Wireless technology is transforming the way people communicate at an unprecedented rate, and the medical community is no exception.
In June 2011, there were more wireless devices in the
United States than people, and more than 73% of physicians owned a smartphone
— a 22% increase from 2008. That number is expected to reach 81% in 2012,
according to estimates from the Manhattan Research Group.
“Pre-2005, there were very few smartphones. Now, we
see practically ubiquitous adoption of what is essentially a mobile computer
that is unbelievably versatile in terms of memory, wireless Internet access,
high-resolution color screens and camera capabilities,” Orrin Franko,
MD, the lead application (app) editor for the newly launched peer-reviewed
Journal of Mobile Technology in Medicine, said in an interview. “It
basically has every tool you can imagine and fits in your pocket.”
Since Apple launched the iPhone in 2007 and the iPad in
2010, smartphone and tablet prices have steadily decreased. Alternative
manufacturers emerged and new mobile carriers began to offer cheaper data plans
to support the devices, helping to make digital technology more accessible.
Once considered specialist items, smartphones and tablets now are becoming
essential tools for many health care providers and their patients.
Photo courtesy of A. Dicker, MD, PhD, reprinted with permission.
“The iPad is profoundly popular as a mobile
device,” said David R. Artz, MD, medical director of information
systems at Memorial Sloan-Kettering Cancer Center. “[In a recent month],
we had more than 7,000 visits to our patient portal using an iPad, and about
4,000 using an iPhone. The next closest individual device had around 250 visits
because Android devices come in so many versions. The tablet has changed the
landscape for patients and providers.”
‘A huge step forward’
Paul A. Volberding, MD, director of the AIDS
Research Institute at the University of California, San Francisco (UCSF), and
an oncologist by training, stays up-to-date with the latest research in his
field by accessing journal articles on his iPad at breakfast.
“The way journals are packaging their information
in mobile apps for the iPhone and iPad is remarkable. You get instantaneous
access to the article you’re interested in, plus any background
information through clickable hyperlinked references,” Volberding said.
“That’s a great way to start the day.”
Volberding keeps his iPad with him when he works with
trainees at UCSF in case someone asks a question that he cannot immediately
answer.
“There is no second guessing,” he said.
“I can say, ‘I don’t know the answer, but let’s find
out.’”
Volberding sees enormous potential for mobile health
(mHealth) telemedicine opportunities. For example, videoconferencing is
becoming a major component in the Veterans Affairs Medical Center health care
system.
Clinicians also can use the devices to explain various
aspects of a disease, said Adam P. Dicker, MD, PhD, chairman of the
department of radiation oncology at the Jefferson Medical College of Thomas
Jefferson University and the Kimmel Cancer Center in Philadelphia.
“There are apps surgeons use to show where tumors
are and what is happening in the corresponding anatomy,” Dicker said.
“As radiation oncologists, we can explain where the beams are coming from.
We can use a 3-D visual to explain what’s involved with the radiation and
treatment of their disease. It’s all very versatile.”
Mobile technology also has helped clinicians meet a more
basic need — fulfilling continuing medical education requirements.
“A lot of us don’t have the time, money or
opportunity to travel to get CME credits,” Dicker said. “Being able
to get them through online activities is a huge deal.”
Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS,
associate director for clinical pharmacy services at the University of
Rochester Medical Center in New York, said mHealth makes once time-consuming
tasks — particularly communicating medication reconciliation issues with
patients and other health care providers — more efficient.
Elizabeth S. Dodds Ashley
Dodds Ashley uses the free mobile app MyMedSchedule from
MedActionPlan.com, an app designed to help patients remember how to take their
medication. When she interviews patients, she uses her iPad to input
information from their medication list into the program, including the
medication’s purpose, the appropriate dose and when it should be taken.
She then prints the patient’s medication schedule and emails copies to the
patient and his or her primary care physician.
“We are able to use mHealth right at the
bedside,” Dodds Ashley said in an interview. “That’s a huge step
forward for us.”
Another real-time source for drug information is the
social media website Twitter. Dodds Ashley follows the FDA (@FDArecalls) to
stay up-to-date with drug recalls and shortages. On two occasions, Dodds Ashley
became aware of recalls for anti-infectives on her Twitter feed when traveling.
