Mobile Health FA14

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The mobile Healthcare industry is anticipated to be a fast growing industry with endless possibilities. The rise of new technologies can address issues in healthcare cost, inefficiencies, and accessibility. New technologies can also aid the processes of monitoring, tracking, diagnosing, and predicting health-related information.

Contents

Background of Healthcare Issues

Cost

Healthcare is increasingly becoming a large cost for many governments around the world, many times accounting for up to 45% to 50% of government expenditure [1]. The United States annual expenditure for 2013 was $3.652 trillion and is projected to be $3.83 trillion and $4.010 trillion for 2014 and 2015 respectively [2]. The growth in health care expenditure is growing rapidly, from 75 billion in 1970, 2 trillion in 2005 and a projected 4 trillion for 2015 [3]. Since 1970, healthcare spending has grown at an average annual rate of 9.8%, or 2.5 percentage points faster than the economy as measured by the nominal gross domestic product (GDP) [3]. This growth in healthcare costs are unsustainable which is why Mobile Health can be a part of the solution.

Inefficiencies

The healthcare system also faces many inefficiencies adding to the costs of healthcare and inevitably reducing the quality of the system. In Vancouver, 12% of hospital beds are filled with patients already discharged but have no place to go home to [1]. With the hospital bed shortage that already exists in Vancouver, having discharged patients taking up beds is inefficeint given the demand for people actually needing the beds. Furthermore, many people are visiting doctors for very trivial matters that could otherwise be handled in more efficient ways. A common example of this is going to the doctor just to get a prescription refilled. Some doctors’ offices have capacities on how many patients they can see in a day, and if a portion of people are coming to get a prescription refilled, other patients with higher priority ailments may not receive timely treatment.

Access to Care

In emerging markets, one of the main problems other than cost is access to care. There are not enough brick and mortar dispensaries, primary care centers and a lack of physicians [4]. In a country such as Tanzania, there are only a couple hundred doctors for 30 million people, which allocates around 150, 000 people per doctor [4]. Furthermore, many people in emerging markets are living on the poverty line. They are making just enough money to take care of their family and have limited savings, if any at all. Many of these people cannot afford to take a day off to see a doctor because they will lose their much needed wage.


Our Population

Diabetes Projection

Currently there is a global trend of an increase in chronic disease. Chronic diseases include allergies, asthma, diabetes, heart disease, obesity and more[5]. The percentage of medicare money spent on chronic illness in the United States for 2002 was 76.3% of total healthcare spending[6]. Just the rate of growth of diabetes in the United States alone is alarming and a sign that something needs to be done. In 1992, in the United States, it was projected that 11.6 million people would have diabetes by 2030. That prediction was nearly doubled in 1998 as the estimates reached 21.7 million people with diabetes by 2025. Then in 2010 there was a projection that there would be 29 million people with diabetes by 2050. A study done in 2010 by Elbert Huang, an assistant professor of medicine at the University of Chicago said there were 23.7 million people with diabetes at the time and a projection of 44.1 million by 2034 [6]. Although these numbers are estimates, the growth of diabetes outpacing even projections is quite alarming and could keep increasing the costs placed on the healthcare system.

Furthermore, obesity is also on the rise in many countries, which is known to lead to further chronic diseases. The baby boomer population is also aging, making them more susceptible to disease. Also, since many of the baby boomers are retiring, they are not only paying fewer taxes but they are also going to be using more of the healthcare system in their senior years. Lastly, the world population is increasing as well. Combined with our environmental factors such as poor air quality, this leads to a further increase in chronic diseases like asthma. In short, there are several factors directly influencing the cost of healthcare and they appear to be getting worse as time goes on.


The Solution

Industry professionals such as Mckinsey, a global management consulting firm and PWC Research have both said there is a promising solution on the horizon [4][7]. A solution that will reduce costs for everyone involved and revolutionize the ways patients receive care. The solution is mobile health, otherwise coined as mHealth. It is commonly said that mHealth is just a way of monitoring one’s health but it goes much beyond that.

