December 19, 2011

mHealth in Action
By Susan Chapman
For The Record
Vol. 23 No. 23 P. 24

While smartphones are helping improve care for distinct patient groups, several barriers to more widespread success remain.

A growing number of healthcare organizations around the world are using mobile health (mHealth)—text messaging, cell phones, walkie-talkies, and other tools—to advance care. One segment of the movement has focused on using smartphones to better meet the needs of new mothers and diabetics. While many of these initiatives offer positive outcomes, they also face significant challenges to gaining widespread use.

Prenatal and Neonatal Care
Among the objectives of the United Nations’ Millennium Development Goals, an aligned strategy to eradicate poverty and support health and development, is the reduction of child mortality rates. In maternity care, especially in developing nations, mHealth programs help advance this goal by supporting emergency medical responses, point-of care support, health promotion, and data collection.

To better understand how well the aims of this subcategory of the Millennium Development Goals is being met, researchers Tigest Tamrat and Stan Kachnowski explored mHealth’s role in improving outcomes in both prenatal and neonatal care in developing nations. They published their findings in the article “Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World,” slated for publication in the Maternal and Child Health Journal.

The article’s abstract notes that the proliferation of mobile technology across the world has generated a new tool for improving healthcare access and delivery and meeting healthcare challenges. The International Telecommunications Union reports that 90% of the world’s total population and 80% of those living in rural areas have mobile coverage. Clearly, the ubiquity of mobile phones has helped fuel the initiation of mHealth.

Mobile phones thrive in resource-limited health systems despite the scarcity of other technologies and infrastructure, a permeation that offers new means to address health needs.

Tamrat and Kachnowski conducted an electronic literature review of studies that involved people literate in mobile technology to whom cell phones were distributed. In these studies, health workers who were already embedded in the community received mHealth government-sponsored intervention training in areas such as immunizations, identifying pregnancy risks, lactation consultation, hygiene, and sanitation.

The team learned that in nations where women deliver babies at home with the help of midwives or in cultures in which health workers generally triage women for delivery at lower-level health facilities, mHealth served as a communications bridge. When complications arose in pregnancy or delivery, the health workers were able to use mHealth as a way to refer women for care in more sophisticated health facilities that were often located some distance away.

While mHealth helped facilitate contact with the health facilities, the research team discovered data that uncovered how the technology brought to light several challenges stemming from a lack of infrastructure in developing nations. For instance, many of the facilities lacked equipment and human resources for more complex procedures, including ultrasounds and amniocentesis. In Gambia, West Africa, mHealth provided opportunities for health workers to make emergency referrals. However, the health facilities to which patients were referred often lacked space, personnel, and ample blood supply.

Tamrat notes that the team’s investigation revealed that better coordination among stakeholders—providers, patients, policymakers, and philanthropists—is a necessity. “There are many policy and funding barriers,” she says. “And these are applicable to providers in the United States as well as in the developing world. mHealth is not a silver bullet. While mHealth can improve prenatal and neonatal outcomes to some extent, it still needs to be part of a holistic approach, from the perspective of stakeholders to important components like staffing, sanitation, and equipment.”

Diabetes Management
In diabetes management, much like in maternal care, mHealth offers many advantages and faces challenges to extensive adoption. However, the obstacles differ.

According to the American Diabetes Association (ADA), 8.3% of the U.S. population, or 25.8 million children and adults, have diabetes, of which 18.8 million have been diagnosed. In 2010, there were 1.9 million new cases of diabetes diagnosed in individuals over the age of 20. Further, the ADA states that 79 million people are considered prediabetic, and the Centers for Disease Control and Prevention forecasts that one-third of all Americans will have diabetes by 2050.

There are two types of diabetes: type 1, in which the body does not produce insulin, the hormone necessary to convert sugar and starches into usable energy, and type 2, the more common form of the disease in which the body does not produce enough insulin or the body’s cells are resistant to it. Both forms have the same effects on the body and can lead to serious complications, including heart disease, stroke, kidney disease, neuropathy, high blood pressure, blindness, and amputations. The disease is one of the most common causes of death in the United States, claiming more than 230,000 lives in 2007, according to the ADA.

Howard Steinberg, founder and CEO of dLife, a diabetes resource that offers practical solutions for diabetes management online, on TV, and via evidence-backed interventions for payers and providers, says successfully managing the disease often requires complex behavioral changes. “If diabetes were easy to manage,” he says, “then we wouldn’t have all of the consequences of poor control. There is more attention paid to treating the dire and costly complications due to diabetes than there is in establishing new therapeutic approaches to behavior change that would help avoid these consequences. Ultimately, effecting meaningful behavior change requires a high level of patient engagement, knowledge, and self-care.”

Because diabetes requires patients to frequently monitor blood sugar levels to determine behaviors throughout the day, mHealth can play a major role. Jenifer Levinson of Avalere Health, an advisory company focused on healthcare strategy and policy, says the use of smartphone technology in diabetes management is relatively recent. Still, the advances have been impressive. For example, through a smartphone application, patients can remotely upload glucose monitoring device information for physicians and other healthcare providers to use. Glucose monitor data can be uploaded to patients’ computers via a USB port, and the information can then be sent directly to a provider.

