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mHealth: Innovative collaboration between physicians, patients and technologists
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Wireless technology is transforming the way people communicate as quickly as a mutating virus, and the medical community is not immune. In June 2011, there were more wireless devices in the United States than people, and more than 73% of physicians owned a smartphone — a 22% increase from 2008. This proportion is expected to reach 81% in 2012, according to estimates from the Manhattan Research Group.
“Pre-2005, there were very few smartphones. Now, we see practically ubiquitous adoption of what is essentially a mobile computer that is unbelievably versatile in terms of memory, wireless Internet access, high-resolution color screens and camera capabilities,” Orrin Franko, MD, the lead application (app) editor for the newly launched peer-reviewed Journal of Mobile Technology in Medicine, said in an interview. “It basically has every tool you can imagine and fits in your pocket.”
Since Apple launched the iPhone in 2007 and the iPad in 2010, smartphone and tablet prices have steadily decreased, with alternative manufacturers emerging and more mobile carriers offering cheaper data plans to support the devices. This is making digital technology more accessible for everyone. Once considered specialist items, smartphones and tablets are now becoming essential tools for many health care providers.
Paul A. Volberding, MD, director of the AIDS Research Institute at the University of California, San Francisco (UCSF), said he stays up-to-date with the latest research in his field accessing journal articles on his iPad at breakfast.
“The way journals are packaging their information in mobile apps for the iPhone and iPad is remarkable. You get instantaneous access to the article you’re interested in, plus any background information through clickable hyperlinked references,” Volberding said. “That’s a great way to start the day.”
This ease of access, along with the tablet computer’s unprecedented versatility, assures that smartphones and tablets are not likely to be left behind on the kitchen table like their print counterparts.
Volberding said he likes to keep his iPad with him when he works with trainees at UCSF, in case a question comes up that he cannot immediately answer. “There is no second guessing. I can say: ‘I don’t know the answer, but let’s find out.’”
He also sees enormous potential for mobile health (mHealth) telemedicine opportunities. Volberding said videoconferencing is becoming a major component in the Veterans Affairs Medical Center health care system.
“We have clinics in the community that are far away from the main medical center. So if there is a health care provider and a patient at one site and experts back at the main site, we use videoconferencing to link the two sites and improve communications and patient care,” he said.
UCSF is not the only medical system using videoconferencing. The University of Arizona uses Skype to offer face-to-face medical consultations to the large proportion of Native American patients who span the state, without requiring them to cross long distances.
Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS, an infectious diseases pharmacist, associate director for clinical pharmacy services at the University of Rochester Medical Center in New York, said mHealth makes once time-consuming tasks more efficient, particularly communicating medication reconciliation issues with patients and other health care providers.
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Dodds Ashley uses the free mobile app MyMedSchedule from MedActionPlan.com, an app designed to help patients remember how to take their medication. When interviewing patients, she uses her iPad to input any information from their medication list into the program, including the medication’s purpose, the appropriate dose and when it should be taken. She then prints a copy of the patient’s medication schedule directly from the tablet to the printer on the hospital floor, and emails a copy to the patient and the patient’s primary care physician or infectious diseases specialist if desired.
“We are able to use mHealth right at the bedside — that’s a huge step forward for us. We can also retrieve this information later and share it with our colleagues,” Dodds Ashley said in an interview.
She also finds Lexicomp’s Lexi-Drugs app useful for looking up drug information on the go. Lexicomp offers a suite of mobile drug applications for the iPhone, iPad and iPod touch that range in price from $75 to $285. (Demo video for Lexi-Drugs app available to embed in the online article: www.lexi.com/individuals/iphone/)
Other apps Dodds Ashley uses include Micromedex’s Drug Interaction app, priced at $9.99 for both Apple and Android devices, and free apps from major infectious diseases organizations to help stay organized with information and scheduling at medical conferences.
Another real-time source for drug information is the social media website Twitter. Dodds Ashley follows the FDA (@FDArecalls) to stay up-to-date with drug recalls and shortages, because in her experience, information reaches the “Twittersphere” faster than traditional email notifications. On two separate occasions, Dodds Ashley became aware of recalls for anti-infectives on her Twitter feed when traveling.
“Once a recall hits for one manufacturer, the supply for similar medications from other manufacturers runs out fast,” Dodds Ashley said. “When I saw the Twitter notifications, I was immediately able to call my purchaser and have her order replacement medications 18 hours before the recall announcement came through in my email.”
Public health outreach for chronic conditions
Although the technological capabilities of mHealth are impressive, the human component remains essential to the success of any mHealth program or intervention.
Lygeia Ricciardi, EdM, senior adviser for consumer e-health at the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology, said facilitating communication between patients and doctors and encouraging improved self-care are top priorities for her program.
