dw2

23 February 2013

Health improvements via mobile phones: achieving scale

Filed under: Accenture, Barcelona, Cambridge, healthcare, mHealth, MWC, partners — David Wood @ 10:27 pm

How can mobile reach its potential to improve both the outcomes and the economics of global health?

MWC13_logoThat’s the headline question for the panel I’m chairing on Wednesday at the Mobile World Congress (MWC) event in Barcelona.

MWC is an annual conference that celebrates progress with mobile technology. Last year, there were over 67,000 attendees, including:

  • More than 12,000 mobile app developers
  • 3,300+ press members representing 1,500 media outlets from 92 countries
  • CEOs from more than 3,500 companies.

This year, a larger venue is being used, and the attendee numbers are expected to be even larger. Keynote speakers include the CEOs or Presidents from Vodafone, Telefonica, China Mobile, AT&T, Telecom Italia, NTT DoCoMo, Korea Telecom, Deutsch Telekom, Qualcomm, Nokia, General Motors, CNN Digital, American Heart Foundation, Bharti Enterprises, Qtel, Ericsson, Viber Media, Juniper Networks, Dropbox, Foursquare, Deezer, Mozilla, Ubuntu, Tizen, Jolla, and countless more.

And in the midst of all that, there’s a panel entitled Health: Achieving Scale through Partnerships – which, in my role as Technology Planning Lead for Accenture Mobility, I’ve been asked to chair.

MWC as a whole generates a lot of excitement about mobile technology – and about relative shifts in the competitive positions of key companies in the industry. However, it strikes me that the subject under discussion in my panel is more profound. Simply put, what we’re discussing is a matter of life and death.

Done well, mobile technology has the potential to enable the delivery of timely healthcare to people who would otherwise be at risk of death. Prompt diagnosis and prompt treatment can spell the difference between a bitterly unpleasant experience and something that is much more manageable.

But more than that: mobile technology has the potential to address very significant financial problems in the delivery of healthcare. Runaway medical bills impact individuals around the planet. According to a 2010 report by the World Health Organisation (PDF):

When people use healthcare services, they often incur high, sometimes catastrophic costs in paying for their care.

In some countries, up to 11% of the population suffers this type of  severe financial hardship each year, and up to 5% is forced into poverty. Globally, about 150  million people suffer financial catastrophe annually while 100 million are pushed below the poverty line.

It’s not just individuals who are facing ruinous costs from healthcare. A 2011 study by the World Economic Forum and Harvard University anticipates that productivity losses and medical treatment for diabetes, heart disease and other non-contagious chronic diseases will cost economies $47 trillion by 2030. In the UK, the growing cost of treating diabetes alone is said to be likely to “bankrupt the NHS in 20 years”. In countries around the world, surging costs of healthcare treatment are exceeding the growth rates of the national economies.

In principle, mobile technology has the potential to reduce these trends in a number of ways:

  • By enabling more cost-effective treatments, that are less time-consuming and less personally intrusive
  • By enabling earlier detection of medical issues: prevention can be much cheaper than cure!
  • By monitoring compliance with treatment regimes
  • By improving real-time communications within busy, geographically separated teams of clinicians
  • By reducing barriers for people to access information relevant to their health and well-being.

The Creative Destruction of MedicineHere, the key phrase is “in principle”. The potential of mobile technology to beneficially transform healthcare has long been recognised. Success stories can indeed be found. This recent NBC news video featuring physician Eric Topol contains some excellent examples of the use of smartphones in medical practice; for my review of Dr Topol’s award-winning book “The Creative Destruction of Medicine” see my previous blogpost Smartphone technology, super-convergence, and the great inflection of medicine. Nevertheless, the mobile industry is full of people who remain unsure about how quickly this potential can turn into a reality.

Indeed, I regularly encounter people in the mobile industry who have been assigned responsibility in their companies for aspects of “mHealth programmes”, or similar. The recurring refrain that I hear is as follows:

  • The technology seems to work
  • Small-scale pilot trials demonstrate encouraging results
  • But it’s hard to see how these trials can be scaled up into self-sustaining activities – activities which no longer rely on any strategic subsidies
  • Specifically, people wonder how their programmes will ever deliver meaningful commercial revenues to their companies – since, after all, these companies are driven by commercial imperatives.

In this sense, the question of scaling up mobile health programmes is a matter of commercial life-or-death for many managers within the mobile industry. Without credible plans for commercially significant revenues, these programmes may be cut back, and managers risk losing their jobs.