Currently, the definition of mHealth can be broken down into three main parts:

  • Delivering information to the health consume, to empower him or her to make healthier choices for themselves
  • Remotely monitoring information from the patient through a mobile device
  • Delivering information or insight to a health care practitioner at the point of care with a patient

Right now Mhealth is at its early stages of development. As time goes on and more technology becomes compatible with mHealth, the definition of this revolutionary technology may change as well.

How Is It Going To Help?

Cost Savings

The introduction of mHealth on a large scale will lower costs for everyone that is involved [7]. This includes the governments, private and public companies, insurance companies and most importantly, the people needing care. A top down estimate on a worldwide level was done, looking at the impact of the application of remote health monitoring with the current technology [4]. The estimated potential savings is $200 billion per year when monitoring for most chronic conditions only [4]. Although this number may seem low compared to just the United States expenditure, it is a starting point and can only go up from here. Right now the technology developed and available is limited, therefor limiting what functions mHealth technology can do right now. As time goes on and more technology is developed, this number is sure to increase.

Accessibility

Other than reducing costs, another goal of mHealth is to increase accessibility to healthcare. There are many people that do not have insurance or any plan that helps with their medical costs [6]. Many of these people may avoid seeking medical attention altogether because they simply cannot afford it [4]. However with mHealth, costs could be reduced or even eliminated by having access to a mobile doctor. To have a doctor, whether it is on the phone or tablet is better than having no doctor or any medical professional’s input at all. Furthermore, some people living in remote areas of developing countries cannot access medical help because there is nothing close by. Although the interaction with a doctor using mobile technology cannot be on the same level as in person, the patient and doctor can together work out if their conditions or symptoms are more serious that may need help from a doctor. This way the patient can be sure that it is worth it for them to set out to go see a physical doctor.

Improve Patient Outcomes

One of the major benefits of mHealth is patients being able to monitor themselves over a longer period of time and being able to take those results to a doctor. The doctors can analyze the results, see trends, then diagnose and give prescriptions based on more information than what the patient gives or the information they can get from a single appointment. Furthermore, data can be monitored in real time which is very beneficial for both patients and doctors [8]. For example, after a colon surgery in Stanford, the patient’s daily symptoms tracker is integrated into mobile technology which communicates actionable information to patients and healthcare providers who receive notifications, which ultimately facilitates workflow and improves health outcomes [8]. Health related apps hold tremendous potential to facilitate better integration of scientific evidence into clinical practice for the greater benefit of a patient’s health [9]. Furthermore, having your personal health information at your fingertips allows you to take greater control of your health10. A person can see the consequences of their actions and make informed decisions rather than guessing their progress or health conditions [10].


What Does It Look Like?

Currently mHealth consists of wearable technologies and electronic devices that connect to the user’s compatible mobile devices. Currently, some of the mobile health technologies are still relatively new, therefor having limited functions for the user.

Wearable Technologies

Smart Watch

Currently, a fair portion of mHealth comes from wearable health technology. However, since it is still a newer concept, wearable health technology is at a basic level of monitoring at this point. Although this technology is new, devices worn on or close to the body are expected to produce the most ground-breaking innovations [11]. Furthermore, it is also projected that by 2016, wearable wireless health devices sales will reach over 100 million devices annually equating to $2.6 billion, accounting for at least half of all wearable technology sales[11].

Smart Jacket

The most commonly known form of wearable health technology are smartwatches and wristbands. Currently they are able to monitor steps taken, calories burnt, heart rate, and blood pressure, skin temperature, and galvanic skin response [12]. A newer more revolutionary wearable product are smart textiles. The shirt has “smart sleeves” that can measure a user’s heart rate, respiration rate, and skin temperature[11]. It can also be further customized to measure skin moisture, and electrophysiological signals such as EKG, EEG, and EMG [11]. There are also wireless insoles available as well that can measure the distribution and motion parameters for patients and athletes[11]. They are currently used for patient monitoring, rehabilitation measures, and for training analysis in sports. Currently in the prototype stage, headsets are another wearable technology that will soon be available[11]. The headsets will be able to keep tabs on our heart and brain levels respectively[11].

