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.
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