Another day, another flyer arrives for a seminar on “mHealth.” One that showed up in my mailbox this week is typical: high-gloss images of mobile phones and heart signals, celebratory claims about how all of this will “revolutionize” healthcare, and liberal use of the words “innovation” and “transformation” in almost every keynote title. I bet I could circle the globe going to all of these mHealth events if I would let myself. Then there are the numerous press articles starting to beat the drum about mHealth. Concepts like “home health” and “wireless” and “smart phone” and “telehealth” are being bandied about as if they are all the same thing, under the rubric of “mHealth,” without much distinction between these very different capabilities, value propositions, and markets. Methinks we doth proclaim too much!
I have no doubt that we are living in a world in which personal technologies–from PCs to smart phones to game machines to wearable and eventually even implantable sensors–will become increasingly important for capturing healthcare data, prompting us to adhere to care plans, and connecting us with providers and each other in some powerful new ways for collaborative care. I have done, sponsored, and funded R&D at Intel in wireless technologies, sensor networks, mobile applications, and home-based services for healthcare. And I believe that consumer empowerment tools are a disruptive and important part of healthcare reform globally. However, this well-intentioned but premature celebration of all things “mHealth” may come back to bite us, if we’re not more careful. Here are some of my concerns:
1) Defining mHealth: I am becoming worried that we don’t really know what each other is talking about when we say “mHealth.” I’ve been asking a lot of the conference organizers calling how they define the term–what’s in and what’s out of the definition. There is always a long pause followed by lots of stammering and false starts when I ask what should be a pretty simple question.
Then, some tell me it is all about “wellness” applications for the masses to drive prevention. Others define it as mobile applications, usually on smart phones, that leverage some of the government’s public health data so consumers can know things from their pollution exposure to flu migrations. Still others focus on it as videoconferencing with a doctor from a cell phone (I wish I could just get graphic-intensive websites to load consistently on my 3G smart phone and am skeptical that we’re ready for a video chat to review ultrasound results with my kidney specialist yet!). Some tell me it is about anything healthcare, or anything “wireless,” done outside of an institutional environment, and still others say it is about any “gadget” (a terrible word!) that enables consumer health empowerment.
As a supposed expert in the field (at least by measure of the number of invitations I have to speak at these forums), I’m left having no clue what this “movement” (I’ve heard it called) is really supposed to be about. If “mHealth” is all of these things and more….if “mHealth” is everything…then it is nothing. The phrase has become so slippery, so ubiquitous as to become almost useless. We must be more careful in defining and aligning what we’re talking about, and I encourage these various workshops and organizers to spend some time clarifying and specifying what’s at play here.
2) Managing expectations: As we’re reaching a fevered pitch about mHealth, I fear that no technology solution could ever achieve the enormous claims and utopian breakthroughs so many are promising. We’re doing a terrible job with expectations management because consumers and clinicians are all likely to believe that these solutions and services are widely proven, affordable, and available. This is just not the case yet. The potential is there, but not yet the products and price points.
I once begged a prominent engineering school in the United States not to do one of their legendary “fashion shows” of new concepts for telehealth and wearable health technologies. I was concerned that they would do a Flash-in-the-pan demo of cool concepts but wouldn’t stay around long enough to do the long, hard, expensive work of building real solutions with a real evidence-base. Even worse, the painstakingly slow progress made over the years to convince already-skeptical physicians and nurses about the value of telehealth technologies could come to a crashing halt if they were exposed to hype-filled demos without hard-found diligence.
So, too, there is much risk in trumpeting the power of mHealth prematurely. It’s easy and quick to put up a slick demo. It’s hard and time-consuming to do a clinical trial, or a complete redesign of a care model that integrates mHealth data into meaningful medical practice, or a longitudinal ROI or behavior change study. We can’t let mHealth technologies become silicon-and-software “supplements” that drive consumer fads and fraudulent claims like so many so-called “diet pills.” No, not every mHealth application or service requires a randomized, clinical trial to prove its worth, but some kind of evidence is warranted.
For that matter, there are still regulatory issues abounding around software, mobile devices, decision support tools, and online forums that provide medical protocols, care plans, or advice. I’ve seen no end of small and large companies making incredibly un-validated medical claims on keynote stages, and the jury is still out on how, when, and to what degree the FDA and other regulatory bodies are going to weigh in on these new capabilities. Similarly, there are HIPAA and privacy policies to be negotiated and navigated with this convergence of consumer electronics and medical technologies. And it’s hard to even ascertain how many consumers are meaningfully incorporating mHealth technologies into their lives today. The oft-cited “explosion” of I-phone apps involving health, for example, is perhaps an indicator of consumer (or developer) interest, but how many of these programs are downloaded more than once? Are actually paid for? Or used in a sustained way by consumers a month after “first contact”?
