The mobile health revolution: New technologies have changed the landscape for providers and patients

Wireless technology is transforming the way people communicate at an unprecedented rate, and the medical community is no exception.

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. That number 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. Alternative manufacturers emerged and new mobile carriers began to offer cheaper data plans to support the devices, helping to make digital technology more accessible. Once considered specialist items, smartphones and tablets now are becoming essential tools for many health care providers and their patients.

“The iPad is profoundly popular as a mobile device,” said David R. Artz, MD, medical director of information systems at Memorial Sloan-Kettering Cancer Center. “[In a recent month], we had more than 7,000 visits to our patient portal using an iPad, and about 4,000 using an iPhone. The next closest individual device had around 250 visits because Android devices come in so many versions. The tablet has changed the landscape for patients and providers.”

‘A huge step forward’

Paul A. Volberding, MD, director of the AIDS Research Institute at the University of California, San Francisco (UCSF), and an oncologist by training, stays up-to-date with the latest research in his field by 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.”

Volberding keeps his iPad with him when he works with trainees at UCSF in case someone asks a question that he cannot immediately answer.

“There is no second guessing,” he said. “I can say, ‘I don’t know the answer, but let’s find out.’”

Volberding sees enormous potential for mobile health (mHealth) telemedicine opportunities. For example, videoconferencing is becoming a major component in the Veterans Affairs Medical Center health care system.

Clinicians also can use the devices to explain various aspects of a disease, said Adam P. Dicker, MD, PhD, chairman of the department of radiation oncology at the Jefferson Medical College of Thomas Jefferson University and the Kimmel Cancer Center in Philadelphia.

“There are apps surgeons use to show where tumors are and what is happening in the corresponding anatomy,” Dicker said. “As radiation oncologists, we can explain where the beams are coming from. We can use a 3-D visual to explain what’s involved with the radiation and treatment of their disease. It’s all very versatile.”

Mobile technology also has helped clinicians meet a more basic need — fulfilling continuing medical education requirements.

“A lot of us don’t have the time, money or opportunity to travel to get CME credits,” Dicker said. “Being able to get them through online activities is a huge deal.”

Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS, associate director for clinical pharmacy services at the University of Rochester Medical Center in New York, said mHealth makes once time-consuming tasks — particularly communicating medication reconciliation issues with patients and other health care providers — more efficient.

Dodds Ashley uses the free mobile app MyMedSchedule from MedActionPlan.com, an app designed to help patients remember how to take their medication. When she interviews patients, she uses her iPad to input 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 the patient’s medication schedule and emails copies to the patient and his or her primary care physician.

“We are able to use mHealth right at the bedside,” Dodds Ashley said in an interview. “That’s a huge step forward for us.”

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. On two 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

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 of 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.

Whereas much of the Western world is enamored with the high-tech aspects of mHealth, the utility of simple text-messaging programs is important to improve access to health care, said Jesse Coleman, MSc, an independent consultant who has served as the mHealth project manager for the British Columbia CDC and performed field research on mHealth programs throughout Africa.

“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. 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, called WelTel Kenya1, that included 538 adult patients. The study, conducted from May 2007 to October 2008, was designed to determine 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.

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 medication adherence and were more likely to have viral loads suppressed below detection levels than those who received standard care, Coleman and colleagues found.

The benefits of the intervention extended beyond the statistical realm.

“Patients often said they felt like somebody cared about them,” 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.

Integration of 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 expand as the ability for apps to integrate with EHRs improves.

“We don’t have an app yet, but I’m still able to access the EHR system from my smartphone,” Dodds Ashley said. “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.”

The Epic EHR system in use at Franko’s institution — the University of California, San Diego — 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,” Franko said.

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.

Mobile technology is still in its early stages, and many of these kinks will likely be worked out over time, Artz said.

“For our purposes, we need this technology to be secure, fast and stable,” he said. “The security we can handle, but if you use a personal device on our network, all of its data will be wiped away when you leave.”

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. It 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 believe cloud computing will make those situations 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 any way less secure than online banking.”

IMEI numbers

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, a move that should reduce 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.

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.”

Dicker highlighted a more basic security concern.

“We need to continually remind our patients that people may be reading our emails or theirs,” he said. “Scheduling appointments and handling questions via email is obviously convenient and eliminates the phone tag factor, but it’s a drawback to the current trend that this medium is not confidential.”

Future of mHealth

As more health care providers begin to use their smartphones in the clinical setting, more attention will shift to pre-implementation testing and post-implementation monitoring to ensure that the devices are reliable, accurate and consistent.

According to Ricciardi, there are three key requirements to ensure mHealth is successful:

• It must provide specific, actionable information.
• Text services or apps must be evidence-based.
• mHealth programs must 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 private corporations will play a larger role in funding and developing the mHealth industry as they begin to realize the business potential of the mHealth market, while government health organizations facing tight budgets will contribute less funding.

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.

“No one is throwing away their smartphone anytime soon, so medical software developers will continue to find new ways to integrate with mobile technology,” Franko said. “In the future, health care providers will be using mobile technologies in ways I can’t even imagine.” – by Nicole Blazek and Rob Volansky

References:

• Berg A. Carriers, FCC crack down on smartphone theft. Wireless Week. April 10, 2012.
• Blumberg SJ. Natl Health Stat Report. 2011;39:1-26.
• 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
• Rajagopalan Ms. J Oncol Pract. 2011;7:319-323.

Disclosures:

• Drs. Artz, Dicker, Dodds Ashley, Franko, Ricciardi and Volberding, and Mr. Coleman, report no relevant financial disclosures.

Will the rapid proliferation of mHealth technology pose a threat to patient confidentiality?

If users of mHealth technologies follow appropriate protocols, privacy will not be threatened and confidentiality will be maintained.

Any technology — indeed, any device or intervention — has the potential to be misused. Technology only facilitates 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.

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 assure patients’ rights is particularly important, especially since privacy can be breached relatively easily in the digital era.

Innovative information technologies offer a spectrum of health care applications, including the Internet (e-health), smartphones and tablet computers (mHealth), electronic health records (EHR), 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 e-health 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 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, and 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.