The data collected from these wearable devices in most cases transfers automatically to the users’ mobile device via Bluetooth or wi-fi. In some cases the data is uploaded at various times and in other products such as the headset, the data is uploaded in real time. Furthermore, some devices that are not fitted with Bluetooth or wi-fi technology may need a direct connection to the device to upload the data.


Electronic Health Devices

iBGStar Blood Glucose Monitor

Electronic health devices are a little more advanced than the wearable health technologies because the underlying technologies were already developed. Electronic health devices include blood glucose monitors, heart rate (ECG) monitors, blood pressure monitors, inhalers, scales and more.

Blood Glucose Monitor

The mobile blood glucose monitors seamlessly connect to mobile devices. The monitors come with their own app that connects to the blood glucose monitors and manage the data received from it. The app keeps track of blood glucose levels, carbohydrate intake, and insulin dosage levels to manage the user’s diabetes in real time. The app also keeps track of trends in your glucose and the user can easily go to the doctor and show them the results. Lastly, some mobile blood glucose monitors offer free access to a personalized diabetes management system, which is a team of diabetes experts and a personal health coach that will give you advice based on your data [1].

Blood Pressure Monitor

Blood pressure monitors work very similar to mobile blood glucose and heart rate monitors in that you can connect the device to your phone and see your results, look up past results, note important results, send data to your doctor, gives warnings and provides insights. The blood pressure monitors also create visually dynamic results to track progress and it is smaller and more mobile than traditional blood pressure monitors [2].

Heart Rate Monitor

AliveECG Heart Rate Monitor

The most common mobile heart rate monitors attach to your phone via a specialized phone case for the users phone. Once the user opens the app provided and rests their fingers on the monitor, the app instantly records your results. If it detects atrial fibrillation, it will tell you right away. The user is also able to keep notes on the app to see what is affecting their heart health. Past ECG’s can be easily brought up and more important ones can be marked to bring them to the screen. The user’s ECG results can easily be sent to their doctor via email in a pdf format. Lastly, the user can track their prescription medications to see if their working for them or need to be changed[1].

Inhaler

mHealth inhalers are a big step above the traditional inhalers available. They wirelessly sync with the users phone using Bluetooth technology and captures data from the inhaler’s sensor whenever it is nearby. The mobile app for the inhaler allows you to view the data captured by the sensor and gives the user personalized feedback and education on ways they can improve their asthma control. The app also records the GPS location of where the inhaler was used so the user can see areas where they have historically had their symptoms show up more often [2].

Scale

One of the more new electronic mhealth devices is the scale. The wireless scale syncs with the user’s mobile device via wifi to display further results other than the weight. The app on the user’s device can show them their body fat, muscle mass, body water, bone mass, and even estimate the user’s calorie intake. Once the scale is connected to the home network, it helps create a personal weight goal, makes a timeline and helps the user track their progress. The app also keeps a history of your data which the user can share with people such as their doctor [3].


Users

General Wellness Users

These are users who are curious about their health and want to be and stay healthy. Some of these users are monitoring just for the sake of monitoring. In case they catch an irregularity in something they can visit their doctor before the problem becomes more serious. Another big part of general wellness users are people who are at risk to certain chronic diseases. For example, some people have diabetes in their family, therefor they may want to watch their blood glucose levels a little more than another person because they are more at risk.

Fitness Users

These are users who want to be fit or stay fit. This includes people who are overweight and want to lose weight, or people who are just looking to gain muscle. This also includes people who feel like they are at their ideal weight and they want to maintain that as well. They may use mhealth to track their progress towards their goals or to monitor their eating habits.