For all these reasons, I see the panel on Wednesday as being highly relevant. Here’s how the MWC organisers describe the panel on the event website:

There are hundreds of live and pilot mHealth deployments currently underway across many and diverse territories, but many of these projects, both commercial and pilot, will remain short term or small scale and will fold once initial funding is exhausted.

To reach scale, mHealth systems must in many cases be designed to integrate with existing health systems. This is not something the mobile industry can achieve alone, despite operators’ expertise and experience in delivering end-to-end services to their customers, and will require strong working partnerships between mobile network operators, health applications and health IT providers.

Speakers in this session will draw upon their own experience to showcase examples of mHealth projects that have gone beyond the small scale and pilot stages.

They will seek to identify best practice in making mHealth sustainable, and will discuss the progress and challenges in partnering for mHealth.

The panellists bring a wealth of different experience to these questions:

Faces

  • Pamela Goldberg is CEO of the Massachusetts Technology Collaborative (MassTech), an economic development engine charged with charged with catalyzing technology innovation throughout the Massachusetts Commonwealth. She has an extensive background in entrepreneurship, innovation and finance, and is the first woman to lead the agency in its nearly 30 year history. MassTech is currently advancing technology‐based solutions that improve the health care system, expand high‐speed Internet access, and strengthen the growth and development of the state’s technology sector.
  • Kirsten Gagnaire is the Global Partnership Director for the Mobile Alliance for Maternal Action (MAMA), where she manages a cross-sector partnership between USAID, Johnson & Johnson, the UN Foundation, the mHealth Alliance and BabyCenter. MAMA is focused on engaging an innovative global community to deliver vital health information to new and expectant mothers through mobile phones. She recently co-lead the Ashoka Global Accelerator, focused on getting mid-stage social entrepreneurs in developing countries the support & resources they need to scale their work across multiple countries and continents. These organizations are focused on using innovation and technology to address global health issues. She recently spent a year living in Ghana, where she was the Country Director for the Grameen Foundation and managed a large-scale mobile health project focused on maternal and child health across Ghana.
  • Chris Mulley is a Principal Business Consultant within the Operator Solutions department of ZTE Corporation. He is responsible for the analysis of market and business drivers that feed into the development of cost-effective end-to-end solutions, targeted at major global telecom operators, based on ZTE’s portfolio of fixed-line and wireless infrastructure equipment and ICT platforms. A key part of this role involves informing ZTE Corporation’s strategic approach to the provision of solutions that meet the objectives of the European Commission Digital Agenda for Europe policy initiative for the wide scale adoption of ICT in the provision of e-Health, e-Transport and e-Government across Europe. Chris was instrumental in the establishment of an e-Health collaboration between ZTE Corporation, the Centro Internazionale Radio Medico and Beijing People’s Hospital.
  • Tong En is Deputy General Manager of the Data Service department and Director of the R&D center at China Mobile Communications Corporation (CMCC), JiangSu Company. He has long been engaged in the research of mobile communication and IoT related technologies, and has chaired or participated more than 10 CMCC research projects. He is a multiple winner of CMCC innovation awards, and has published nearly 20 academic papers.
  • Oscar Gómez is Director of eHealth Product Marketing in Telefónica Digital, where he leads the creation and implementation of a Connected Healthcare proposition to help transform Health and Social Care systems in the light of the challenges they are facing. Oscar has global responsibility over Telefonica’s portfolio of products and solutions in the eHealth and mHealth space. Oscar holds an Executive MBA from Instituto de Empresa, a M.Sc. degree in Telecommunication Engineering from Universidad Politécnica de Madrid and a Diploma in Economics from Universidad Autónoma de Madrid. He graduated in Healthcare Management from IESE in 2012.

In case you’re interested in the topic but you’re not able to attend the event in person, you can follow the live tweet stream for this panel, by tracking the hashtag #mwc13hlt1.

Postscript

Although I passionately believe in the significance of this particular topic, I realise there will be many other announcements, debates, and analyses of deep interest happening at MWC. I’ll be keeping my own notes on what I see as the greatest “hits” and “misses” of the show. These notes will guide me as I chair a “Fiesta or Siesta” debrief session in Cambridge in several weeks time. Jointly hosted by Cambridge Wireless and Accenture, on the 12th of March, this event will take place in the Møller Centre at Churchill College, Cambridge. As the event website explains,

Whether you attended Mobile World Congress (MWC), or you didn’t, you will have formed an opinion (or read someone else’s) on the key announcements and themes of this year’s show. “MWC – Fiesta or Siesta?!” will re-create the emotion of Barcelona as we discuss the hits and misses of the 2013 Mobile World Congress, Cambridge Wireless style…

Registration for this “Fiesta or Siesta” event is now open. Knowing many of the panellists personally, I am confident in predicting that sparks will fly in this discussion, and we’ll end up collectively wiser.

