moving about a robot arm. Seemingly none of the delegates realised that a surgeon does more than wave their arms about prod Patients with a finger and that the human body isn’t transparent…

Cisco Systems

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Cisco are the world’s 3rd largest telecommunications equipment company (not including mobile device sales) and their MWC17 headline was that they would be a key tech supplier for a trial with Verizon to deliver 5G service to pilot customers in 11 markets across the U.S. by mid-2017.

This is the same Verizon that rebranded 3G as 4G CRACKED VIDEO and sells unlimited* data plans that even today in the real world are actually limited to 22 GB/month (apparently these 5G networks will apparently be able to provide Gigabit per second speeds (meaning that the 2017 monthly data cap will be going in less than a minute!).

On the #MWC17 booth Cisco’s Dan Kushner, SP Mobility Marketing Manager, explained why 5G is so important to Cisco right now and it shows how far 5G is to even being intelligible to telecom equipment buyers:

“…quite simply for Cisco 5G is our open system architecture that forms an enabling platform to launch innovative services and applications. We use advanced automation to create a unifying network fabric and when you put that together over the infrastructure you create a 5G unified enabling platform”

Nokia Networks 

Nokia Networks  are the world’s 4th largest telecommunications equipment company (not including mobile device sales) and their pavilion and keynote talk showcased toy Monster Trucks being driven around a figure 8 via 5G network connectivity.

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Maybe the delegates never had a Scalelectrics set growing up but hasn’t the Mobile Industry learnt nothing from Tesla (the only automotive company to realise how daft it is to try and have 2 different source power plants in a vehicle). If they can fit a 3G connected computer in a sleek performance can safely SELF DRIVE a car on actual roads TODAY and upload/download updates/feedback why wouldn’t you want a computer onboard to eliminate any potential latency risks when you have a Monster Truck hurtling about a easy to define smooth/obstacle free figure of 8? This is an example of a computing problem NOT a network problem!

 

What happens if Apple decides to define 5G?

Clearly Apple are never going to start playing the technical one upmanship game with telco equipment manufacturers but they’ve got good form for taking away all the complexity (remember when in 2014 they replaced SIM cards in the Apple iPad Mini with the “Apple SIM” that turned out to be easy to use software that let customers choose which mobile network they wanted without the need for a SIM Card?) and they have the affluent end of the customer base that is the only group who could possibly afford to download a unlimited* monthly data plan inside 30 seconds!.

What if Apple 5G isn’t going to be a new network technology but a new way of using the existing network technologies?

What if you could seamlessly roam onto multiple 3G, 4G, WiFi networks and Apple just took care of it all and always kept you connected as required without you having to worry about issues like security.

Could Apple define 5G as seamless AlwaysBestConnected access to connectivity without any concerns about how much you’re going to be billed?

What’s this got to do with mHealth?

Sometimes it’s not always about giving customers more connectivity it can be about giving them better connectivity and in the mHealth market the difference between these is critical.

Can you imagine any Patients/Carers/Medics who don’t want to have Always Best Connected access to all the mobile networks?

Can you imagine any regulators who won’t insist that the medical devices they approve have Always Best Connected access to all the mobile networks?

*** UPDATE 7 March 2017 ***

Don’t miss Nick Hunn’s take on the 5G Myth being perpetuated at MWC17. 

“But there’s a cold wind of change.  It’s becoming clearer that 5G isn’t providing new applications.  Instead, it’s a story that being conceived and propagated for the benefit of the 5G myth makers.  They need to keep selling major infrastructure upgrades, as without that they have a very bleak future”

Qualkia – Constructing the 5G Myth

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