“It’s important not only to think about how technology can improve the delivery of health care services, but also about how it can help to engage patients in their own health,” Ricciardi said in an interview. Mobile phones and smartphones offer several distinct advantages to other forms of digital technology for public health efforts, one of which is reaching populations in underserved areas.
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Whereas much of the Western world is enamored with the high-tech aspects of mHealth, Jesse Coleman, MSc, an independent consultant and mHealth expert who has held positions as the mHealth project manager for the British Columbia CDC and performed considerable field research on mHealth programs throughout Africa, said the utility of simple text-messaging programs is important to improve access to health care.
“In Kenya, the health system is pretty limited to begin with and the basic population level health knowledge is much lower than in Western nations,” Coleman said. “People do not have access to the Internet to diagnose every health problem and too many do not even understand basic health concepts.”
However, cellphone use has been growing more rapidly in Africa than in any other part of the world, and, in 2011, the continent became the second largest mobile market in the world, with more than 600 million subscribers — surpassed only by Asia.
To assess whether the growing interest in cellular technology could translate into health benefits, Coleman and researchers from several African, American and Canadian universities conducted a randomized controlled trial, dubbed WelTel Kenya1, that included 538 adult patients to see whether text messaging between health care workers and patients initiating antiretroviral therapy in Kenya could improve self-reported medication adherence and HIV viral loads.
The researchers randomly assigned 273 patients to an mHealth intervention in which patients received weekly text messages to remind them about the availability of phone-based health care support. These patients were compared with 265 patients assigned to standard care between May 2007 and October 2008.
The intervention group received a “How are you?” text message every Monday that prompted them to report within 48 hours whether they were doing well or had a problem. Clinicians followed up with patients who responded that they had a problem or those who failed to respond within 2 days.
Patients who received the text-message support were more likely to report ART adherence and were more likely to have viral loads suppressed below detection levels than those who received standard care, Coleman and colleagues found.
Furthermore, the number needed to treat to achieve viral suppression outside of the intervention group was only 11 patients. If the 297,800 people assigned ART via Kenya’s The US President’s Emergency Plan for AIDS Relief (PEPFAR) program in 2008 were assigned to the text message mHealth intervention, an additional 26,354 people may have achieved viral suppression, according to the researchers’ estimates.
The benefits of the intervention also extended beyond the statistical realm. “Patients often said that they felt like somebody cared about them when we conducted focus groups,” Coleman said. “It’s interesting how much just being able to interact with a health care provider to get support when it’s needed affects people. It’s not something a lot of people in resource-poor settings feel that they have.”
This is the type of interaction that Ricciardi said HHS wants to achieve with mHealth interventions for US patients with chronic diseases, such as diabetes and cardiovascular disease. “We want to use mHealth to shift the health care model from the more traditional model, in which patients see their health care providers only when they’re sick, to one in which patients are encouraged to be a partner working toward the shared goal of staying healthy or managing a chronic condition.”
Ricciardi said specific groups of patients within the United States are more likely to benefit from mHealth campaigns than others. These group include racial and ethnic minorities, and those living in urban areas, which have some of the highest uninsured populations. For members of underserved populations who may not have personal computers, mobile phones often serve as the primary source of information as well as communication.
mHealth public outreach programs
Other potential areas for developing infectious diseases-related mHealth public outreach programs in the United States and Canada include text-messaging campaigns to improve vaccine adherence, reminders for hospital staff to follow appropriate hygiene and infection control protocols, and alert systems to notify health care providers and the public when there are disease outbreaks in their communities.
Since wrapping up the WelTel Kenya1 trial in Africa, Coleman has been involved in several ongoing North American pilot studies at the British Columbia CDC that use similar text-messaging strategies. For example, he and colleagues are conducting a study to see whether a text-messaging intervention could help identify medication side effects earlier among patients with latent tuberculosis, and a “5x5 model” HIV-Positive Women’s Pilot Study, in which text messaging is being used to encourage previously incarcerated HIV-infected women to stay in contact with health care providers.
“One of the primary goals with both of these projects is to see if patients are using mobile devices enough to reduce the number of office visits necessary and to lengthen the time between visits while still providing better health care than they were previously receiving,” Coleman said.
A third ongoing pilot study he is working on involves using a text-message campaign to encourage young adults in the British Columbia area who are at high risk for STDs to come to public health clinics for regular STD testing.
“MHealth technology is unique because it is almost always accessible and since most people own their own phones, this technology has the ability to be much more personal than traditional means of accessing the Internet through computers, which are often shared,” Ricciardi said. “We’ve found that people are more likely to use their mobile phone or smartphone to look up just in-time information about potentially sensitive topics, such as services related to STD management, mental health or substance abuse.”