In a more complex system, a patient who uses an insulin pump—an external device that delivers insulin throughout the day to meet the body’s needs—has the capability of having the pump communicate wirelessly with the glucose meter. The meter uploads information to the pump, and all data are then transmitted to the physician by way of a secure, password-protected server.

“In glucose monitoring and communication with one’s physician, mHealth can be a terrific platform for personalized medicine,” says Lynette Ferrara, a partner in CSC’s informatics practice. “Now there are approximately 17,000 smartphone apps available for diabetes management. About 40% are for professionals, and the rest are for consumers.”

Ferrara says the WellDoc app can perform such activities as reviewing a patient’s behavior and then responding by sending the patient a message indicating if his or her blood sugar level is too low. The app tells the patient what steps to take next. If the patient’s phone is turned off, the app will automatically turn it on. “This type of app helps in decision making and reminds the patient of best practices,” she notes.

Other apps also inform patients and give clinical responses to doctors. For example, apps can report to doctors how a patient is taking medication and what modifications may be needed. “These provide very good advice on what’s happening with the patient. It helps with goal planning that is then integrated into the cycle of care.” Ferrara says.

One drawback to all of these apps, Ferrara says, is that no current model focuses on prevention. “Also, many diabetes management programs come from insurance companies,” she says. “Patients are uncomfortable. They want the information integrated with the entire care team. They want to know how the information is shared. Then there are legal and regulatory hurdles that must be overcome.”

Ferrara notes that the best apps are certified as medical devices. The FDA has regulations in place for apps to be considered; there are both certification and postapproval processes. As for privacy concerns, data are encrypted in transit and on servers, she says, adding that vendors, aware of the severe penalties for HIPAA violations, spend a great deal of their budgets to ensure security.

Ferrara points out that these devices and apps will improve outcomes, reducing short-term hospitalizations. “Generally, hospitalizations for complications can cost at least $10,000 for every instance,” she says. “This doesn’t take into account the long-term damage to the nervous system, amputations, and other complications. Both cost savings and quality of life improve. Low-income and economically disadvantaged patients know what diabetes will do to them, yet the decision making is complex. Smartphones help with those decisions.”

Steinberg cautions, however, that mHealth should not be thought of as a panacea in diabetes management. Precisely because the disease is complex, on both physiological and psychological levels, it requires various tools. “Because diabetes is a 24/7 condition, it’s critical for patients to own it. mHealth is one tool but worthless without the individual opting in,” he says. “You’re doing a lot of what the body is not doing for you—measuring blood sugar, delivering insulin, evaluating food and activity impact. The more tools you have, the better. The wonder of mobile’s promise is that it flows into your existing lifestream; it’s always with you. Still, it will require a highly meaningful and engaging content experience to involve those who are passive and apathetic, which goes beyond the tool itself.”

One segment of the population that Steinberg believes benefits more readily than others is women with gestational diabetes, which, according to the ADA, affects about 18% of expectant mothers around the 24th week of gestation. “There is a strong sense of urgency. Pregnancy happens within a defined time frame, as does gestational diabetes,” he says. “In that window, the mother is highly motivated to care for her child’s health and generally willing to do anything for six to nine months. And since young women are technologically savvy and already adept at using mobile technology, the expectant mother can use apps to benefit her and her baby without having to climb a steep diabetes learning curve in a short period of time.”

For the most part, experts view challenges to mHealth’s proliferation on the healthcare provider side of the equation. While mHealth enables patients to gain long-distance access to their physicians, the healthcare system poses obstacles in that physicians often do not have the time or desire to be on call around the clock. In addition, insurance companies do not compensate providers beyond an office visit and do not pay for downloading and reviewing data. Because there is no mechanism for the provider to get paid, physicians are essentially responding for free.

“There are two lines going in opposite directions,” Steinberg says. “Diabetes is increasing … and about 90% of type 2 diabetes patients see a primary care physician and their ranks continue to decline. What mobile technology allows physicians and patients to do is not yet aligned with the availability and incentive for providers.”

Levinson believes mHealth produces information overload for both patients and physicians—neither always knows what to do with the information it generates. “The decision support isn’t there yet,” she says. “It’s time consuming to review. For older adults and those who aren’t tech savvy, there is a huge learning curve. And emergency issues must be addressed immediately. Mobile cannot, then, replace old-fashioned interaction with one’s provider.”

Steinberg concurs that mHealth does not free patients from depending on healthcare providers but adds that patients must also learn to be independent. “It’s great that there are various technologies being applied to allow a doctor to check in with patients, but the barriers are beyond just access,” he says. “Diabetes is not only impacted by data points in time. There is a deep mindfulness to diabetes that is beyond just one device and more about how he or she is willing to live one’s life. In that regard, mHealth sets up a one-dimensional expectation that diabetes is just about what to do at that moment vs. the adoption of self-care skills and emotional commitment that can be facilitated by mHealth but it can’t depend on it alone.”

Levinson offers a different perspective. “Overall, such an important component of self-management has potential. mHealth aims to help patients, and it’s worth the investment,” she says.

— Susan Chapman is a Los Angeles-based writer and author.