mHealth, telehealth and the digital society: Where does the ‘value’ lie?
mHealth, telehealth and the digital society: Where does the ‘value’ lie? Claudia Pagliari PhD FRCPE Senior Lecturer in Primary Care Convener eHealth Interdisciplinary Research Network The University of Edinburgh Medical SchoolHINZ Conference, Rotorua Nov 8th, 2012
Presentation will examine• Environment & ‘ecosystems’• Policy context & digital society• Vision for transformation & benefits• Challenges & possible disbenefits• Complexity & value chains• Some issues for the future
Overlapping conceptsTypically morepolicy driven, eHealth - Use of networked ICT to support the organisation &system centred & delivery of health carecontrolled Telehealth – Subfield concerned with supporting remote care provision or enabling patient self-care via condition monitoringTypically more mHealth - Use of wireless devices, networks & ‘apps’consumer driven, to support the management of health and wellness.user-centred, less Increasingly underpins telehealth interventionscontrolled [Multiple definitions and terminologies exist e.g. Digital Health, Telemedicine etc. Terms are poorly defined and subfields overlap considerably]
Mobile and internet use are growing & changingSource: Predicted rise of 4G in developed Asia Pacific regionsGartner Source: www.analysysmason.com
Functional ecosystem– Communicating & networking– Informing & educating– Monitoring condition or wellness– Supporting tasks or decisions– Encouraging behaviour change– Reaching large groups
Market ecosystem– Illness • patients, carers, clinicians, HMOs, payers • chronic & acute conditions– Wellness • healthy citizens, well with LTC, active elderly • leisure, lifestyle and looks– Market appidemiology? • Apple: 15000+ ‘Wellness’ vs 9000 ‘Medical’ • Impact of FDA medical device directive?
Ecosystem as Community?http://www.echcampus.com/index.php?option=com_content&view=article&id=293&Itemid=61
Personal ecosystem• Increasing device interoperability & cloud computing -> – health as part of digital lifestyle (social networking, finance, entertainment, education, home eco-logistics etc.) – always on, ever present, IoT, unrestricted data volumes – Flexible & personalised
Personalised eHealth– Personal Health Records– Personal Health Self-Management Systems– Tailored health messaging– Choice-based consulting “What we are starting to see is a patient-– Tailored telehealthcare led healthcare revolution” Orion COE quoted in Pulse IT Oct 2012
Where does eHealth sit in the policy landscape? …a quick view from Europe
Seven Pillars of the ‘Digital Agenda for Europe’• Pillar 1: A vibrant digital single market• Pillar 2: Interoperability and standards• Pillar 3: Trust and security• Pillar 4: Fast and ultra-fast Internet access• Pillar 5: Research and innovation• Pillar 6: Enhancing digital literacy, skills and inclusion *• Pillar 7: ICT-enabled benefits for EU society • eHealth Digital Society • eGovernment Digital Economy
“The Digital Agenda will support thedevelopment of eHealth though actions toequip Europeans with secure online accessto their medical health data by 2015 and toachieve by 2020 widespread deployment oftelemedicine services” European Commission (2010) Digital Agenda for Europe. Action 75.
‘The Vision Thing’Vision statements from policymakers and industry are overwhelmingly positive
Stating the obvious• Mobile brings – Convenience – Portability – Accessibility – Flexibility• Already part of our lifestyle• iPads & apps are sneaking into the workplace• Mobile telehealthcare taking place informally
‘Transformation’• Key theme in the prevailing narrative ...of services, business processes, relationships• e.g. “mHealth is about distributing care beyond clinics and hospitals and enabling new, information-rich, relationships that drive better healthcare decisions by patients and providers” (Intel speaker at mHealth 2011)• ‘Horizontal alignment’ of patients and clinicians? e.g. Marceglia et al (2012) How might the iPad change healthcare? JRSM 105
The BIG promises• m- & tele- health will – A) save money – B) improve patient outcomese.g "mHealth …solutions deliver health. The ubiquity ofmobile devices … presents the opportunity to improvehealth outcomes"www.mhealthalliance.org/about/frequently-asked-questions
Dangers in ‘overselling’ "Weve trialled it, its been a huge success, and now were on a drive to roll this out nationwide," ... "The aim - to improve three million lives over the next five years” David Cameron. 5th December 2011Headline findings announced in Parliament long before trialresults were published. Researchers’ conclusions more cautious …“If used correctly…”
Market forces• Hype often disguises a mismatch between ‘inflated expectations’ and reality• Market forces are shaping the appiverse – Natural selection, sometimes unpredictable• Many consumer health apps functionally worthless – “For entertainment purposes only”• When does it matter, when does it not? – Context, purpose, risk, expectation
The Evidence-Hype Chasm Bellagio e-Health evaluation declaration 2011
Demonstrating RoISource: Friderichs (2011) Improving the evidence for mobile health. Mobile Asia Conference