Special Users

These are users who have chronic diseases. This includes people who have allergies, asthma, diabetes, heart disease, obesity and more. For these people it is very beneficial to be using mhealth technologies to monitor their health because of the intuitiveness of it and the vast information they are provided. Furthermore, when they bring their results in to a doctor, the doctor gets a bigger picture of their health versus just a snapshot. Many of the users of this category have been advised by a doctor to monitor themselves.

Monitors

These are the people who are monitoring or looking over someone using the mhealth technology. This includes doctors, specialists, friends, and family members. If a user is not familiar with the technology, they may have a friend or family member monitor their results and data. Since it is easy to export results, this information is readily available to anyone that the user wants to release their data to.


Healthcare Communication Mediums

Physicians generally interact with patients in person, SMS, video chat, and social media. All of the communication mediums have relative benefits in certain markets. In person interactions are the preferred method of interactions by patients because they will be diagnosed more accurately. For physicians, there is a growing number adopting mHealth practices because they can see more patients and thus make more money [4]. For mHealth to be a success there must be adoption from both patients and physicians.

In-Person

In person interactions are beneficial because they can increase the accuracy of diagnoses for patient illnesses. The reason mHealth is increasing in popularity is because of the unsustainable nature of in person interactions. The two major challenges are increasing healthcare costs and limited physician availability to treat patients. The transition to mHealth potentially trades accuracy of diagnoses for decreased cost of treatment.

Benefits

In person physician-patient interactions are common in all markets but the availability of physicians for this medium is more common in developed markets. This medium provides increased accuracy when diagnosing patients because the physician has the ability to test several symptoms. The added advantage is the preventative implications of in person interacts as the physician can detect other ailments before they become serious just by doing a thorough check up.

Challenges

Although in person provides the best care for patients it is not a feasible solution due to cost and physician constraints. The increasing costs of healthcare make it unsustainable with the current system [5]. In person interactions are very expensive and quite inefficient because it seems as though physicians are not being fully utilized in some cases [6]. For example, making an appointment to refill the same prescription you have had for the past five years. Another challenge with in person interactions is the lack of physicians available to see all the necessary patients. This is a problem in developed nations like the United States and an even larger problem in emerging markets [7]. In the U.S alone there is an expected shortage of 63,000 doctors by 2015. With this in mind we need to find alternative means to leverage the doctors available. By using technology doctors can see more patients but as noted below there are trade-offs.

Video Chat

Video Chat is used in developed markets because of its convenience relative to in person physician –patient visits. This would generally be used for patients to consult on non-urgent issues without having to make the trip to see the doctor. In the U.S alone it is estimated that 7% of physicians are using this medium to treat patients [8]. For the most part this medium would be uncommon in emerging markets because of the technological knowledge needed and the high cost of hardware.

Benefits

This type of communication is cheaper for the healthcare system because physicians are able to see more patients in a shorter period of time [9]. This medium also provides quite a bit of transparency from patient to physician. For example, the physician will be able to see the ailment and hear the patient talk about what was wrong. In this case the physician cannot touch and feel the affected area.

Challenges

The increased cost of hardware for video capabilities limits the ability of video chat to adopt more patients. The unclear physician liability also poses a challenge for this medium to attract physicians. In addition, the unprotected communication channels used by video chat pose security threats to users communicating confidential information [10].

Social Media/ Blogs

Social Media and Blogs can be used for very general issues on a macro level. It is useful to communicate with the masses in the population quickly so they are aware of threats in third world countries. The problems of this medium occur when individual patients use information on the internet to self-diagnose themselves.

Benefits

This type of communication is able to reach the masses in the population very quickly which is very valuable when epidemics need to be communicated and how to prevent the diseases. This type of communication by doctors is very valuable for current illnesses across the world and what developed nations can do to prevent this from coming. Relative to how many people social media and blogs can connect to it is very cheap for the healthcare system as a whole.