30 December 2011

Factors slowing the adoption of tablet computers in hospital

Filed under: Connected Health, mHealth, security, tablets, usability — David Wood @ 12:35 pm

Tablet computers seem particularly well suited to usage by staff inside hospitals.  They’re convenient and ergonomic.  They put huge amounts of relevant information right in the hands of clinicians, as they move around wards.  Their screens allow display of complex medical graphics, which can be manipulated in real time.  Their connectivity means that anything entered into the device can (in contrast to notes made on old-world paper pads) easily be backed up, stored, and subsequently searched.

Here’s one example, taken from an account by Robert McMillan in his fascinating Wired Enterprise article “Apple’s Secret Plan to Steal Your Doctor’s Heart“:

Elliot Fishman, a professor of radiology at Johns Hopkins… is one of a growing number of doctors who look at the iPad as an indispensable assistant to his medical practice. He studies 50 to 100 CT scans per day on his tablet. Recently, he checked up on 20 patients in his Baltimore hospital while he was traveling in Las Vegas. “What this iPad does is really extend my ability to be able to consult remotely anytime, anywhere,” he says. “Anytime I’m not at the hospital, I’m looking at the iPad.”

For some doctors at Johns Hopkins, the iPad can save an hour to an hour and a half per day — time that would otherwise be spent on collecting paper printouts of medical images, or heading to computer workstations to look them up online. Many doctors say that bringing an iPad to the bedside lets them administer a far more intimate and interactive level of care than they’d previously thought possible. Even doctors who are using an iPad for the first time often become attached, Fishman says. “Their biggest fear is what if we took it away.”

However, a thoughtful review by Jenny Gold, writing in Kaiser Health News, points out that there are many factors slowing down the adoption of tablets in hospital:

iPads have been available since April 2010, but less than one percent of hospitals have fully functional tablet systems, according to Jonathan Mack, director of clinical research and development at the West Wireless Health Institute, a San Diego-based nonprofit focused on lowering the cost of health care through new technology…

UC San Diego Health System’s experience with iPads illustrates both the promise and the challenge of using tablet technology at hospitals. Doctors there have been using the iPad since it first came out, but a year and a half later, only 50 to 70 –less than 10 percent of physicians– are using them…

Here’s a list of the factors Gold notes:

  1. The most popular systems for electronic medical records (EMRs) don’t yet make apps that allow doctors to use EMRs on a tablet the way they would on a desktop or laptop. To use a mobile device effectively requires a complete redesign of the way information is presented.  For example, the EMR system used at UC San Diego is restricted to a read-only app for the iPad, meaning it can’t be used for entering all new information.  (To get around the problem, doctors can log on through another program called Citrix. But because the product is built on a Windows platform and meant for a desktop, it can be clunky on an iPad and difficult to navigate.)
  2. Spotty wireless coverage at the hospital means doctors are logged off frequently as they move about the hospital, cutting off their connection to the EMR
  3. The iPad doesn’t fit in the pocket of a standard white lab coat. Clinicians can carry it around in a messenger bag, but it’s not convenient
  4. There are also worries about the relative newness of the technology, and whether adequate vetting has taken place over patient privacy or data security.  For example, as my former Symbian colleague Tony Naggs asks, what happens if tablets are lost or stolen?
  5. Some clinicians complain that tablet computers are difficult to type on, especially if they have “fat fingers”.

Let’s take another look at each of these factors.

1. Mobile access to EMRs

Yes, there are significant issues involved:

  • The vast number of different EMRs in use.  Black Book Rankings regularly provide a comparative evaluation of different EMRs, including a survey released on 3 November 2011 that covered 422 different systems
  • Slower computing performance on tablets, whose power inevitably lags behind desktops and laptops
  • Smaller display and lack of mouse means the UI needs to be rethought.

However, as part of an important convergence of skillsets, expert mobile software developers are learning more and more about the requirements of medical systems.  So it’s only a matter of time before mobile access to EMRs improves – including write access as well as read access.

Note this will typically require changes on both the handset and the EMR backend, to support the full needs of mobile access.

2. Intermittent wireless coverage

In parallel with improvements on software, network improvements are advancing.  Next generation WiFi networks are able to sustain connections more reliably, even in the complex topography of hospitals.

Note that the costs of a possible WiFi network upgrade need to be born in mind when hospitals are considering rolling out tablet computer solutions.

3. Sizes of devices

Tablets with different screen sizes are bound to become more widely deployed.  Sticking with a small number of screen sizes (for example, just two, as in the case with iOS) has definite advantages from a programmers point of view, since fewer different screen configurations need to be tested.  But the increasing imperative to supply devices that are intermediate in size between smartphone and iPad means that at least some developers will become smarter in supporting a wider range of screen sizes.