So again, I hope the mHealth proponents and prognosticators (and I count myself as one of those!) can better manage expectations, tease out these thorny issues, and under-promise while over-delivering what mHealth has to offer.
3) Moving Beyond mHealth Biases: I recently had a revealing exchange with the chair of a mHealth conference who had invited me to keynote. I dutifully sent in my proposed abstract. Some weeks later, she called to tell me that my topic (showing an in-home independent living prototype) wasn’t really a good fit for their event. I asked what was wrong. First she told me that my talk didn’t feature a cell phone–this, after I had been told repeatedly that “mHealth” is an all-inclusive term for anything that consumers use outside of a clinic environment. Then she told me the sensors in my demo (simple accelerometers to detect motion changes to help prevent falls in elderly households) weren’t “novel enough” and “do you have any cooler gadgets you can bring?” And then she asked: “Do you have anything that focuses on younger populations instead of seniors?”
She had managed to include all three of the biases of the mHealth movement that concern me in one two-minute phone call: it’s supposed to be about cell phones, with cool gadgets, for young people. I know there are many out there who don’t share these biases, but that phone call, like so many other conversations I have had around mHealth recently, underscores real issues I think we need to tackle.
First, do we really understand who the users of these technologies will be and what the specific scenarios and contexts of usage are? In particular, I am concerned there is some anti-aging bias in this movement. While there is great promise for mHealth applications to drive a more prevention-oriented paradigm for younger populations worldwide, the fiscal reality is that we’re going to have an aging demographic–many of whom aren’t comfortable with or just can’t see smart phone screens–to reckon with for the next 20 years or so. The Medicare-eligible population with multiple chronic conditions are the largest cost challenge we face in healthcare–they see more than a dozen physicians, fill 50 different prescriptions annually, and account for almost 3/4th of physician visits (see Gerard Anderson’s Senate testimony). We need to make sure we are designing solutions and systems that fit well into the lifestyles and cohorts who most need them.
Second, there is a certain amount of “technology bias” here–I think we’re caught up in a bit of Apple I-mania, in particular, that focuses our attention way too much on the technology and not enough on the use cases and care models which these technologies need to enable. Our cultural obsession with the mHealth “gadget” of the moment (perpetuated in press clipping after press clipping which tries to out-shock the audience by showing what is technically possible) leaves us with a cheap, one-night stand with these technologies whereas we need a more sustained, meaningful relationship with (and through) them. Yes, I-phones, Android phones, old phones, smart phones, and new, futuristic Jetson-like phones we haven’t even imagined yet will be an increasingly important part of the healthcare landscape some day, but personal health will require many touchpoints, form factors, and connected devices (some of them may even still be wired!) to meet the diverse needs of a diverse set of consumers.
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I’m the first to admit that I have probably been too hard on mHealth and have made too many gross generalizations about the movement in this blog post. I do so decidedly, to counteract some of the hype machine and to caution us to “slow down” and not get ahead of ourselves in our claims and expectations. I do so to try to get us to focus all of this attention and investment on the care models and use cases we’re trying to enable first and foremost, with the technologies taking a distant second place.
I happened upon a great blog post from Jon Linkous, CEO of the American Telemedicine Association, that makes many of the same (and many other) points that I try to make here. Maybe Jon and I are just “old school.” (Sorry, Jon, perhaps I should just speak for myself!) Maybe some of you reading this will adopt a more conspiratorial view that I am just defending old technologies in Intel’s best interest–like the PC and home telehealth appliances. (We do sell amazing microprocessors into–and believe in–the mobile and wireless revolutions!) But it is because I so believe in the potential of mHealth solutions that I caution us to be more wary of the hype around them…so that there is real hope that they can become commonplace and affordable in all of our lives.
So true! Lots of talking, less and less understanding of the core needs. I see it as a simple hype cycles story that mHealth needs to go through.
Eric-
Thanks for these important insights. Indeed the definitions are all over the map. To me this reflects a lack of basic understanding and agreement on what we are trying to build in a future Health Care System that focuses on prevention and customized/personalized strategic health planning. Absent an agreed upon endpoint, it’s not surprising that technologic enablers are “all over the map”. One other thought – the issue of generational conflicts (technology for young vs. old) – eHealth at the very least should aim to increase efficiency and effectiveness of care. One critical element is connectivity of the multi-generational family, with learnings moving down the generational divide and caring moving up that ladder. Once again, this expectation (that technology properly and strategically applied could help advantage family human and social capital) has been poorly defined. Under these circumstances, you can’t hit the mark because no one has ever laid out the original target. That’s why I agree with you. Let’s put down the brushes for a moment and agree on the masterpiece we are attempting to paint.
Mike
Hi Eric,
Thank you so much for sharing your thoughts.