State of the evidence?• Systematic reviews reveal mixed picture• Lack of rigorous, well-theorised studies• Not clear what is being evaluated• Most evaluations take health service perspective• Poor integration of social & economic indicators Mistry (2012) Systematic review of studies of the cost-effectiveness of telemedicine and telecare. Changes in the economic evidence over twenty years. Jn Telemed & Telecare Black et al. (2011) The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. PLoS Med 8 McLean (2011) Two systematic reviews on telehealth for asthma (Cochrane database) and COPD (Can Ass Med Journal) Balas et al (2009) Healthcare via cell phones: a systematic review. Telemed J E Health Forthcoming in PloS Med: Systematic reviews by Free et al. on effectiveness of mHealth for improving health and health services. Older but relevant: Jennet et al (2003) Socioeconomic impact of telehealth: Systematic review. Jn Telemed &Telecare Conclusions supported by recent expert consensus (e.g. Whittaker 2012, JMIR)
Testing the Value PropositionProposition: m-Health will save money for HS e.g. by supporting healthy living with LTC, keeping the elderly out of hospital • But what will it cost to implement? • Is it the technology that makes the difference? Proposition: mHealth will make money by offering sellable benefits • what type (e.g. choice, convenience, access, life years, monetary savings), and to whom? Proposition: The market is willing to pay • Which markets (provider, insurer, government, citizen, patient, carer) and why?
More than the gadgets… • Economists and sociologists are revisiting concepts of ‘value’ in the digital age and recognising that it comes from what we get out of interacting with technology, not from the technology itself. • We ‘co-create’ value.Value comes from the whole system, notthe components, from what it can ‘do’rather than what it ‘is’, and from whatthe thing it can do offers to the peoplewho use it, at the time and place theyuse it. Slide by Irene Ng
A few challenges… • Devices, back end services & training cost money – Who will pay? • For what types of devices or applications? – What is the critical RoI to leverage state investment? – When is it necessary and when is it just nice to have? • Costs can increase where systems haven’t evolved to accommodate innovations – Technology needs to be tamed* in order to integrate – Where does this leave the business case? – How much faith do we need? – Do we need to question our expectations/theory?* Pols & Willems (2011). Taming & unleashing telecare. Sociology of Health & Illness; Ure et al (2011) Piloting tele-monitoring in COPD:exploration of issues in design and implementation. Primary Care Respiratory Journal
Complexity, impact & value• What you think you’re buying (off-the-shelf solution) may not be the same as what you’re actually getting (opportunity to reconfigure your service)• Need to ask: – What process changes are needed to implement this service? – At the end of the day, what is ‘the intervention’?• Likely costs vs. savings? Do the sums add up? – Will they add up once this has been embedded? • Sponsored evaluations typically <6 mth
Tales of the UnexpectedSome insights from our research
Supported COPD monitoring Phase Driver Intervention? Method Sponsor Procure- Sale of concept by major Tech: VC, monitoring, Researchers flag ment vendor. Goal to reduce decision support, importance of admissions through education formative evaluation home telehealth Vision: Nexus of GP & patient Design & Questions over Planning process shifts Qualitative Technology set-up readiness, fit, emphasis to nurse-led observation & supplier configuration service with call-centre interviews Trial in Need for evidence of Specialist nurse-led RCT with Gov. practice value & safety service with or without embedded qualitative research ‘telehealth’. No call Study programme centre or VC• Quantitative: No difference in admissions or mortality. Clinical indicators improve in both trial arms. Prescribing costs increase.• Qualitative. Vision very different from what emerged. Patient satisfaction high (perceived safety, access, legitimisation). Uncertainty over ‘normal’ readings. Key change agents: high nurse-patient engagement; service redesign & optimisation Pinnock et al (2009) PCRJ; Ure et al (2011) PCRJ
mHealth for asthmaPhase Driver Intervention? Method SponsorFormative Producer seeking Mobile self- Qualitative study Industrypilot insights to inform monitoring via developments peripherals with automated feedbackTrial in Need for evidence Updated version of RCT Asthmapractice of outcomes & product charity practicality Results from trial: – No difference in clinical outcomes – Both groups improved, suggesting telehealth not the critical factor (care ‘optimised’ in both groups) Ryan et al. (2012) Clinical and cost-effectiveness of mobile phone supported self- – Phone more expensive monitoring of asthma: multi-centre randomised controlled trial BMJ 344 Insights from pilot: Most likely to be used by people adapting to asthma – Issue for market segmentation & value Pinnock et al. (2009) Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study. Clin Exp All 37