“Once a recall hits for one manufacturer, the
supply for similar medications from other manufacturers runs out fast,”
Dodds Ashley said. “When I saw the Twitter notifications, I was
immediately able to call my purchaser and have her order replacement
medications 18 hours before the recall announcement came through in my
email.”
Public health outreach
Although the technological capabilities of mHealth are
impressive, the human component remains essential to the success of any mHealth
program or intervention.
Lygeia Ricciardi, EdM, senior adviser of consumer
e-health at the Department of Health and Human Services’ Office of the
National Coordinator for Health Information Technology, said facilitating
communication between patients and doctors and encouraging improved self-care
are top priorities for her program.
Lygeia Ricciardi
“It’s important not only to think about how
technology can improve the delivery of health care services, but also about how
it can help to engage patients in their own health,” Ricciardi said in an
interview.
Mobile phones and smartphones offer several distinct
advantages to other forms of digital technology for public health efforts, one
of which is reaching populations in underserved areas.
Whereas much of the Western world is enamored with the
high-tech aspects of mHealth, the utility of simple text-messaging programs is
important to improve access to health care, said Jesse Coleman, MSc, an
independent consultant who has served as the mHealth project manager for the
British Columbia CDC and performed field research on mHealth programs
throughout Africa.
“In Kenya, the health system is pretty limited to
begin with and the basic population level health knowledge is much lower than
in Western nations,” Coleman said. “People do not have access to the
Internet to diagnose every health problem and too many do not even understand
basic health concepts.”
However, cellphone use has been growing more rapidly in
Africa than in any other part of the world. In 2011, the continent became the
second largest mobile market in the world with more than 600 million
subscribers, surpassed only by Asia.
To assess whether the growing interest in cellular
technology could translate into health benefits, Coleman and researchers from
several African, American and Canadian universities conducted a randomized
controlled trial, called WelTel Kenya1, that included 538 adult patients. The
study, conducted from May 2007 to October 2008, was designed to determine
whether text messaging between health care workers and patients initiating
antiretroviral therapy in Kenya could improve self-reported medication
adherence and HIV viral loads.
The researchers randomly assigned 273 patients to an
mHealth intervention in which patients received weekly text messages to remind
them about the availability of phone-based health care support. These patients
were compared with 265 patients assigned to standard care.
The intervention group received a “How are
you?” text message every Monday that prompted them to report within 48
hours whether they were doing well or had a problem. Clinicians followed up
with patients who responded that they had a problem or those who failed to
respond within 2 days.
Patients who received the text-message support were more
likely to report medication adherence and were more likely to have viral loads
suppressed below detection levels than those who received standard care,
Coleman and colleagues found.
The benefits of the intervention extended beyond the
statistical realm.
“Patients often said they felt like somebody cared
about them,” Coleman said. “It’s interesting how much just being
able to interact with a health care provider to get support when it’s
needed affects people. It’s not something a lot of people in resource-poor
settings feel that they have.”
This is the type of interaction that Ricciardi said HHS
wants to achieve with mHealth interventions for US patients with chronic
diseases, such as diabetes and cardiovascular disease.
“We want to use mHealth to shift the health care
model from the more traditional model, in which patients see their health care
providers only when they’re sick, to one in which patients are encouraged
to be a partner working toward the shared goal of staying healthy or managing a
chronic condition,” Ricciardi said.
Integration of apps and EHRs
As more US medical practices move toward meeting federal
goals for universal adoption of electronic health records (EHRs) by 2014, many
expect the role of mHealth in ensuring continuity of care to expand as the
ability for apps to integrate with EHRs improves.
“We don’t have an app yet, but I’m still
able to access the EHR system from my smartphone,” Dodds Ashley said.
“I can immediately get the patient information I need at my fingertips,
see the cultures and make appropriate recommendations. Or if I’m on a
pharmokinetics consult, I can see the exact time of the patient’s last
dose from wherever I am. That’s helpful in providing up-to-the-minute care
from inside or outside of the hospital.”
The Epic EHR system in use at Franko’s institution
— the University of California, San Diego — has two apps available to
review patient information: Haiku for the iPhone and Canto for the iPad.
However, he said a major limiting factor is that these are read-only systems.
“The apps are beautiful aesthetically. They are
well done, but you can’t place orders on them or write notes,” Franko
said.
