How mHealth Will Change Healthcare

January 28, 2011

In a recent post, I noted the role that I believe mobile health applications (mHealth) could impact healthcare in developing nations. In the last few days, I have come across other articles that reinforce the value of mHealth approaches to health promotion and for providing care over distances.

First, Kent Bottles (@KentBottles on Twitter) has written an article that emphasizes his belief that mHealth applications will be a major direction for healthcare development in the near future. He makes a compelling case that the availability, flexibility and mobility inherent in mHealth approaches to care will be valuable tools to make health care more accessible.

Second, a recent series of articles in Perspectives in Health Information Management evaluates the role of mHealth in improving the health of minority communities in the United States. I only just found the articles and have not yet read them fully, but the big picture summarized here and here is that access to mHealth tools helps overcome barriers to health care that minority communities face, and represent a new approach to addressing health care inequalities. I suspect that much more discussion (and more posts) will be forthcoming on these topics.

It appears that mHealth and social media approaches will allow nations—both our own, and developing nations overseas—to expand healthcare services to marginalized or underserved communities.


Health Care? Yep, There Ought To Be An App For That

January 26, 2011

With Apple already having achieved its 10 billionth iPhone  app download, there is sufficient reason to think the age of the app has reached critical mass. What about health care-oriented apps? What can be considered “the best” from the pack? What is still missing from the app menu in medical offerings? Those questions were at the center of the Health Care and Social Media (HCSM) chat group discussion on Twitter on Jan 23rd. To see the full transcript, go to http://healthsocmed.com/2011/01/23/hcsm-january-23-2011/.  A summary of the group’s consensus is featured below, along with suggestions from my blogging mates on what more is needed on the app landscape  for patients, physicians and health care providers.

Given the patient-centered focus of HCSM chats, it came as no surprise that most members agreed that the best apps are those that affect the practical lives of patients, or as @DaphneLeigh colorfully put it, “[The app] Obviously has to be relevant and friggin’ user-friendly.” For added rigor, @MarksPhone stated, “a good app is one that aids the patient in participating in their health care effectively.”

When the HCSM group was quizzed on their recommended apps that fit that criteria, they offered the following descriptions:

For Patients/Consumers

  • apps that build in a social network (e.g. @FitBit or Zeo)
  • apps that monitor mood (e.g. Mood Journal)
  • apps that track migraine activity (e.g. iManage Migraine)
  • apps that log diet and exercise (e.g. Calorie Tracker by LIVESTRONG.COM)
  • apps that help patients find clinical trials or learn about the clinical study process (e.g. cTrust  and A Guide to Clinical Trials)

For Physicians/Health Care Providers

  • apps for special dietary needs (e.g. Is That Gluten Free? by Midlife Crisis Apps)
  • apps that help with drug guidance (e.g. Epocrates)
  • app that writes prescriptions and faxes or emails the pharmacy (e.g. RxWriter)
  • apps that convey imaging data that can be used in the office and the operating room (e.g. Osirix is an open-source digital imaging viewer; iPad viewing is made easier when transferring files into Dropbox and opening them from that app)
  • app that helps clinical sites find patients for diabetes study outreach (e.g. MyOutreach)
  • app that offers medical calculators, surgery checklists, pregnancy wheel (e.g. Calculate)
  • app that offers reviews by medical students of medical apps (e.g. iMedicalApps)

As for missing gaps in apps, the HCSM community noted several chasms across all therapeutic areas, noted below:

Wish list For Patients/Consumers

  • an app that helps the users find medical apps as a one-stop shop

@GailZahtz affirmed this by claiming  a European study found nearly all apps that patients requested are already built, but can’t be easily located. In an effort to create a public space where reviews of medical apps are offered by users, @Scrubdin has built a website to gather these opinions at Scrubdin.

However, resistance to adoption cannot entirely be attributed to difficulty in finding apps. In a study by the European Commission’s Information Society and Media, it determined that reluctance to adopt telemedicine services is based on a lack of confidence in securing private data (see Telemedicine for the benefit of Patients, Healthcare Systems and Society, June 2009, http://ec.europa.eu/information_society/activities/health/docs/policy/telemedicine/telemedecine-swp_sec-2009-943.pdf).