Challenges

The problems of this medium occur when individual patients use information on the internet to self-diagnose themselves. Whether the information is from a physician or a regular citizen it is not advantageous to use because patients are different and there are several factors that need to be considered before a proper diagnosis can occur. In addition, the threat of improper treatment can provide more challenges from this medium. If doctors are not recommending what to use the problem could get worse or the patient may be using something too strong for their ailment.

SMS

SMS is commonly used in emerging markets because of its capabilities on all mobile devices, relatively cheap cost and ease of user adoption [11]. The challenges for SMS include unclear physician liability, limited SMS character usage and potential security flaws [12]. The usage of SMS for medical purposes should be limited to only answering basic questions. For example, a patient could require more information about a prescription they received and a doctor could answer those questions over SMS.

Benefits

This type of communication is cheaper than the other mediums listed because it relies on basic hardware [13]. SMS is compatible on all devices so it can be a communication medium of choice to make sure that the majority of the population has access to it. In addition, the benefit of SMS is that it requires very little technological knowledge to facilitate the communication which makes it easy to use.

Challenges

The unclear physician liability also proposes a challenge for this medium to attract physicians. If physicians cannot see the problem or hear the patient’s illness there could be miscommunication over SMS if the illness is too complex [14]. In the same way, limited character constraints (160 characters) posed by the basic phones can complicate the communication between patients and physicians. In addition, the unprotected communication channels used by SMS pose security threats to users communicating confidential information [15].


eHeath Challenges to Overcome

Many of challenges for further adoption of mobile health technologies are explained in the Clinical Adoption Framework[16]. Some main ones we will focus within it are the talent challenge, data challenge, and security challenge.

Clinical Adoption Framework

Talent Challenge

While there are many experts in both healthcare and technology fields, there are few individuals or even teams with sufficient depth in both fields[17]. For example, we can see a rapidly growing number of basic health attribute monitoring applications such as ECG heart rate monitors. However, due to a lack of healthcare expertise from software developers, technological advancements in mobile health monitoring is considered slow to incorporate more in depth health concerns. There is an observable trend in increased technological knowledge in healthcare professionals and this will likely foster more innovations in healthcare technologies.

Data Quality Challenge

Data Quality Dimensions

The data quality of the data collected from the patients is also a concern for healthcare practitioners. The Data Quality Dimensions on the right can help define what is good data.
Of these dimensions, the dimensions of accuracy, timeliness, and consistency are especially important for the current mobile health industry. The ideal mobile health monitoring technology will be able to provide accurate health statistics of the patient in a timely fashion. These information will then also have to be in a standard format for integration and analysis in order to return understandable insights for the users.

Data Integration Challenge

The data integration challenge involves the data cleaning and data communication between entities of the healthcare ecosystem. With different developers creating the technologies in the mobile health industry, multiple disparate databases will exist, with potential for interoperability between across devices or servers [17]. In practice, users may be on multiple platforms which can cause repetition of data which holds more potential for input errors and confusion. Therefore, standard format in healthcare information can be expected to be implemented soon to offer uniform, accessible information to stakeholders. An alternative for information gathering can be a shareable medical records, but that can impose many security issues mentioned as follows. Big data analytic would then also be required to derive useful information for differing stakeholders [17]. As monitoring devices start populating the daily lifestyle, vast amounts of health data can be available for diagnosis. Developers will have to utilize medical knowledge to gain valuable insight.

Security Challenge

Currently, information stored in our medical records include personal identification, personal medical history, prescription history, family history, and added prescription notes, images, and signed forms. Consequences of unwanted information leakage can include not only exposing personal information for malicious actions but also inconvenience factors such as changes to insurance and unwanted advertisements. To protect these information, both governing regulations and technologies are put in place.

Governing bodies currently in place

One of the most important federal laws governing confidential health information in the United States is the federal Health Insurance Portability and Accountability Act of 1996[18]. The HIPAA can be simplified down to the privacy and security rules, each respectively relating to data handling procedures and technical and organizational requirements. The HIPAA was further updated in 2009 with the “HITECH Act”.