Integrating apps and EHRs
As more US medical practices move toward meeting federal goals for universal adoption of electronic health records (EHRs) by 2014, many expect the role of mHealth in ensuring continuity of care to grow even further as the ability for apps to integrate with EHRs improves.
“We don’t have an app yet at our institution, but I’m still able to access the EHR system from my mobile device, and that’s helpful in getting the patient information I need with appropriate secure networking,” Dodds Ashley said.
This is especially useful when out of the office, but she said she wants to provide answers to real-time questions or if she gets a call to approve an antibiotic.
“I can immediately get the patient information I need at my fingertips, see the cultures and make appropriate recommendations. Or if I’m on a pharmokinetics consult, I can see the exact time of the patient’s last dose from wherever I am. That’s helpful in providing up-to-the-minute care from inside or outside of the hospital,” Dodds Ashley said.
The Epic EHR system in use at Franko’s institution has two apps available to review patient information: Haiku for the iPhone and Canto for the iPad. However, he said a major limiting factor is that these are read-only systems. “The apps are beautiful aesthetically. They are well done, but you can’t place orders on them or write notes.”
Other limiting factors include the relatively small screen size on smartphones, the limited amount of space available to store data, short battery lives and no standard keyboard for those who wish to type, but technology is evolving at a rapid pace to meet these needs. Voice recognition software is becoming increasingly accurate and popular, virtually eliminating the need to type.
Cloud computing
Cloud computing, whereby users on a network access data stored on a remote secure server via a Web browser or app housed on a smartphone or tablet, makes the amount of space available to store data limitless, and also offers solutions to security concerns about remaining Health Insurance Portability and Accountability Act (HIPAA) compliant in an mHealth world.
Health care data breaches involving patient information increased 32% from 2009 to 2010 in a network of 65 health care organizations, according to data from the Ponemon Institute’s Second Annual Benchmark Study on Patient Privacy and Data Security.
During the 2 years before the study’s publication in 2010, 60% of participants reported that they experienced more than two data breaches, with each participant experiencing an average of 2.4 data breaches during the study period. A lost or stolen computing device was among the top three causes given for these security breaches, along with unintentional employee action and third-party error.
Many said cloud computing will make situations such as these less likely. “As we move into a cloud-based mobile computing world, very little patient information will actually be stored on phones and, therefore, very little information will be at risk for theft,” Franko said.
MHealth may actually improve patient privacy in the long run. “If you walk into any hospital in the world, you will see paper charts all over every counter top,” Franko said. “People bank online. They have all of their finances online. I don’t see how a mobile phone connected to a cloud-based database is in anyway less secure than online banking.”
IMEI number
In April, the Federal Communications Commission and the International Association for the Wireless Telecommunications Industry announced an initiative to help curb the theft of smartphones that should eliminate concerns about stolen patient information.
The initiative will enable smartphone owners to disable the device after reporting it lost or stolen using an international mobile equipment identity (IMEI) number, the equivalent for smartphones to a vehicle identification number.
Tampering with a smartphone’s IMEI number will be designated as a federal crime, and smartphone service providers are creating databases of all IMEI numbers so that those reported lost or stolen cannot be reactivated.
Databases for smartphones that operate on the Global System for Mobile (GSM) communication are expected to be ready in October, and databases for phones operating on Long Term Evolution (LTE) should be active by Nov. 30, 2013, after which any lost or stolen smartphone will essentially be useless for accessing confidential information.
In the meantime, health care organizations must make sure that they are following appropriate security protocols.
“If I’m accessing any sort of patient data, I always do it through a secure virtual private network (VPN) connection set up through the medical center,” Dodds Ashley said. “Our organization’s policy is that we don’t store any patient data on the devices.”
Future of mHealth
As more health care providers begin using their smartphones in the clinical setting, ensuring that tools are reliable, accurate and consistent through pre-implementation testing and post-implementation monitoring are the goals for mHealth in 2012 and beyond.
According to Ricciardi, the three key requirements for mHealth to be successful are: that it provide specific, actionable information, that text services or apps be evidence-based and that mHealth programs be regularly evaluated to determine what is working and what is not.
“It’s going to take a concerted effort on the part of health care providers to encourage patients to engage in improving health care using mHealth technology,” Ricciardi said.
Coleman expects that mHealth industry will see more funding and development from private corporations as they begin to realize the business potential of the mHealth market and less funding from government health organizations facing tight budgets due to global economic constraints.
“In the future, health care providers will be using mobile technologies in ways I can’t even imagine at this point,” Franko said. “No one is throwing away their smartphone anytime soon, so medical software developers will continue to find new ways to integrate with mobile technology.”