They’ve given me lots of food for thought and I’ve posted a response (that’s even longer!) over on my blog as there just isn’t space here to do it justice. Here’s the link:
http://bit.ly/dlsSoS
As always I’m interested in your thoughts and feedback.
Eric,
Since forming the Wireless Health group on LinkedIn last year I’ve also encountered the moving target definition of mHealth used by its advocates. Fortunately, wireless health, which is my focus, resists such ambiguity because “wireless”, unlike the vague term “mobile”, is simply a technical product feature that, in the context of “health”, typically refers to the gathering and transmission of health-related information via the RF spectrum. Simple!
Nonetheless, I do feel that the key value provided by wirelessly-enabled products and services used in consumer health and clinical healthcare applications is usually the mobility of people and resources.
As Darrel Drinan, founder of Corventis has pointed out on several occasions – and I paraphrase here – it makes no sense to push technology as a solution in search of a problem. In this regard we must do as you say and “focus all of this attention and investment on the care models and use cases we’re trying to enable first and foremost” and then endeavor to identify and deliver the best solutions, whatever they may be.
Paul
When you are at the crossroads of newer technology adoption and vendor enthusiasm in healthcare, it’s hard to find unanimity.
Agreed, we are in the hype cycle and this will subside leaving behind some great thoughts and lessons. For those of us who stay with it and really look at how the tech can create value, we will discover that sustainability of value will define the tech instead of short-term importance like “fun and cool for the always-on.”
Really nice piece Paul…I share your pain.
I feel your pain, and can relate– particularly relating to the conference. I publicly shared my frustrations and lack of support for the mHealth (NIH/UN) for similar reasons…. they required free products and seemed interested in the social networking and careerism, not the technology.
Unfortunately, the timing of herding was unavoidable to some degree- I had been planning out healthcare platform for years, but until we could make sense of the legislation, and then observe direction of standards determined by HHS Sec., making decisions prior to could have been catastrophic.
We’ve published a use case scenario here if interested– story telling format for challenged execs–
http://www.kyield.com/images/Kyield_Diabetes_Use_Case_Scenario.pdf
What really irritates me frankly is that in our attempt to marry our technology with logical strategic business partners– in one case a hospital chain and another a major healthcare company…. they decide they want to become software architects and vendors, to include EHRs….
What do you think the probabilities are of a health insurer approving reimbursement of their own software versus others?
What are the odds patients will trust them?
It is a zoo out there for certain. Best of luck.
To me, the crux of the ambiguity about mHealth (or M-Health as Qualcomm recently dubbed it) is the ‘M’.
No doubt the fact that apps can BE mobile doesn’t mean they are exclusively mobile or that they target populations who are all dressed up and ready to be mobile. We have a chasm of usage (http://www.ageinplacetech.com/blog/generational-mobile-access-divide) on the use of smart phones. The PERS market is still growing and most don’t even extend more than 600 feet from the home! Remote health or activity sensor monitoring price points haven’t dropped yet to consumer levels — forget the do-it-yourself wire-my-own-house crowd. And none of that has any ‘M’ in it. I hope someone will post the Gartner definition of mHealth that accompanies their assertion that we’re at the top of the hype cycle. When we talk about virtual doctors’ visits and find out that we mean they accept e-mail messages, I think the hype cycle is just getting rolling.
Laurie
Dear Eric and “mHealth” Aficionado,
Thank you so much for your commitment to imagine how the rapid spread of telecommunications infrastructure and uptake of mobile phones and mobile broadband services should impact global, national, district, community, and individual Health.
I believe “the use cases and care models which these technologies need to enable” are indeed critical. Evidence based analysis published through PubMed, Embase, Web of Science, Scopus and the Cochrane divide “mHealth” into at least five theme: 1) Treatment compliance, 2) Data collection and disease surveillance, 3) Health information systems and point‐of‐care support, 4) Health promotion and disease prevention and 5) Emergency medical response.
With that in mind, shouldn’t we avoid geeky discussions between the “wireless” vs. “m” hypes but could we care more and empathize with these populations who have hard time to get better health?
So, let’s engage into moving “mHealth” into the slope of enlightenment and get clear on the emotional & risk/benefit barriers.
RF
Eric, spot-on: when it comes to the broad brush stroke definition of mHealth, it’s a disservice to some of the very constituents who need remote health services most and use the greatest resources: people who are older and/or sicker, usually managing more than 1 chronic condition. But remote health services that target these health citizens and can move the needle just a bit on empowering individuals to care more at home will improve outcomes, reduce the strain on expensive health resources (inpatient, ERs, ICUs among them), and bend that seemingly immoveable U.S. cost curve. Your story about the mHealth conference organizer provides the perfect backdrop to your thesis. “Cool gadgets” aren’t going to solve the problem of America’s long-term deficit challenge: managing Medicare and LTC costs. Sound, evidence-based solutions, simple elegant ones, will — at least for the next decade as the cohort of Boomers enters retirement, um, like now.
