Claudia Pagliari Senior Lecturer in Primary Care The University of Edinburgh Medical School (Thursday, 8.45am, Forum Room)

1. 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 School
HINZ Conference, Rotorua
Nov 8th, 2012

2. Presentation will examine
• Environment & ‘ecosystems’
• Policy context & digital society
• Vision for transformation & benefits
• Challenges & possible disbenefits
• Complexity & value chains
• Some issues for the future

3. Overlapping concepts
Typically more
policy driven,
eHealth - Use of networked ICT to support the organisation &
system centred &
delivery of health care
controlled
Telehealth – Subfield concerned with supporting remote care
provision or enabling patient self-care via condition monitoring
Typically more
mHealth - Use of wireless devices, networks & ‘apps’
consumer driven, to support the management of health and wellness.
user-centred, less Increasingly underpins telehealth interventions
controlled
[Multiple definitions and terminologies exist e.g. Digital Health, Telemedicine etc. Terms are poorly defined and subfields overlap considerably]

4. Mobile and internet use are growing & changing
Source: Predicted rise of 4G in developed Asia Pacific regions
Gartner
Source: www.analysysmason.com

5. Complex and inter-related
‘ecosystems’

6. Device ecosystem
– Regular mobiles (voice & text)
– Smart phones (web, video, email etc.)
– Laptops & tablets
– Wireless sensors, monitors, BAN, RFID
– etc…

7. Functional ecosystem
– Communicating & networking
– Informing & educating
– Monitoring condition or wellness
– Supporting tasks or decisions
– Encouraging behaviour change
– Reaching large groups

8. 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?

9. Ecosystem as Community?
http://www.echcampus.com/index.php?option=com_content&view=article&id=293&Itemid=61

10. 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

11. 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

12. Where does eHealth sit in the
policy landscape?
…a quick view from Europe

13. 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

14. “The Digital Agenda will support the
development of eHealth though actions to
equip Europeans with secure online access
to their medical health data by 2015 and to
achieve by 2020 widespread deployment of
telemedicine services”
European Commission (2010) Digital Agenda for Europe. Action 75.

15. ‘The Vision Thing’
Vision statements from policymakers and
industry are overwhelmingly positive

16. 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

17. ‘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

18. The BIG promises
• m- & tele- health will
– A) save money
– B) improve patient outcomes
e.g "mHealth …solutions deliver health. The ubiquity of
mobile devices … presents the opportunity to improve
health outcomes"
www.mhealthalliance.org/about/frequently-asked-questions

19. Where are we? (It depends…)

20. Dangers in ‘overselling’
"We've trialled it, it's been a huge success, and
now we're on a drive to roll this out
nationwide," ... "The aim - to improve three
million lives over the next five years”
David Cameron. 5th December 2011
Headline findings announced in Parliament long before trial
results were published. Researchers’ conclusions more cautious …
“If used correctly…”

21. 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

22. Peer review
Unsystematic but influential….

23. The Evidence-Hype Chasm
Bellagio e-Health evaluation declaration 2011

24. Demonstrating RoI
Source: Friderichs (2011) Improving the evidence for mobile health. Mobile Asia Conference

25. 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)

26. Testing the Value Proposition
Proposition: 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?

27. 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, not
the components, from what it can ‘do’
rather than what it ‘is’, and from what
the thing it can do offers to the people
who use it, at the time and place they
use it.
Slide by Irene Ng

28. 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

29. 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

30. Tales of the Unexpected
Some insights from our research

31. 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

32. mHealth for asthma
Phase Driver Intervention? Method Sponsor
Formative Producer seeking Mobile self- Qualitative study Industry
pilot insights to inform monitoring via
developments peripherals with
automated feedback
Trial in Need for evidence Updated version of RCT Asthma
practice 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

33. Supported home BP monitoring
Phase Driver Intervention? Method Sponsor
Post Academic & clinician Mobile reminders to check BP RCT Government
market 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 thresholds
Results 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 increased
Interpretation:
– 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

34. 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 therapy
Franklin et al (2006 ) Randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine
Franklin et al (2008) Patients’ Engagement With “Sweet Talk” – A Text Messaging Support System for Young People With Diabetes. JMIR 10 (2)

35. Risks and uncertainties for
telehealth & mHealth

36. 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?

37. Safety
Users 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

38. 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

39. Psychosocial risks
UK Financial Times, August 4, 2011
Teenagers ‘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/

40. 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

41. 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…

42. 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

43. Contact:
claudia.pagliari@ed.ac.uk