Supported home BP monitoringPhase Driver Intervention? Method SponsorPost Academic & clinician Mobile reminders to check BP RCT Governmentmarket interest using peripherals linked to mobile health research • Common consumer phone. Automated feedback & agency + device purchase advice with weekly clinician review supplier (kit) • Equivocal evidence and immediate response if outwith safe thresholdsResults from trial: – Significant improvement in BP compared to usual care. No difference in other outcomes – Increased prescription of drugs in the actively monitored group. – Clinician and nurse time (and cost) also increasedInterpretation: – Telehealth made readings impossible for primary care staff to ignore, leading to increased use of antihypertensives, but did not influence patient lifestyle – Technology as catalyst, not cause Padfield et al (2012) ) Early Results from the Health Impact of Telemetry-Enabled Self-monitoring (HITS) Trial. Conference paper. British Hypertension Society
mHealth for paediatric diabetes Phase Driver Intervention? Method Sponsor Development Poor medication Scheduled SMS messages RCT with Diabetes charity & evaluation compliance in tailored to personalised embedded and mobile adolescents. clinical goals and qualitative network Reported benefits of motivational drivers (‘push study provider costly high effort goal- support’) directed interventions Quantitative : – No difference in Hba1c compared to usual care – Increase in clinic visits – Increase in self-efficacy and self-reported adherence Qualitative: – Patients actively sought interaction with a system designed mainly to ‘push’ messages – Some believed the automated messages were coming from a human Soft benefits (e.g. self-efficacy) may add value downstream e.g. aiding transition to intensive insulin therapyFranklin et al (2006 ) Randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic MedicineFranklin et al (2008) Patients’ Engagement With “Sweet Talk” – A Text Messaging Support System for Young People With Diabetes. JMIR 10 (2)
Risks and uncertainties for telehealth & mHealth
Information security & privacy• Data custodianship & liabilities unclear• Risks due to – Technical/system issues – Human error – Malign intent Greater knowledge about data harvesting & security will deter some users Will it also spawn techno sub-cultures?
SafetyUsers can co-create risk as well as value… – Patients • Dangers of false expertise • Unwarranted trust in junk apps • Unjustified trust in systems or their overseers • Dependency vs. self-reliance – Professionals • Under-the counter clinical transactions • Context-inappropriate tools • Failure to integrate hand-held & organisational data • Failure to define lines of responsibility
Societal risks: Equity– Those with greatest need may be in worst position to benefit from eHealth– Avoiding ‘double dip’ requires tailored solutions that capitalise on familiar & available technologies • e.g. ‘edutainment’ & social media for the young, DTV & videophones for the elderly– Important not to further isolate the disenfranchised through digital ‘help’– Hype around mHealth for developing nations is obscuring still vast disparities in health & access to medical care
Psychosocial risksUK Financial Times, August 4, 2011Teenagers ‘addicted’ to using smartphones “Just under half of British children aged 12 to 15 own a smartphone, with many claiming to be “addicted” to the devices, which they use while eating, at the cinema and in bed” (Source: Ofcom)Journal of Public Health, May 2011 “Problematic mobile phone use in adolescence should become a public health issue” (Martinotti et al.) http://www.springerlink.com/content/u05163w878367037/
Physical risks: Can mobiles cause cancer? May 2011: WHO finally concedes it may be ‘possible’ July 2011: Danish observational study suggests not April 2012: Dedicated conference takes place in London June-Oct 2012: Major western health agencies release new, reassuring, analyses Oct 2012: Nature blog reports a successful Italian lawsuit by a cancer patient 2013-50?? What level of risk would make us give up our mobiles? What’s the trade-off for mHealth?e.g. http://www.youtube.com/watch?v=K4uz2TUcwnI
Looking the future…• Smart phones, tablets, cloud and IoT become the norm• With pervasive systems the term ‘mobile’ becomes redundant• The eHealth sector explodes & then rationalises as evidence accumulates, value chains are clarified & market segmentation is better understood• Return on government investments in HIT is demonstrated• As society ‘digitises’ eHealth integrates with consumer-centred platforms and already-owned devices• Tensions between the need to innovate for growth and the need to control quality, spending & governance continue…
Key issues for ‘value’• Without better evidence current levels of spending on telehealth & mHealth cannot easily be justified• Complexity presents challenges for demonstrating RoI• Value is co-created by systems & users – Lack of clinical or economic impact does not mean lack of value • But ‘soft’ impacts can be hard to monetise – Evidence of clinical impacts may confuse human & technological causes• In this fast-moving environment creative paradigms are needed to evaluate technology programmes while they happen It’s not a no-brainer