Eric,
In light of the recently released reports from Deloitte and PWC, your post is prescient. As an analyst I’ve seen such confusion occur in the past, remember eProcurement?, and the mHealth rage is no different. We are only just beginning on this path and there will be many bold new ideas, loud pronouncements and some truly innovative thinking. But at the end of the day, at the end of all this current hype, what we end up with will likely be far different than what we imagine today.
This market is like a young adolescent, lots of energy, lots of spunk mixed with a certain amount of irreverence. As the market matures, so will it gain wisdom. My only hope is that it does not lose its enthusiasm as we will need these new ideas, these new care models that leverage the technologies that enable mHealth if we truly wish to see any bending of the cost curve a curve that on its current trajectory could bankrupt us all.
Definitions are important.
Way back in ’07, I did a study of “the evolving role of wireless technology” for the California HealthCare Foundation. After surveying all of the then-existing applications, I came up with a simple 2-part typology: remote monitoring applications, which are being driven by the emergence of versatile, low-cost sensors; and “patient engagement” applications whose goal is to support positive health behavior change by providing reminders or other interventions at the *right* time and place. I believe that the latter category holds great promise in a world in which millions of patients are the primary caregivers for their own chronic conditions (diabetes, hypertension, COPD, obesity, etc.)
I also concluded that many effective interventions can be delivered via one of the simplestof mobile technologies — SMS text messages — which is why I helped organize the TEXTING 4 HEALTH conference at Stanford and co-edited, with BJ Fogg, the book of the same title.
Unfortunately, because texting is so un-sexy, it gets ignored by those who are in search of the latest coolest gadget. But texting-based apps are not only relatively simple inexpensive to create, they have the advantage of being able to reach 96% of all mobile phones. and the work of researchers like Dr. Kevin Patrick at UCSD (mDiet) and Deb Levine (SexText) demonstrate how sophisticated and useful SMS apps can be.
In the medical device field, 99% of “fall prevention” devices are aimed at notifying us when a fall has already taken place. (They should be renamed to “fall notification” or “fall alert” devices.) Yet, the manufacturers of the devices proclaim great safety benefits. Perhaps because medical treatment can be applied faster, certainly not because the device prevents falls.
Instead, I agree that the research into why falls happen is the proper entry point. Apply the technology there and lets see where it take us.
As for mHealth (whatever the definition) let’s not look to consumers to ‘buy’ actual fall prevention products, because they won’t. Just like teenagers don’t modify dangerous behavior because they feel impervious, seniors refuse to believe that a fall may be in their future. For the current over 65 population, most won’t wear any ‘badge of distinction’, like a fall detection device without strict orders from a physician. No matter how cool.
Instead, once the research points us in the right direction, let’s find the right incentive. Perhaps the incentive is cost savings – for medicare, for insurers and ultimately for us regular folks. That will provide the urgency to bring this to reality for the larger population. Not the soft stuff, like better health outcomes.
Re: aging “users” of technology meant to keep the elderly out of nursing homes. Even if someone had been adept with a mobile device, fingers get rigid, eyes lose acuity, and memory gets confused. Monitoring equipment that is mostly or entirely working on its own may be ideal for the most frail, yet mostly still living at home cohort.
I-phones and their other touch screen siblings are awkward for anyone to use as a keyboard, and with sometimes balky screens/apps, they seem pretty useless for most older seniors.
Good post.
Re: technology to empower the consumer
One healthcare insurance provider has a web app to seek local hospitals with the best track record of success with a particular type of surgery, along with mortality and infection rates. Progress is being made, but we should not promise too much, too soon.
A wonderful post. I’m going to focus on your statement: “It’s hard and time-consuming to do a clinical trial, or a complete redesign of a care model that integrates mHealth data into meaningful medical practice, or a longitudinal ROI or behavior change study.”
It’s hard, yes, but we need to perform robust evaluations and provide quantitative data showing what works, what positive health impact is catalyzed by mHealth.
There will be a roundtable to jumpstart this work at the mHealth Summit in DC Nov 8 – 10.
Eric,
Some interesting observations/concerns – many shared. mHealth is, in many respects, a new frontier but I think we are yet to see to true benefit of this approach in terms of its transformational power for healthcare. Part of the issue is the variety of problems being addressed and corresponding approaches being undertaken – all of which are defined by a view of the problem that is shaped by resources, assumptions etc. One approach may view an mHealth application as one that allows a patient to consult with a doctor over a phone. Another, such as ours (www.ncsr.ie & http://www.bdi.ie), views the mobile phone as a generic diagnostic platform capable of providing quantitative, real-time actionable results. Ultimately, the scale of the problem being addressed and the degree to which the solution is successful will define the utility of the mHealth approach.