Exploring the mHealth Application Clusters 

What are new communication patterns in healthcare?

The notion that doctors and patients only communicate when the patient visits the doctor is dying. In our society at large, communication between businesses and customers has changed drastically: How often do you speak with your banker? How often do you discuss your next flight with a travel agent? Communication patterns between patients and clinicians are poised to change, as is communication among clinicians and with other professionals such as pharmacists and health insurers.

mHealth Application Cluster 1: Patient Communication

Communication Between Providers and Patients

Increased communication between providers and patients means that they supplement or replace in-person visits with communications by voice, email, texting, and social networking. There are also some early attempts at providing direct online care.

Providers to Patients

A principle of healthcare in the 21st century is to “stay in touch”. This may mean a simple ‘canned’ text message “How r u?” or other communication means to ensure the patient is adequately participating in the care process and that the patient and provider are connected. A wide range of stand-alone or integrated apps are available to remind patients to take their medication, of upcoming appointments, or of pending procedures or tests that their care requires. Examples of new communication software:

• Texting management systems help a provider to manage text broadcasting to patients

• Identification systems allow a provider to automatically identify a patient through the phone (also called “remember me” programs)

• Automatic email to text transcription systems allow for better management of voice mail messages as the clinician is not interrupted by a phone call but can read the transcribed voice message at her convenience

Patients

Consumers/patients benefit from communicating more regularly with their healthcare professionals than through infrequent office visits. This requires a change in habits. For instance, instead of making another appointment to address new symptoms, a patient may send an email to the clinician explaining why she would like to see the physician. The clinician, after putting the complaint into perspective, given the patient’s health history, might recommend an appointment or encourage the patient to have relevant tests done before determining the need to have an office visit.

For improved healthcare, the occasional short visit must be replaced through regular monitoring of one’s health and sharing such information ad hoc or at specified intervals with the healthcare provider. The potentially emotionally laden encounter should be accompanied by the rich communication pattern of events that may have arisen and subsided, e.g., pain may have increased or decreased after specific events or at specific hours. Called Observations of Daily Living (ODLs), these communication patterns require new systems and behavioral changes for providers, consumers, and patients.

For patients, this means taking a greater interest in one’s health status and care, making an effort to manage one’s health data, collecting and monitoring vital data, and sharing relevant data on a regular basis with the provider.

Almost 1,000 apps are available for patients on the iPhone and other smart phones. Examples include

• Personal health record on the phone

• Healthy lifestyle suggestions

• Health activity programs monitored by “activity directors”

• Medication adherence and selection programs

• Physician selection

• Second opinions

• Monitors of vitals

• Health/disease monitoring and management (including home monitoring)

Seniors

Some seniors are not interested in or resistant to using mobile phones. They report problems with the small keys, the hard-to-read screens, and the technology in general. Healthcare providers should be encouraged to recommend senior-friendly devices, such as the Jitterbug or simplified email systems and other user-friendly networks and devices. Apps for seniors include:

• Home monitoring

• Emergency communication

• Activity sensors

• Medication reminders

• Safety ‘fencing’

• Monitoring of vitals

The Texting Generation: From Children to Age 40+

Until recently, there was very little text messaging communication between patients and providers. Yet, providers need to prepare for communication via this very popular communication method. Some providers have experimented with sending administrative messages to their patient population.

See this interesting article: “Texting as a Health Tool for Teenagers,” in the New York Times, November 5, 2009.

Uses of text messaging include:

• Appointment reminders

• General patient communication

• Administrative communication

Between Patients and Payers

A priority in our healthcare system is the introduction of real-time financial transactions, which will allow online or real-time adjudication of claims. The goal is to send all claims electronically (not in EDI format) and to communicate between providers and payers without paper. At the same time, patients are seeking a more open financial healthcare system. They want to be better informed about eligibility and costs both in advance and following services. Here are some examples

• Providers submitting claims to payers, allowing online adjudication of claims while patients are still at the provider’s office

• Patients being able to determine alternative services and their costs during an encounter

• Patients accessing a second opinion via the Internet on their mobile phone while being in the waiting room or with the provider

Communication Management

These new communication patterns for patients, whether with mobile phones or ordinary land lines, whether through voice, texting, secure email, or social networks pose a challenge to health information management professionals and others faced with the transition to mHealth. First, one must select a clinical grade email system that is easy to use and guarantees the security features needed for healthcare applications.

Another problem is that healthcare professionals are concerned about an information overflow once patients send them many emails and/or text messages in addition to voice calls and messages. Here communication management systems are needed that manage such information flow in a way that the new system is not an additional burden to the clinician.

Examples are:

• Systems that transcribe voice messages and allow a clinician to review such messages much more quickly than by listening to the voice message itself

• Support staff to sort incoming messages according to priority and workflow for higher efficiency

• Identification systems that are directly linked to specific mobile phones. (If a mother acts as the ‘family health manager”, policies and agreements must be signed that determine which health information may be communicated through her and which may not.

Privacy

New requirements for privacy and confidentiality must be implemented. Included in such efforts is the creation of new policies, including a strict “no unauthorized pictures” policy. Security officers, IT specialists, and health information management professionals must develop a whole new set of rules, guidelines, education programs, monitoring systems, and sanctions.

New Patient Communication Patterns Will Evolve

The communication patterns described above will continue to evolve as patients and providers increasingly adopt them. While described here as cluster #1, it is important to note that they link and/or overlap with the other 11 application clusters.