Other limiting factors include the relatively small
screen size on smartphones, the limited amount of space available to store
data, short battery lives and no standard keyboard for those who wish to type.
Mobile technology is still in its early stages, and many
of these kinks will likely be worked out over time, Artz said.
David R. Artz
“For our purposes, we need this technology to be
secure, fast and stable,” he said. “The security we can handle, but
if you use a personal device on our network, all of its data will be wiped away
when you leave.”
Cloud computing
Cloud computing, whereby users on a network access data
stored on a remote secure server via a Web browser or app housed on a
smartphone or tablet, makes the amount of space available to store data
limitless. It also offers solutions to security concerns about remaining Health
Insurance Portability and Accountability Act (HIPAA) compliant in an mHealth
world.
Health care data breaches involving patient information
increased 32% from 2009 to 2010 in a network of 65 health care organizations,
according to data from the Ponemon Institute’s Second Annual Benchmark
Study on Patient Privacy and Data Security.
During the 2 years before the study’s publication
in 2010, 60% of participants reported that they experienced more than two data
breaches, with each participant experiencing an average of 2.4 data breaches
during the study period. A lost or stolen computing device was among the top
three causes given for these security breaches, along with unintentional
employee action and third-party error.
Many believe cloud computing will make those situations
less likely.
“As we move into a cloud-based mobile computing
world, very little patient information will actually be stored on phones and,
therefore, very little information will be at risk for theft,” Franko
said.
Orrin Franko
MHealth may actually improve patient privacy in the long
run.
“If you walk into any hospital in the world, you
will see paper charts all over every counter top,” Franko said.
“People bank online. They have all of their finances online. I don’t
see how a mobile phone connected to a cloud-based database is in any way less
secure than online banking.”
IMEI numbers
In April, the Federal Communications Commission and the
International Association for the Wireless Telecommunications Industry
announced an initiative to help curb the theft of smartphones, a move that
should reduce concerns about stolen patient information.
The initiative will enable smartphone owners to disable
the device after reporting it lost or stolen using an international mobile
equipment identity (IMEI) number, the equivalent for smartphones to a vehicle
identification number.
Tampering with a smartphone’s IMEI number will be
designated as a federal crime, and smartphone service providers are creating
databases of all IMEI numbers so that those reported lost or stolen cannot be
reactivated.
Databases for smartphones that operate on the Global
System for Mobile (GSM) communication are expected to be ready in October, and
databases for phones operating on Long Term Evolution (LTE) should be active by
Nov. 30, 2013.
In the meantime, health care organizations must make
sure that they are following appropriate security protocols.
“If I’m accessing any sort of patient data, I
always do it through a secure virtual private network (VPN) connection set up
through the medical center,” Dodds Ashley said. “Our
organization’s policy is that we don’t store any patient data on the
devices.”
Dicker highlighted a more basic security concern.
“We need to continually remind our patients that
people may be reading our emails or theirs,” he said. “Scheduling
appointments and handling questions via email is obviously convenient and
eliminates the phone tag factor, but it’s a drawback to the current trend
that this medium is not confidential.”
Future of mHealth
As more health care providers begin to use their
smartphones in the clinical setting, more attention will shift to
pre-implementation testing and post-implementation monitoring to ensure that
the devices are reliable, accurate and consistent.
According to Ricciardi, there are three key requirements
to ensure mHealth is successful:
- It must provide specific, actionable information.
- Text services or apps must be evidence-based.
- mHealth programs must be regularly evaluated to determine what is
working and what is not.
“It’s going to take a concerted effort on the
part of health care providers to encourage patients to engage in improving
health care using mHealth technology,” Ricciardi said.
Coleman expects private corporations will play a larger
role in funding and developing the mHealth industry as they begin to realize
the business potential of the mHealth market, while government health
organizations facing tight budgets will contribute less funding.
In the meantime, Franko encourages health care providers
from a wide range of specialties to become more involved with designing apps to
meet the unique needs of their respective professions.
“No one is throwing away their smartphone anytime
soon, so medical software developers will continue to find new ways to
integrate with mobile technology,” Franko said. “In the future,
health care providers will be using mobile technologies in ways I can’t
even imagine.” – by Nicole Blazek and Rob Volansky
References:
- Berg A. Carriers, FCC crack down on smartphone theft. Wireless
Week. April 10, 2012.