In the meantime, Franko encourages health care providers from a wide range of specialties to become more involved with designing apps to meet the unique needs of their respective professions. – by Nicole Blazek
References:
Berg A. Carriers, FCC crack down on smartphone theft. Wireless Week. April 10, 2012.
Blumberg SJ. Natl Health Stat Report. 2011;20:1-26.
Fox S. The Pew Research Institute Report on Mobile Health 2010. Available at: www.pewinternet.org/Reports/2010/Mobile-Health-2010.aspx.
Ghosh PR. The spectacular mobile phone revolution in Africa. International Business Times. Nov. 17, 2011.
Kaiser Family Foundation. Mobile technology: smart tools to increase participation in health coverage. March 2011. Available at: www.kff.org/medicaid/8153.cfm.
Lester RT. Lancet. 2010;376:1838-1845.
Ponemon Institute. Second annual benchmark study on patient privacy and data security. December 2011. Available at: www.ponemon.org/blog/post/second-annual-patient-privacy-study-released.
Disclosures: Mr. Coleman and Drs. Dodds Ashley, Franko, Ricciardi and Volberding report no relevant financial disclosures.
Will the rapid proliferation of mHealth technology pose a threat to patient confidentiality?
Any technology — indeed, any device or intervention — has the potential to be misused.
Whether this happens depends on the user. Technology only facilitates to a greater or lesser degree, the intent of the user. mHealth technology merely differs from other recording and communicating devices or techniques in that its use occurs in what is essentially a public forum. The Internet is unlike other means of communicating health data because it is susceptible to interception, alteration and misuse, to a much greater extent than what was previously possible. However, the technology itself provides a means of safeguarding privacy and ensuring confidentiality that do not exist with traditional paper-based methods of communication. Specifically, the encryption techniques and related methodologies that are available can assure a level of protection that was essentially unavailable before. There’s an old saying from computer programming: “The short circuit is between the keyboard and the seat.” In other words, it’s the human element that poses the problem, not the technical parameters. If users of mHealth technologies follow appropriate protocols, privacy will not be threatened and confidentiality will be maintained. But no one can guarantee that users will not make mistakes. Laziness, cost-cutting measures and simple errors cannot be eliminated, whether at the design level or the user level. However, they can be minimized — at which point the question becomes whether the potential risk is balanced by the tremendous benefits in terms of access, quality and timeliness of health care delivery that mHealth technology offers. I believe the benefits outweigh the risks.
Eike-Henner Kluge, PhD, is a professor of philosophy at the University of British Columbia, in Vancouver, Canada, with a research focus in medical informatics and biomedical ethics. Disclosure: Dr. Kluge reports no relevant financial disclosures.
The need to protect medical information and patients’ privacy are well-known concerns and receive much attention in states’ statutes and federal legislation.
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Innovative information technologies offer a spectrum of health care applications, including the Internet (ehealth), smartphones and tablet computers (mhealth), EHRs, medical databases and the emerging telemedicine industry. In areas where information technology is restricted, cellular services are readily available. Thus, mHealth has the potential to alleviate some infrastructure deficiencies, helping increase telemedicine and ehealth potency. The need to protect medical information and patients’ privacy are well-known concerns and receive much attention in states’ statutes and federal legislation — most notably through HIPAA. As interest in and the development of EHR increases, the need to assure patients’ rights is particularly important, especially since privacy can be breached relatively easily in the digital era. As more mHealth applications are developed to interface with EHRs, detailed assessments of where and when confidentiality might be breached are sorely needed. Transferring medical data to remote sites via mHealth may occur in several ways, depending on the medical specialty. In radiology, for instance, imaging studies are the most likely items to be shared. If a consultation is performed remotely, a patient’s entire medical record may be shared. Within surgical and psychiatric specialties live video files are created and then stored, copied and transmitted. All of these instances involve informational risks that must be contained. Assuring that patients are informed about all possible risks and have provided necessary consent forms should be a priority for health care providers. However, the starting point for any such regulation to protect patients should aim to enable mHealth proliferation while containing confidentiality concerns. Halting the development of mHealth technology until all qualms are completely resolved is not an option. In an era in which every detail of a person’s life can be managed via the Internet, even banking, mHealth should be the next evolution of IT-driven health care.
Gil Siegal, MD, LLB, SJD, is a professor of law at the University of Virginia School of Law, in Charlottesville, the director of Center for Health Law, Bioethics and Health Policy at Ono College and an otolaryngologist at Tel Hashomer Medical Center, both in Israel. Disclosure: Dr. Siegal reports no relevant financial disclosures.