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Mobile Health at ‘Interesting Inflection Point’

By Ryan Mcaskill

There is no question that mobile technology is making a splash in the healthcare field. However, despite the popularity, there are a number of barriers to widespread adoption.

- In an interview with, Harry Greenspun, the Director of Deloitte’s Center for Health Solutions, spoke about the the current state of mHealth, the major challenges to widespread adoption and what the future might hold. What is the current state of mHealth?

Harry Greenspun: We are at an interesting inflection point. We have a lot of things that are poking around with mHealth, largely because we can. We have an infusion of different apps that are making mobile health more accessible and of course there are other people that are utilizing the fitness and wellness community around diet and exercise and wearable devices. The exciting part is transitioning into value-based care, paying for outcomes, paying for value, and it really is opening the door for innovation.

We are moving from this feeling of “hey, we can do this” to “hey, we need to do this.” We need to be able to share data more effectively, we need to do care coordination, we need to engage consumers and we need to harness the data that is available across all these things in order to actually conduct the practice of medicine.

That has been the biggest driver of innovation and the adoption of mobile health. That is what really has changed in the last couple years.

READ MORE: Providers Visualize New mHealth, Telehealth Uses for the Video What will it take to get over the hump? Will it be a singular event or continued gradual change?

HG: I think it depends on where you live. if you look at the map of accountable care organization, or at people that are doing values like Colorado, Texas, certain parts of California or Boston, you are seeing a push toward value and a rapid change in the reimbursement process which really outlines the incentives to adopt these things.

But if you look elsewhere in the country, you are seeing very little activity. You said straight-up fee-for-service. So their incentive to adopt mobile health is relatively low. Similarly, if you look in different organizations, like people in larger groups like Kaiser or those involved with the VA or other closed systems, there is tremendous push to get greater mobile tools out there because ultimately it hits their bottom line. Whether it’s in terms of attracting and retaining patients or getting better outcomes or reducing costs, all of these things are important so they are investing in it. What are the biggest challenges when it comes to actually implementing mHealth strategies?

HG: The number one challenge is actually return on investment. For many of them, the return on this actually very low, if the economic incentives are not aligned. For the average place that is still doing predominantly fee-for-service to make things faster and easier for consumers, it can actually hurt their bottom line. Think about some simple telehealth and secure messaging stuff, when you do those you reduce your in-person visits with your provider, which is awesome if you are a closed system but it’s economically disastrous for fee-for-service. So again its really about the alignment.

READ MORE: Providers Like Virtual Care, But Sustainability Issues Linger

The second thing is that many of the apps and other things that are available are narrow. They were designed by technical people and solve a narrow technical problem and they often don’t deal with the hard issues. They don’t deal with integration of medical records. It might help remind you to take your medication but what you really need is to take all your medicine and adhere to a diet and exercise regiment and other things that I’m suppose to do.

The other things that they tend to do id avoid dealing with protected health information and HIPAA and they avoid being rigorous around their data collection and the devices they may interact with to avoid being regulated as a medical device. That makes a simpler business model but reduces the impact and utility that these things can have. Have the challenges of mHealth evolved or will they change in the future?

HG: The challenges are going to go down. The bug challenge several years ago was who actually has a smartphone? Now everyone has one. The other thing was questioning whether consumers would be able to do sophisticated stuff.

Think about it in terms of a banking app. Five years ago it would tell you where the closest ATM is located. Three years ago, you could deposit a check with your phone and now your phone is money. It’s not that consumer’s needs have changed, it that their expectation have risen pretty dramatically. Consumers are now expecting the types of services they get in other industries to come to healthcare.

READ MORE: 10 Guidelines to Launching a Successful Telemedicine Practice

When we survey consumers, the main message is, when you ask they about quality, they focus on service, what its like to get care and how it relates to other experiences they have. We are finding providers are needing to adopt some of these things in order to demonstrate that they are high quality organizations. It’s simple stuff too. It’s not having a continuous EKG  and EEG monitoring sent to a call center that my doctor sees to make sure i’m doing well, it’s the ability to check in to an appointment like I do a flight or manage co-pay or send a message or get an alert when it’s my turn to get an X-ray like when you are waiting for a table at a chain restaurant.

The other thing that has gotten less airplay but is just as important is the issue around interoperability, and not just EHR interoperability, but also device interoperability. This is slowly being addressed but it doesn’t help to collect silo after silo of data and not be able to pull that stuff together. Once we solve the interoperability problem, we will speed up the adoption of mHealth. Is interoperability the by product of needing ?

HG: You have organizations popping up and other consortia focusing not only on EHR interoperability but also device interoperability in order to make the data useful. I have a friend with chronic lyme disease that has to monitor her exercise, mood, diet and medication, but unless there is someone that can aggregate that data in a meaningful way and provide insightful feedback on what’s working and what isn’t, it’s not going to be useful to them. That has been an issue, where we have interesting apps and devices but the information remains locked in their own system and ultimately is not that useful. What do you see as the main trends of mHealth going forward?