4. Device security

Enterprise software already has a range of solutions available to manage a suite of mobile devices.  This includes mechanisms such as remote lockdown and remote wipe, in case any device becomes lost or stolen.

With sufficient forethought, these systems can even be applied in cases when visiting physicians want to bring their own, personal handheld computer with them to work in a particular hospital.  Access to the EMR of that hospital would be gated by the device first agreeing to install some device management software which monitors the device for subsequent inappropriate usage.

5. New user interaction modes

Out of all the disincentives to wider usage of tablet computers in hospitals, the usability issue may be the most significant.

Usability paradigms that make sense for devices with dedicated keyboards probably aren’t the most optimal when part of the screen has to double as a makeshift keyboard.  This can cause the kind of frustration voiced by Dr. Joshua Lee, chief medical information officer at UC San Diego (as reported by Karen Gold):

Dr Lee occasionally carries his iPad in the hospital but says it usually isn’t worth it.  The iPad is difficult to type on, he complains, and his “fat fingers” struggle to navigate the screen. He finds the desktop or laptop computers in the hospital far more convenient. “Are you ever more than four feet away from a computer in the hospital? Nope,” he says. “So how is the tablet useful?”

But that four feet gap (and it’s probably frequently larger than that) can make all the difference to the spontaneity of an interaction.  In any case, there are many drawbacks to using a standard PC interface in a busy clinical setting.  Robert McMillan explains:

Canada’s Ottawa Hospital uses close to 3,000 iPads, and they’re popping up everywhere — in the lab coats of attending physicians, residents, and pharmacists. For hospital CIO Dale Potter, the iPad gave him a way out of a doomed “computer physician order entry” project that was being rolled out hospital-wide when he started working there in 2009.

It sounds complicated, but computerized physician order entry really means something simple: replacing the clipboards at the foot of patient’s beds with a computer, so that doctors can order tests, prescribe drugs, and check medical records using a computer rather than pen and paper. In theory, it’s a great idea, but in practice, many of these projects have failed, in part because of the clunky and impersonal PC interfaces: Who really wants to sit down and start clicking and clacking on a PC, moving a mouse while visiting a patient?

Wise use of usability experience design skills is likely to result in some very different interaction styles, in such settings, in the not-too-distant future.

Aside: if even orang utans find ways to enjoy interacting with iPads, there are surely ways to design UIs that suit busy, clumsy-fingered medical staff.

6. Process transformation

That leads to one further thought.  The biggest gains from tablet computers in hospitals probably won’t come from merely enabling clinicians to follow the same processes as before, only faster and more reliably (important though these improvements are).  More likely, the handy availability of tablets will enable clinicians to devise brand new processes – processes that were previously unthinkable.

As with all process change, there will be cultural mindset issues to address, in addition to ensuring the technology is fit for purpose.  No doubt there will be some initial resistance to new ways of doing things.  But in time, with the benefit of positive change management, good new habits will catch on.

29 December 2011

From hospital care to home care – the promise of Connected Health

Filed under: challenge, Connected Health, converged medicine, healthcare, mHealth, usability — David Wood @ 12:01 pm
  • At least one in four hospital patients would be better off being treated by NHS staff at home

That claim is reported on today’s BBC news website.  The article addresses an issue that is important from several viewpoints: social, financial, and personal:

NHS Confederation: Hospital-based care ‘must change’

The NHS in England must end the “hospital-or-bust” attitude to medical care, says the body representing health service trusts.

At least one in four patients would be better off being treated by NHS staff at home, figures suggest.

2012 will be a key year for the NHS as it tries to make £20bn in efficiency savings by 2015, according to the head of the NHS Confederation, Mike Farrar.

Ministers say modernising the NHS will safeguard its future.

Mr Farrar said: “Hospitals play a vital role but we do rely on them for some services which could be provided elsewhere.

“We should be concentrating on reducing hospital stays where this is right for patients, shifting resources into community services, raising standards of general practice, and promoting early intervention and self-care.

“There is a value-for-money argument for doing this, but it is not just about money and the public need to be told that – this is about building an NHS for the future.”

Mr Farrar said the required changes included treating frail people in their homes, and minimising hospital stays wherever possible.

Politicians and NHS leaders must show the public how these changes could improve care, rather than focusing on fears over the closure of hospital services, he added.

“Many of our hospitals know that the patients that they are treating in their beds on any given day could be treated better – with better outcomes for them and their families – if they were treated outside of hospitals in community or primary care,” he told BBC Radio 4’s Today programme.