  • seamless integration of mobile apps into electronic medical record (EMR) and electronic health record (EHR) for improved clinical efficiency and accuracy
  • apps that tackle small steps (e.g. offering tips) before increasing complexity (e.g. logging calories into diary)
  • apps that provide reminders (e.g. physical exam alerts, lab result alerts to prompt phone calls, medication reminders)
  • apps that measure a user’s learning
  • apps that improve outcomes by taking metrics from current user data to forecast new goals

Wish List For Physicians/Health Care Providers

  • apps that assist with diagnosis and  treatment (e.g. risk assessments, reminders, recommended preventative care, apps, assessing AAP/CDC/ACIP vaccination records)
  • apps that support the new resident work rule obligations (i.e. with limited work shifts, there will many more medical professionals involved in the care of a patient, so apps that better inform and safeguard patient care are welcome)
  • apps that assist in caring for infrequently presenting patient population (e.g. occasional pediatric patient visits could be assisted with PediSTAT for weight-based medical dosing)
  • apps (for the iPhone) that can “bump” (share) information from the health provider to the patient and vice versa regarding discharge instructions, education, etc.
  • app that acts like Shazam! for pills (i.e. allows your phone to snap a photo of the medication and instantly receive information identifying it; presently the NIH is developing this)
  • app that  assists with pre-operative or procedural directions, with a checklist that once completed is sent to the doctor or hospital

In comparing the list of what is used vs. the wish list of apps-to-be, the promise of mobile apps is yet to be fully realized.  It is obvious there is a need for apps that help patients improve their health and well-being, without complicating their lives while respecting their privacy. Yep, there ought to be more apps for that.


What do Physicians Want from Social Media Involvement?

January 23, 2011

Last week’s #hcsm discussion focused on what doctors and patients would want out of social media (SM).  The following discussion was vigorous, and many different ideas were discussed.  This led me to think: If physicians could describe what they would want from SM and what they needed to make it happen, what would they ask for?  Here are some thoughts:

  1. Better patient care.  At the end of the day, this is why any of us should be in health care careers: to improve patients’ health and quality of life.  Whether SM increases patient access with their health care provider, or improves how well chronic disease are controlled, better care should be the first priority for any SM activity.  Enhanced doctor/patient communication would strengthen the therapeutic relationship, and would stand to improve patient-centered outcomes over time.
  2. Payment.  At a time when all physicians–but especially primary care physicians–feel pressed, asking them to add on more unreimbursed work is a hard sell.  Whether an independent practice or part of a larger health care system, there will need to be some return on the time invested in SM.  This could be through (a) increased referrals and a larger patient panel, (b) payment for e-visits conducted via SM (or more likely via a secure patient portal)–either direct reimbursement by insurance companies or through self-pay agreements; (c) as part of new models of care such as the patient-centered medical home (where providers are paid for care management and coordination) or concierge practices (where SM communication may be one of the offered communication options), or (d) being reimbursed by their employer/health system for their SM activities.
  3. Time.  In order to have a realistic and worthwhile presence on SM, one must have time to contribute to the communication.  For physicians, this could include having a part of their schedule (maybe 15 or 20 minutes–one patient slot) set aside to manage SM content.  I would suggest that 30 minutes or an hour would be better, as this would allow more time for physicians to actively engage with patients, or to write a thoughtful blog post.
  4. Credit.  Other than getting paid for SM work, physicians might be more likely to engage in SM if there were some way to get credit for it.  This would be especially true in the case of physicians in academic careers: if a physician manages a blog or contributes content to SM sites, it would be a step forward if this activity was considered in reviewing a faculty member’s promotion and tenure.  I would argue that simply tweeting might not be enough to count, but working on a blog (which involves more time and consideration) could be considered.
  5. More efficient work flow.  SM offers physicians numerous ways to communicate with their patients, especially if secure patient portals, SMS, and e-mail communications are included.  Standardizing these forms of communication and ensuring that they will provide necessary privacy protections would allow physicians to get work done more efficiently and allow offices to increase their productivity.
  6. Access.  Many health care systems still limit access to SM sites such as Twitter or Facebook, even though they can be used for legitimate communication.  Similar to the telephone, these sites can be used to improve patient care or to waste time.  Therefore, for physicians to have a useful presence on SM, health systems will need to allow them access to the tools they will need.
  7. Guidance.  Many docs will claim uncertainty or fear as reasons they will not engage in SM–uncertainty about how to use the tools, or fear that they might run afoul of legal or professional obligations.  Most of us already using SM have found ways to have a substantial SM presence without crossing those boundaries.  Either as individuals (or as part of a health system), experienced users should be willing and able to guide newer users in SM communication.
  8. Professionalism.  Physicians working with SM need to behave professionally, and would expect patients and colleagues to do the same.  This includes respecting individuals’ privacy (patients and peers), avoiding inappropriate pictures or comments, and always being aware of how one’s online presence can be perceived.  It also means that docs need to help mentor medical students while they are still in training.

