Mobile Health The Killer App for Cyberinfrastructure and Consumer Health Audie A. Atienza, PhD, Kevin Patrick, MD, MS
Introduction
I
t has been suggested that electrical lighting was the “killer app” in the early 1900s that precipitated the rapid development of a comprehensive nationwide grid to deliver electricity.1 In this paper, we argue that mobile health (mHealth) may be the killer app for cyberinfrastructure for health in the twenty-fırst century. The speed with which mobile technology is being adopted in the U.S. and globally has been astounding. As of the last quarter of 2009, the U.S. had an estimated 285 million wireless subscribers,2 and there are an estimated 4.6 billion mobile cellular subscriptions worldwide.3 As electronic medical and personal health records (PHRs) expand, and bioinformatics research grids take root and grow, the simultaneous growth in mobile and wireless technologies promises unprecedented opportunities to connect users—whether they be patients, family members, high-risk groups, individuals in the community, and/or healthcare providers—in ways that can improve individual and population health. Tools and technologies that extend beyond the cyberinfrastructure grid are discussed in several of the papers in this supplement to the American Journal of Preventive Medicine,4 – 6 including references to personal devices, real-time monitoring, point-of-care data collection, and telemonitoring. These papers touch on how the mobility of cellular phones, sensors, global positioning systems, physiological monitors, and related tools offer advantages over existing health technologies. Mobile technology has been defıned by Riley and colleagues7 as “computer devices that are intended to be always on and carried on the person throughout the day (i.e., during normal daily activities).” Mobile technologies support the collection and analysis of health-related information in real-time From the Division of Cancer Control and Population Sciences, National Cancer Institute, NIH (Atienza), Bethesda, Maryland; and the Department of Family and Preventive Medicine, California Institute for Telecommunications and Information Technology, University of California at San Diego (Patrick), San Diego, California Address correspondence to: Audie A. Atienza, PhD, National Institutes of Health, National Cancer Institute, 6130 Executive Boulevard, EPN 4082, Bethesda MD 20982-7335. E-mail:
[email protected]. 0749-3797/$17.00 doi: 10.1016/j.amepre.2011.01.008
and in the real world. Mobile devices are increasingly personalized to the individual and thus can potentially support fıne-grained tailoring of communication with the user. Further, growing person-level ecosystems of sensors will support the collection of data from multiple sources and the analysis of these data, either locally on a mobile phone or on more sophisticated back-end servers, to support health messaging to the user and/or to feed into information grids used to study population-level health issues. This vision of ubiquitous mobile health technologies is not a distant one. The rapid growth of smartphone medical and health/fıtness apps demonstrates that developers see a current market for mobile health. For example, the iTunes App Store offers more than 5200 Healthcare and Fitness and more than 3400 Medical iPhone Apps (as of August 7, 2010). Health insurance payers (e.g., Blue Cross Blue Shield of Florida; www3.bcbsfl.com/wps/portal/ bcbsfl/links/mobile); healthcare providers (e.g., the Mayo Clinic; newsblog.mayoclinic.org/2010/03/01/mayo-clinicreleases-mobile-apps/); and laboratory companies (e.g., Quest Diagnostics; www.questdiagnostics.com/hcp/connect/ convenient_mobile_access.htm) now offer mobile phone health or medical apps. Consumer demand, the push to improve productivity and reduce costs for customer service, the increasing acceptance on the part of providers, and the participation of major technology companies such as Microsoft, Google, Intel, Qualcomm, Nokia, and Apple all contribute to a sea change of availability of mobile devices supporting mHealth. Although the proliferation of mobile technology has been remarkable, and there is great promise for their future, it must be acknowledged that there is currently limited evidence about how well and under what circumstances mobile phones (and other mobile/wireless devices) compare with or enhance current means to improve health and health care.8 The newness and variety of devices and platforms contribute to the diffıculty in evaluating mHealth technologies. Even a simple and widely generalizable approach to mobile health, text messaging, has been subject to limited study, albeit with promising results.9,10 As with almost every technology, concerns
Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Am J Prev Med 2011;40(5S2):S151–S153 S151
S152
Atienza and Patrick / Am J Prev Med 2011;40(5S2):S151–S153