- Blumberg SJ. Natl Health Stat Report. 2011;39:1-26.
- Fox S. The Pew Research Institute Report on Mobile Health 2010.
Available at:
www.pewinternet.org/Reports/2010/Mobile-Health-2010.aspx.
- Ghosh PR. The spectacular mobile phone revolution in Africa.
International Business Times. Nov. 17, 2011.
- Kaiser Family Foundation. Mobile technology: smart tools to
increase participation in health coverage. March 2011. Available at:
www.kff.org/medicaid/8153.cfm.
- Lester RT. Lancet. 2010;376:1838-1845.
- Ponemon Institute. Second annual benchmark study on patient privacy
and data security. December 2011. Available at:
www.ponemon.org
- Rajagopalan Ms. J Oncol Pract. 2011;7:319-323.
Disclosures:
- Drs. Artz, Dicker, Dodds Ashley, Franko, Ricciardi and Volberding,
and Mr. Coleman, report no relevant financial disclosures.
Will the rapid proliferation of mHealth technology pose a threat to
patient confidentiality?
If users of mHealth technologies follow appropriate protocols,
privacy will not be threatened and confidentiality will be maintained.
Any technology — indeed, any device or intervention — has the
potential to be misused. Technology only facilitates the intent of the user.
MHealth technology merely differs from other recording and communicating
devices or techniques in that its use occurs in what is essentially a public
forum.
The Internet is unlike other means of communicating health data because
it is susceptible to interception, alteration and misuse to a much greater
extent than what was previously possible. However, the technology itself
provides a means of safeguarding privacy and ensuring confidentiality that do
not exist with traditional paper-based methods of communication. Specifically,
the encryption techniques and related methodologies that are available can
assure a level of protection that was essentially unavailable before.
There’s an old saying from computer programming: “The short
circuit is between the keyboard and the seat.” In other words, it’s
the human element that poses the problem, not the technical parameters.
No one can guarantee that users will not make mistakes. Laziness,
cost-cutting measures and simple errors cannot be eliminated, whether at the
design level or the user level. However, they can be minimized — at which
point the question becomes whether the potential risk is balanced by the
tremendous benefits in terms of access, quality and timeliness of health care
delivery that mHealth technology offers. I believe the benefits outweigh the
risks.
Eike-Henner Kluge, PhD, is a professor of
philosophy at the University of British Columbia in Vancouver, Canada, with a
research focus in medical informatics and biomedical ethics. Disclosure: Dr.
Kluge reports no relevant financial disclosures.
The need to assure patients’ rights is particularly important,
especially since privacy can be breached relatively easily in the digital era.
Innovative information technologies offer a spectrum of health care
applications, including the Internet (e-health), smartphones and tablet
computers (mHealth), electronic health records (EHR), medical databases and the
emerging telemedicine industry. In areas where information technology is
restricted, cellular services are readily available.
Thus, mHealth has the potential to alleviate some infrastructure
deficiencies, helping increase telemedicine and e-health potency. The need to
protect medical information and patients’ privacy are well-known concerns
and receive much attention in states’ statutes and federal legislation
— most notably through HIPAA.
As more mHealth applications are developed to interface with EHRs,
detailed assessments of where and when confidentiality might be breached are
sorely needed. Transferring medical data to remote sites via mHealth may occur
in several ways, depending on the medical specialty. In radiology, for
instance, imaging studies are the most likely items to be shared. If a
consultation is performed remotely, a patient’s entire medical record may
be shared. Within surgical and psychiatric specialties, live video files are
created and then stored, copied and transmitted. All of these instances involve
informational risks that must be contained.
Assuring that patients are informed about all possible risks and have
provided necessary consent forms should be a priority for health care
providers. However, the starting point for any such regulation to protect
patients should aim to enable mHealth proliferation while containing
confidentiality concerns. Halting the development of mHealth technology until
all qualms are completely resolved is not an option. In an era in which every
detail of a person’s life can be managed via the Internet, even banking,
mHealth should be the next evolution of IT-driven health care.
Gil Siegal, MD, LLB, SJD, is a professor of
law at the University of Virginia School of Law, and the director of Center for
Health Law, Bioethics and Health Policy at Ono College and an otolaryngologist
at Tel Hashomer Medical Center, both in Israel. Disclosure: Dr. Siegal reports
no relevant financial disclosures.