“The Privacy Rule requires that certain entities, including health plans and healthcare providers who transmit health information, ensure the confidentiality of certain health-related information. These entities cannot disclose health information except for purposes of treatment, payment for treatment, and health care operations without obtaining authorization from the patient or participant. The Privacy Rule also affords patients and participants certain rights with respect to their data, such as the right to access and suggest changes to records of their health information and to be informed of certain disclosures of their health information to others. The covered entity must also comply with certain administrative requirements, such as providing notices to patients and participants about how the entity handles their health information.”
“The Security Rule provides certain technical and organizational requirements so that covered entities “[e]nsure the confidentiality, integrity and availability”36 of health information. The Security Rule outlines various obligations to ensure this goal, including appointing and training certain employees regarding security, establishing certain plans to identify and respond to risks such as interference with system operations and unauthorized access, use, disclosure or modification or data, and establishing procedures to ensure that only authorized individuals have access to health information.”

In 2009, the “HITECH Act” revised the Privacy Rule and the Security Rule by expanding the entities covered by HIPAA to include Health Information Organizations, entities that provide data transmission services for health information, and personal health record vendors[18]. In addition, the new act also imposes the HIPAA compliance requirements to the health tech providers and their associative subcontractors.

Technology-aided Security

Levels of Mobile Security

Security measures are put in place in accordance to the security rule. However, in the example of mobile phones, there needs to be security at the levels of the application, the mobile operating software, the hardware device, the wireless network and the wireless carrier, and not to mention the servers that transmit, process and store the data and the security practices of the mobile phone users themselves. The following table will include examples of technologies and practice commonly used to tackle security issues.


Security Level Common Issues Safe Practice
Daily usage Password loss * Regularly change password
* Do not disclose personal information online
Application/software Malware, spyware, security loopholes in app development * Use trusted sources of software and applications
* Update firewalls and access controls at OS level
* Limit access to other functions of the device
Device/hardware Theft (Device with stored information) * Mindful practice of device usage
* Encryption and password protection
Wireless network Hackers within wireless network * Use trusted networks
* Use antivirus
Servers Hackers may breach server security * Use products of trusted companies
* Continually upgrade security protocols


FDA Regulations

The FDA is currently taking a risk based approach to regulating mobile health applications and apps that are more involved in the healthcare process must follow regulations[19]. Some such applications:

  • are intended to be used as an accessory to a regulated medical device, or
  • transform a mobile platform into a regulated medical device.

However, a majority of current mobile medical apps pose minimal risk so the FDA will only exercise enforcement discretion. Examples of functions for these apps include:

  • Help patients/users self-manage their disease or condition without providing specific treatment suggestions;
  • Provide patients with simple tools to organize and track their health information;
  • Provide easy access to information related to health conditions or treatments;
  • Help patients document, show or communicate potential medical conditions to health care providers;
  • Automate simple tasks for health care providers; or
  • Enable patients or providers to interact with Personal Health Records (PHR) or Electronic Health Record (EHR) systems.


Future of mHealth

In the foreseeable future, we can expect a more common usage of wearable devices to create connected lifestyle that helps reduce healthcare costs and improve timeliness of treatment. One contributing factor is shown by the Moore’s Law where the computing power to size ratio of the upcoming new wearable devices will be increasing at a rapid pace. It implies the devices will be smaller and capable of collecting and analysing more data in real time. Combining this mobile computing power with cloud-based technologies that allows for real time storing and tracking of data to be viewed by healthcare professionals, the users of these mobile health technologies will benefit from early detection of abnormalities and professional medical assistance at any location. Samsung also share a similar vision and is pursuing it with their visioned product, Simband[20].

Simband

In a distant future, we also have a daring vision where technological advancements allow for self diagnosis and treatment opportunities as illustrated in the popular sci-fi movies, Elysium (2013) and Big Hero 6 (2014). Both of which include scanning patients and relating to medical databases for diagnosis and treatment options.


References

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