also exist about the availability of mHealth to all segments of the population, including those with limited resources. The promising news about mobile health is that disparities in access are diminishing. According to the Pew Internet and American Life Project,11 mobile handset ownership in the U.S. is higher among Latinos and African Americans than among whites (87% vs 80%), and access, while lower in lower SES groups, is increasing across the socioeconomic spectrum. Despite the promise of shrinking the digital divide along racial/ethnic and socioeconomic lines, evidence points to a new digital divide between younger and older consumers. Whether this disparity is related to age or generational issues (i.e., differences in technology adoption from one generation to another) has yet to be defınitively determined (see commentary by Viswanath in this supplement).12 Nonetheless, the anticipated growth of an aging population requires a merging of science and technology to bridge this gap and to more fully capitalize on the promise of mHealth. Although there is much enthusiasm for the public health potential for mHealth and its connection to the cyberinfrastructure, several challenges remain. First, as meaningful-use standards13 in electronic health records (EHRs) are implemented, consideration should be given to the increasing role that mobile technologies will play in personal health and health care. As recently as 5 years ago, few would have predicted potential consumer demand to access their medical records from a mobile phone. Yet, now it is diffıcult to imagine that this will not be the case, perhaps very soon. Health information technology (HIT) companies are developing personalized health records where individuals can text information directly into their care plans and also receive text messages from their PHRs (e.g., Keas Inc.; www.keas.com). Extending this into EHRs is surely soon to follow. Second, progress needs to be made on clarifıcations from the Federal Communications Commission (FCC) and the U.S. Food and Drug Administration (FDA) about wireless medical device regulatory requirements. Many mHealth technologies straddle the medical device and personal health arena, and raise important questions about how to protect consumers while at the same time promote the development and adoption of new technologies that might address critical public health issues. For example, a system composed of a mobile phone, wearable accelerometer, and heart rate monitor might be demonstrated to alter the course of weight gain in an obese adult. The intended use of this system determines whether regulatory approval is required. If it is intended to improve lifestyle behaviors, and marketed in sporting good stores, it does not require FDA regulatory approval. However, if a similar system is intended to be part of what a healthcare
provider prescribes for adults with type 2 diabetes, it then becomes subject to FDA approval. To complicate things further, the fact that this system includes technologies that transmit information wirelessly places them in the domain of FCC regulation to ensure consumer and public safety. Recognizing the need for further regulatory clarity as communication and medical devices increasingly converge, the FCC and FDA recently held a jointly sponsored workshop to begin the process of providing “appropriate clarifıcation” on regulatory requirements between the two federal agencies.14 At this joint workshop, the FDA and FCC formally agreed “to work together to promote initiatives related to the review and use of FDA-regulated medical devices,”15 and the FDA is drafting a guidance document based on the workshop on wireless medical device applications, with input from the FCC. This is a promising step, as regulatory clarity is essential for moving mHealth forward. Additional challenges to mHealth include managing the privacy and confıdentiality of information that is gathered with and potentially stored by mobile devices and sent to cyberinfrastructure databases. For notifıcation and intervention purposes, additional privacy and confıdentiality concerns arise when sending healthrelated data to mobile devices.16 Technology and health information exchange standards for privacy need to be developed by relevant stakeholders to ensure that information gathered and transmitted via mobile devices remains secure. For medical data, the Health Insurance Portability and Accountability Act (HIPAA) requirements also need to be considered. Finally, as noted above, data are needed on the comparative effectiveness of mHealth technologies, compared both to usual care and compared to one another. The best path to the increasing use of mHealth will be one based upon solid evidence of effıcacy, effectiveness, and population-level reach and impact. Developing this evidence base will likely involve partnerships among researchers, the technology and healthcare industry, government, and non-profıt stakeholders who can help ensure that benefıts of mHealth extend as broadly as they can. To facilitate discussions among various stakeholders in the mHealth ecosystem, the NIH recently partnered with the Foundation for the National Institutes of Health and others to organize the 2010 mHealth Summit (www. mhealthsummit.org). While key events like the 2010 mHealth Summit lay the foundation for exploring partnerships, much more work is needed to develop and solidify collaborations that will move mHealth research, practice, and policy forward. The mHealth applications and services offer unprecedented opportunities to reach consumers anytime and anyplace. To accomplish this, it will be essential to incorwww.ajpm-online.net
Atienza and Patrick / Am J Prev Med 2011;40(5S2):S151–S153