Mr Farrar told Today that people had become used to “the hospital being a place of default” and that primary and community healthcare services had sometimes been under-funded.

But he said even where clinicians knew that better care could be provided outside of hospitals, and politicians accepted this privately, the public debate had not helped individuals understand that…

Some of the replies posted online are sceptical:

As a medical doctor based in hospitals, I believe this will not work logistically. Patients are sent to hospitals as they don’t get the specialist care in the community as the skills/services are inadequate/not in place. Patient attitudes must change as many come to a+e against GP advice as they don’t have confidence in community care…

As long as the selfish British public can’t be bothered looking after their own relatives and see hospitals as convenient granny-dumping centres, there is absolutely no way this would work.

There can not be a perfect solution. Not every family can care for a sick person full time, often due to them working. Hospital care may not be a perfect, yet in some cases it does free relatives to be able to work.  Outsourcing care too has a major downside, my wife has done that for years. 15 mins twice a day, can hardly be called acceptable if you apply some form of dignity to the patient.

I saw too many patients I nursed(often elderly or with pre-existing health conditions) kept in hospital too long because no one to care for them at home/wider community. This wasn’t great for them but also blocked an acute bed for someone else. In recent years the pendulum’s swung too far the other way: too many patients discharged without adequate support…

In summary: care in the community would be better in many, many cases, but it’s demanding and challenging:

  • There are social challenges: relatives struggle to put their own lives and careers on hold, to act as caregivers.
  • There are financial challenges: funding for medicine is often preferentially directed to large, centralised hospitals.
  • There are skills challenges: observation of complicated chronic health conditions is more easily carried out in the proximity of specialists.

However, the movement “from hospital care to home care” continues to gather steam – for good reason.  This was a major theme of the mHealth Summit I attended earlier this month in Washington DC.  I was particularly struck by a vision articulated by Rick Cnossen, director of worldwide health information technology at Intel:

In the next 10 years 50% of health care could be provided through the “brickless clinic,” be it the home, community, workplace or even car

As reported in the summary article by Kate Ackerman, “mHealth: Closing the Gap Between Promise and Adoption“:

Cnossen said the technology — such as mobile tools, telehealth, personal health records and social networking — already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

Fellow speaker Hamadoun Toure, secretary general of the International Telecommunication Union took up the same theme:

Mobile phones will increase personal access to health information, mHealth and broadband technology will improve data collection and disease surveillance, patient monitoring will improve and become more prevalent, and remote consulting and diagnosis will be enhanced, thanks to low-cost devices.

“In the near future, more people will access the Internet through mobile devices than through fixed devices,” Toure said. “We are witnessing the fastest change in human history, and I believe (we have) a great opportunity for social development.”

Connected health technology enables better remote monitoring of personal medical data, earlier warnings of potential relapses, remote diagnostics, quicker access to technical information, better compliance with prescription regimes, and much, much more.

But Kate Ackerman raises the question,

So if the technology already exists and leaders from both the public and private sectors see the need, why has progress in mobile health been slow?

It’s an important question.  Intel’s Rick Cnossen gives his answer, as follows:

“The challenge is not a technology problem, it’s a business and a workflow problem.”

Cnossen said, “At the end of the day, mHealth is not about smartphones, gadgets or even apps. It’s about holistically driving transformation,” adding, “mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors…”

He said health care clinicians can be resistant to change, adding, “We need to introduce technology into the way to do their business, not the other way around.”

Cnossen also said that payment reform is essential for “mHealth to survive and thrive.” He said, “We should not be fighting for reimbursement codes for each health device and app. That is ultimately a losing proposition. Instead, we must fight for payment reform to pay for value over volume, regardless of whether the care was provided in a bricks and mortar facility or was it at the home or virtually through electronic means.”

Personally, I would put the emphasis differently:

The challenge is not just a technology problem, it’s also a business and a workflow problem

Moreover, as the technology keeps on improving, it can often diminish the arguments that are raised against its adoption.  Improvements in quality, reliability, miniaturisation, and performance all make a difference.  Improvements in usability may make the biggest difference of all, as people find the experience in using the new technology to be increasingly reassuring.

I’ll finish by noting an excerpt from the keynote at the same conference by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services:

This is an incredible time to be having this conversation. When we talk about mobile health, we are talking about taking the biggest technology breakthrough of our time and using it to take on one of the greatest … challenges of our time. And while we have a way to go, we can already imagine a remarkable future in which control over your health is always within hand’s reach…

This future is not here yet, but it is within sight. And I look forward to working with you to achieve it.

Create a free website or blog at WordPress.com.