Those are some starting points.  I have no doubt that I’m forgetting something, and that I will comeback to edit this post as time goes on. Please suggest what physicians want and/or need in order to get involved in SM in the comments below.


Social Media Could Improve Health In Developing Nations

January 23, 2011

Twice a year, I travel to the Dominican Republic as part of a medical service team.  While there, we work in a barrio called Paraiso just northwest of the capital city of Santo Domingo.  We provide medical care for urgent needs and are working to establish systems for chronic care management: many of the community’s residents have high blood pressure (often poorly-controlled), and the rates of diabetes and high cholesterol are likely significant (though harder to measure).  The residents of Paraiso–especially those in the more-marginalized community of Esfuerzo–face many obstacles to accessing health care.  The nearest hospital is about 2 miles away, a distance which might not seem like much unless you envision an 80 year-old woman with arthritis or heart trouble walking under the tropical sun, up the hill and along the rough roads to reach it.  She could hire a taxi, but this is expensive when one has no reliable income, and the cheapest taxis are motorcycle taxis (“motoconchos”) which are not the safest method of transportation.  If she makes it to the hospital, she faces a clinic that is over-crowded, under-resourced and under-staffed.  If she goes to a private clinic, she will need to travel farther and will pay more for both the office evaluation and her medications.  As a result, many patients with chronic illnesses do not access care reliably.

These chronic illnesses exist within the context of the “social determinants of health” that adversely impact health, including education, living conditions, poverty, etc.  (Read more about the social determinants of health here from the CDC, here, and here from the WHO.)  People who lack education, have uncertain employment and uncertain food security, who live in communities without safe drinking water and with endemic parasitic diseases will face greater challenges in achieving good health than would be the case if these barriers were absent.

Some solutions to this include low-tech interventions: regularly taking anti-parasitic medications to reduce the burden of disease, working to provide safe and low-cost drinking water, and helping individuals take better control of their health by providing them with personal health records that will allow more effective care coordination.  At the same time, social media (SM) could provide a higher-tech answer to meet some needs.

In the Dominican Republic, as is the case in much of the developing world, mobile phones are becoming more and more widespread.  In countries that lack the necessary infrastructure to support “land lines”, mobile telecommunication is a very effective alternative.  This article notes that nearly half of the world’s population has a mobile phone, and that nearly one-quarter of the world’s population has internet access.  Other articles suggest that mobile internet might become a primary way that people in developing countries will access the internet (here, and here).  Finally, some organizations suggest that mobile internet access could affect the underlying social determinants of health in developing countries (here, and here).

In the Dominican Republic, cell phones are widely available.  Many people purchase lower-cost phones and purchase “pay-as-you-go” phone cards instead of a month-to-month contract.  This indicates that health-related communication that is based on mobile technology could successfully reach communities that traditional models of medical care might overlook. SM (especially if you include SMS or text message alerts from SM sites) could be used to send out public health announcements, suggestions for healthy diet and exercise habits, etc.  In addition, public health authorities could receive reports of outbreaks of illnesses or health concerns from individuals via the same means of communication.  Expanding this further, individuals with mobile internet access could use SM sites such as Twitter or Facebook to interact directly with health care providers.  Patients could discuss health concerns with their health care providers, and providers could contact patients directly to actively manage acute illnesses or to monitor chronic problems (within the limits of a nation’s privacy laws).

Obviously, this is a long way from being the standard, and there are barriers that need to be addressed to make this idea successful.  High-speed wireless connections would need to become ever more widespread and robust, and internet-capable mobile phones will need to become ever more affordable.  Service plans will need to become less expensive, or the pay-as-you-go cards will need to provide enough usage for people to use mobile net services.  Privacy restrictions will need to be defined.  Health care providers and public health authorities will need to adapt to these new means of communication, and will need to re-evaluate hierarchical models of health care in which physicians are in charge and patients follow behind.  Communities will be best served by having at least a lay health promoter or community health worker who is trained in basic medical evaluation (such as taking blood pressure measurements, assessing a sick child for dehydration, etc) who can help facilitate communication between patients and health care providers.  And even if this is all in place, it may be some time before the benefits are noted–time during which costs will need to be covered.