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mHealth Application Cluster 2: Resources and Applications

mHealth Initiative is developing an overview of the exploding field of clinical and consumer healthcare applications available on mobile devices (mDevices). Of the wide-ranging 100,000 iPhone apps, approximately 2000 are healthcare related. Close to an additional 3000 healthcare applications are available for other types of smartphones. Some of these 5000 healthcare apps have very widespread adoption. Epocrates, for example, reports more than 100,000 users just on the iPhone and, when taking into account access through other devices, a worldwide subscriber base of 750,000 (http://www.epocrates.com/company/news/072209.html). Clearly, mHealth is advancing healthcare toward the dream of information-guided care that some visionaries expected from electronic medical records 20 years ago. 

What are the best healthcare applications? One has to first consider the operating systems (OS). The major ones are Windows Mobile, BREW, Palm, RIM, Symbian, Apple, and Google.  Generally, all operating systems facilitate new communication patterns, which is at the heart of mHealth. Furthermore, smartphones allow Internet access through their browsers. When considering apps, however, one must keep in mind that while some developers have created apps that can accommodate most or all of these operating systems, most application developers are betting on one or another OS.  As 2009 nears its end, Apple’s iPhone is gaining market share (but has still less than 15%), and Symbian (and Nokia and its partners) seem to be losing ground while still having a much larger market share.  But wait. This can change in 2010. The competitive race for apps and for ease of use is on. 

Preliminary Overview

Most of the current app developments are directed toward clinicians.  They include:

• Drug databases
• Medical calculators
• Reference programs
• Decision support for both physicians and nurses
• Tracking (weight, blood pressure, etc.)
• Patient history accessing, managing, and documenting
• Communication managers
• Payer tools (coding, eligibility determination, etc.)
  
  

Among these, references and decision support dominate the field of clinical apps, with 3,700 applications identified among the following devices, as indicated below (recognizing that we are not including the more than 2000 other devices we estimate are available).

Estimated clinical and consumer health applications on selected mDevices (compiled by mHealth Initiative)

	RIM		Microsoft Windows 6.1			Apple	Symbian	Palm	Total
Phones	Blackberry Curve 8330	Blackberry Storm 9500	HTC Touch HD	HTC Pro	Samsung Code	iPhone	Sony Ericsson 350
Estimated clinical applications	400	375	335	370	150	1,600	150	NK	Approx. 3,725
Estimated consumer health apps	Not known (NK)	NK	NK	NK	NK	970	NK	NK	Approx. 1,000

Marketing

To get a sense of the wide range of healthcare apps, one has to go to an application store. App stores are not a completely new phenomenon. For the BREW, Symbian, Windows Mobile and Palm operating systems, such stores have been available since 2001 or 2002. It took Symbian six years to reach 10,000 applications, while it took Apple only 6 months. In the first year of operation, Apple’s app store brought in 65,000+ apps, 100,000 registered developers, 1.5 billion application downloads, and availability to consumers across 77 countries through 40 million iPhone and iPod Touch devices sold. (Andreas Constantinou at Open Mobile Blog VisionMobile)

Approaching the end of 2009, Apple’s app store has some 100,000 applications, Google’s Android is reported to have 10,000, and Nokia’s Ovi Store has 4,000 (VisionMobile Research).  Among general application stores across these platforms, Handango reportedly offers 140,000 apps, while Getjar offers some 50,000 apps. Because of the size of the business (Apple’s 2009 revenue from the sale of apps is estimated at $700 million), there are many new start-up app stores. They include new sites from operators/carriers, OEMs (original equipment manufacturer), platform and chipset vendors (including Intel). The industry clearly sees the future in millions of specialized mobile phone applications that will guide people in many daily functions, as well as computing and decision making applications.

Selected Future Application Stores

Operators/carriers: Vodafone, Orange, Telefonica/O2, TIM, T-Mobile, Verizon, Sprint, China Telecom, China Mobile, SK Telecom, KT.
Handset OEMs: Apple, Nokia, Sony Ericsson, Samsung, LG, RIM, Palm
Platform vendors: Android, Windows Mobile, S60 (Ovi Store)
Chipset vendors: Qualcomm, Intel, Mediatek
Source: A. Constantinou, Vision Mobile

What Does this Mean for Healthcare?

Thousands of apps on mobile devices will be used by people in their daily and professional lives. There are already almost a thousand applications for consumers designed to help them to improve their life styles, manage their health issues, and communicate with health professionals. mHealth Initiative’s vision is that there will be many more apps for people and patients, and their adoption will stimulate consumers toward participatory health. At the same time, an equal or perhaps more important factor will be the transition of the scientific body of medicine from being stored in clinicians’ heads and medical texts to being accessible through numerous decision-making apps that will help the healthcare professional deliver care more efficiently and with improved outcomes. The industry is in the midst of re-organizing medical information and making it available at the point of care through mDevices. However, documenting patient care on mDevices will take some time because it will require easier, more cost-effective documentation methods, speech recognition, structured purpose communication (SPC), and other developments to converge. 

In the meantime, apps are being launched on a daily basis. Some of the developers report that healthcare applications are in such high demand that they may result in a real healthcare revolution. But the unchecked growth of clinical apps will not continue forever. The Food and Drug Administration (FDA) has shown an interest in mobile devices for some time, but the shear number of apps being introduced would overwhelm the FDA. Since it is the medical content and health implications that are causing greatest concern, perhaps medical schools and medical professional organizations such as the AMA and AAFP will step in to provide either certification or a sales platform, or both. Our research team will continue to analyze the offerings and post information on our Observatory. 

Watch for postings about the remaining clusters.

Resources

Know of sources we should know about as we explore the world of mHealth applications? Send us an email: .

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