HG: The first trend we will see, if you image a bell shaped curve for distribution of people from healthiest to sickest, right now a lot of the adoption of mHealth is on the left side of that graph with the health people. Those are the ones that are tracking how much water they are drinking and their their exercise, are watching leaderboards on fitness apps.

We will also see a pushing in from left to right, when it comes to the health and wellness portion of mHealth that will push into a population that needs it more.

On the other side, with the sickest patients, we will see a broader adoption of mHealth to do remote monitoring and help move people from the hospital to the home to allow patients to age in place. Many of these things will be done without the active participation of the users. It is going to be set up by the family members or a caregiver or an additional service where its transparent to make sure they are doing okay. We will see that expand from the sickest five percent, which is responsible for a tremendous amount of healthcare spending to to maybe the sickest ten percent, moving from right to left on the graph.

Eventually we will see growing adoption across the big fat middle of healthcare. Will the push from the healthier side be age related? I’m on the cusp of 30 and can not remember a time in my adult life where I have not have a cell phone on me.

HG: Yeah, that is part of your expectations a a consumer. You are not going to a doctor that you can’t communicate with. You wouldn’t go to a bank that didn’t have online banking.

The other thing is that you are going to be taking more personal responsibility and financial responsibility as a consumer. You are going to need that information or documentation that you are doing the right stuff to get discounts, the same way you would for car insurance. Or your employer may ask you to do something for a big incentive. That is a side that will continue to push in.

As time goes on, and value-based care takes greater hold, you are going to see a drive to have tools in place to make better decisions, understand what is going on with them, get better data and control costs. What about the security issues?

HG: Privacy and security is always going to be an issue. We are either going to satisfy this in a way that individuals are comfortable and it will be an accelerant or we are not going to do it well and this will be an anchor on progress. People are becoming more aware of breaches that can happen in healthcare. In some cases, healthcare data can be more valuable than financial data on the black market these days because it tends to be more resilient and last longer, so privacy and security is going to be a big issue.

This happens for two reasons. It is either going to accelerate or inhibit adoption by consumers and we need to solve this problem so that new technology come out don’t shy away from managing protected information so the apps themselves can be more valuable. Why is security such a challenge?

HG: It’s hard. There is so much data related to health that it tied up with mobile devices. It’s not only data you would have about your vital signs or your medications, but it’s also where you go, what you did, what you ate, who you have interacted with. It’s the kind of privacy stuff that people who talk about the hyper-connected world outside of healthcare where anyone can know what happened to you based upon where your phone was and the security cameras that are all over and your credit card bills, but we are now understanding that that kind of data is really valuable in terms of your health.

People can get their genome sequence by  spitting into a tube and sending it off but I can probably tell you more about your risk of a heart attack from your visa bill that your genome. If you are eating fast food six or seven times a day, you don’t belong to a gym, you’re spending all your money on on demand movies at home, you are probably not getting much exercise and eating bad stuff, you are probably at risk of something bad happening - heart attack, hypertension, diabetes, something.

So it’s non-healthcare information that can be important and when you pair that up with actual health information you can get some very powerful conclusions. The rest of the non healthcare world is grappling with these security and privacy issues and I believe we will solve them. Then there is safeguarding information on their phone, information in transit, the devices you wear, the devices that are implanted in your body and that stuff has to remain front and center in order to keep adoption going. Does reliable broadband and infrastructure factor into adoption?

HG: People get real excited about mHealth but they forget that big parts of the country don’t have reliable broadband. We often don’t think about our infrastructure in this case. You travel around this country or you look at the coverage maps of telecom companies and you see places that are not colored in and you know they do not have broadband.

I drove from Boston to Hartford and I lost signal several times going down the Mass Pike. Often if you do into a building, you can lose coverage. For this stuff to really be successful, it has to be ubiquitous or it needs to be built around a system that works when you get in an elevator, when you travel on the highway, when you get on an airplane. That is how real life works. It’s not just sitting in a place that has superfast internet access. Can healthcare embracing mHealth help expand access and quality of broadband overall?

HG: The FCC, in their rural broadband plan, has a whole thing about healthcare and how one of the important reasons for having broadband is healthcare. It’s this whole technical world that people don’t really think about.

The FDA sent out guidelines for wearable devices. Most of the wearable devices were designed for gym rats, they were not designed for my dad. They were not designed to be used by old people, they were not designed to be used when the power is out, they are not designed for airplanes or going across time zones and they were not designed to be resilient to the kinds of things that medical devices are. Now we want to use them as such, but have realized that they are not designed for that and there needs to be design changes that reflect the reality of taking care of people.


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