However, envision how this could work once a system is in place: isolated communities could notify public health authorities of disease outbreaks at an early stage.  A community health worker could check patient’s blood pressures and relay them to a health care provider, who could suggest medication changes without having to be on-site.  Patients and communities can learn about low-cost interventions that could benefit their health, and can have dialogues with health care providers about how to prevent chronic illness and how lifestyle modifications (diet, exercise, etc) could improve one’s health status even if a chronic disease is already present.  There is evidence that one of the best ways to improve a family’s health is to educate the mother: SM communication could increase the access women have to information they can use to keep their family healthy.

Mobile telephone and internet technology can be joined with SM tools to allow health care to reach marginalized and distant communities, and to reduce the morbidity and mortality associated with disease.  There is much work to be done, but the stepping stones are already in place.  More-developed nations (such as the US, Canada, and Europe) could help move the process along by using similar approaches to provide care to rural communities that lack their own health care providers.  Small-scale projects have shown promise in the United States, while in India there are a number of services offering physician consultations via the internet and accessible via mobile devices.

We can make this happen, but we need to open our minds to the possibilities.


Net Neutrality: A New Social Media Divide in the Works?

January 5, 2011

Last month, the Federal Communications Commission voted 3 to 2 to adopt new rules regarding net neutrality. These rules call for greater transparency, prohibit blocking and ban “unreasonable discrimination” on wireless and fixed networks. However, there are differences set aside for wireless networks that have additional implications for people to access information—consequences that impact the ability of individuals to access health care information over the Web.

Before we get ahead of ourselves, let’s take a look at each of the new rules. As to transparency, the FCC now requires that all broadband providers  be more transparent about their services and performance. That includes being clearer on how they operate their networks, how optimal their service is (i.e. slow or fast) and offering more detail on their pricing models. This is pretty straight-forward and now offers consumers an opportunity to file a compliant with the FCC if their provider is found wanting.

On to blocking. FCC rules now bar an Internet Service Provider from blocking select applications or services on the basis of improving network performance. So while there are ultra-active users out there sucking up a lot of bandwidth, the FCC has restrained ISPs from banning system hogs. This also places a ban on ISPs from charging content providers (e.g. Hulu for streaming movies) that are increasing network traffic.  There is also no blocking of legal content or services that compete with the service providers’ own properties. However, there is an exception for mobile broadband application stores, so blocking is acceptable here. The basis for the exception is lost on me, as this is content that should similarly be protected.

In fact, given that many people who are on the lower economic ladder rely on mobile technology alone to access the Web, this new ruling disadvantages them. It should be added that FCC Commissioner Mignon Clyburn recognized this fact, but his ideas on extending the ban on blocking content on mobile phones did not win out. To be precise, according to the Pew Internet Research Center, 36% of Americans have limited access to the Internet and 13% have no broadband at home or at work. Furthermore, the Pew Research Institute determined that overall, the typical profile of a person without broadband is older (0ver age 63), has a low-income (less than $40,000/yr) and is not as educated as the general population (without a high school diploma or only a high school education). For less financially able persons, this ruling confers a second-class status when it comes to accessing content online. Given the focus of this blog with all things social media and health care, there is a concern I raise here about the ability of people to fairly access information on the Web, including health care information, in  a manner that is comparable to  fixed service recipients. This divide also impacts rural residents who are often without adequate access to broadband services to begin with.

This ruling is troublesome, but it is further worsened by the FCC’s ruling on banning  “unreasonable discrimination.” The goal is loftly, but the definition utterly lacking. So what constitutes “unreasonable discrimination”? If I am reading this correctly, ISPs can throttle the traffic on their systems if they do so impartially and across the board, so as to avoid discriminating against isolated applications. Using our prior example of a person streaming movies from Hulu, the ISP would be banned from shutting off service exclusively from this site to modulate service over its network. There is a gray area, however, as to adjusting traffic when a company pays a premium for streaming its services faster—something called paid prioritization. So, if you are a  big company like Amazon, your site can load faster than a smaller competitor’s site, as long as you pay for this premium.  Combine this possibility with the prior worry above regarding a two-tiered system and you have a new digital divide on the horizon for the user and the content-provider.

These rulings I fear do not go far enough to secure access in what is becoming a highly reliant populace on the Internet for gaining information, including health care data and resources.


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