porate the perspectives and preferences of consumers as mHealth technologies are developed. To this end, researchers and developers working on mHealth are encouraged to base their work on principles from the increasing body of knowledge in user-centered design.17 While the rapid proliferation and ubiquitous use of mobile devices has been remarkable, little is known about how and under what circumstances consumers currently use— or may prefer to use in the future—mobile technology for health-related purposes. If mHealth devices and the other elements of health-related cyberinfrastructure discussed in this supplement do not enhance each other or lack interoperability, consumers may abandon their use. Similar to mobile banking, consumers may wish to transfer health information from mobile device to mobile device or may wish to have ready access to information stored in centralized locations. Others may want to receive notifıcations on mobile devices from centralized systems when urgent health information exists. As these systems evolve and mature, the quality and security of health-related messaging via mobile devices may become an increasingly essential commodity if the healthcare system is to serve the needs of its users. The unsustainable rise in healthcare expenditures is in need of breakthrough solutions rather than business as usual. Whether mHealth is such a solution remains to be seen. But the unprecedented rate of uptake of mobile technologies; their use among essentially all strata of the socioeconomic spectrum; and the reduced barriers to entry for imaginative “app developers” for smartphones, tablet computers, and the other personal devices in the mHealth ecosystem all create a fertile ground from which such breakthroughs might emerge. Mobile health promises to drive the adoption of increasingly consumercentric health cyberinfrastructure, transform individual and population health by providing universal access to critical health information, and strengthen the connections among consumers, their social networks, and healthcare providers. As electrical lighting was to the power grid in the early 1900s, ubiquitous mobile technologies may well be the killer app for cyberinfrastructure for health. The views expressed in this paper represent those of the authors and not necessarily those of the DHHS, NIH, or National Cancer Institute. KP is co-owner of Santech, Inc., which is developing mobile phone– based health applications based, in part, upon his research at the University of California, San Diego. The terms of this arrangement have been reviewed and approved by the University of California, San Diego in accordance with their conflict of interest policies.
May 2011
S153
Publication of this article was supported by the National Institutes of Health. No other fınancial disclosures were reported by the authors of this paper.
References 1. Fleishman G. The killer app of 1900. Publicola. 2009. www.publicola.net/2009/12/11/the-killer-app-of-1900-2/. 2. CTIA—The Wireless Association. www.ctia.org/advocacy/ research/index.cfm/AID/10323. 3. International Telecommunication Union. www.itu.int/ITUD/ ict/publications/idi/2010/Material/MIS_2010_Summary_E.pdf. 4. Ahern DK, Woods SS, Lightowler MC, Finley SW, Houston TK. Promise of and potential for patient-facing technologies to enable meaningful use. Am J Prev Med 2011;40(5S2): S162–S172. 5. Abernethy AP, Wheeler JL, Bull J. Development of a health information technology– based data system in communitybased hospice and palliative care. Am J Prev Med 2011; 40(5S2):S217–S224. 6. Bosworth A, York C, Kotansky H, Berman MA. An inventor’s perspective on consumer health informatics. Am J Prev Med 2011;40(5S2):S241–S244. 7. Riley WT, Rivera DE, Atienza AA, Nilsen W, Allison SM, Mermelstein R. Health behavior models in the age of mobile interventions: are our theories up to the task? Transl Behav Med: Pract, Policy, Res. In Press. 8. Patrick K, Griswold W, Raab F, Intille SS. Health and the mobile phone. Am J Prev Med 2008;35(2):177– 81. 9. Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short message service. Am J Prev Med 2009;36(2):165–73. 10. Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epi Reviews 2010;32(1):56 – 69. 11. Pew Research Center. Mobile Access 2010. www.pewinternet. org/Reports/2010/Mobile-Access-2010.aspx. 12. Viswanath K. Cyberinfrastructure: an extraordinary opportunity to bridge disparities and inequalities? Am J Prev Med 2011;40(5S2):S245–S248. 13. DHHS. edocket.access.gpo.gov/2010/pdf/2010-17207.pdf. 14. Federal Communications Commission, and the U.S. Food and Drug Administration. Enabling the Convergence of Communications and Medical Systems Workshop. www.fda.gov/ downloads/MedicalDevices/NewsEvents/Workshops Conferences/UCM219932.pdf. 15. Federal Communications Commission, and the U.S. Food and Drug Administration. Memorandum of understanding between the Federal Communications Commission and the Food and Drug Administration Center for Devices and Radiological Health. www.fcc.gov/Daily_Releases/Daily_Business/2010/ db0726/DOC-300200A2.pdf. 16. Kang HG, Mahoney DF, Hoenig H, et al. In situ monitoring of health in older adults: technologies and issues. J Am Geriatr Soc 2010;58(8):1579 – 86. 17. Shneiderman B, Plaisant C. Designing the user interface: strategies for effective human– computer interaction. 4th ed. Boston: Pearson/Addison Wesley, 2004.
