Wireless technology is transforming the way people
communicate as quickly as a mutating virus, and the medical community is not
immune. 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. This proportion 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 with
Infectious Diseases in Children. “It basically has every tool you
can imagine and fits in your pocket.”
Orrin Franko, MD, said medical software developers
will continue to find new ways to integrate with mobile technology.
Photo courtesy of Franko O
Since Apple launched the iPhone in 2007 and the iPad in
2010, smartphone and tablet prices have steadily decreased, with alternative
manufacturers emerging and more mobile carriers offering cheaper data plans to
support the devices. This is making digital technology more accessible for
everyone. Once considered specialist items, smartphones and tablets are now
becoming essential tools for many health care providers.
Paul A. Volberding, MD, director of the AIDS
Research Institute at the University of California, San Francisco (UCSF), said
he stays current with the latest research in his field 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 said he likes to keep his iPad with him when
he works with trainees at UCSF, in case a question comes up that he cannot
immediately answer. “There is no second guessing. I can say: ‘I
don’t know the answer, but let’s find out.’”
Volberding said he also sees enormous potential for
mobile health (mHealth) telemedicine opportunities, and Infectious Diseases
in Children Chief Medical Editor Richard F. Jacobs, MD, said he
agrees. He sees the future of medicine and interaction with patients changing,
along with health care and health care finance. Therefore, technology is
helping to fill in where gaps in funding would otherwise adversely affect
“Due to work force shortages, especially in rural
areas and in primary care, the use of non-MD health care professionals to
deliver coordinated patient care and do primary care is changing to models with
advanced practice nurses, physician assistants, and links to physician networks
using telemedicine. The continued shortage of many subspecialty disciplines and
the availability of appointments, driving distances and convenience for
patients and families are also driving these new initiatives in specialty
care,” Jacobs said. “Local primary care physicians have to be
supported and enabled to care for more patients in their local communities. The
availability of telemedicine consultation will grow significantly in the coming
years. The need for patient privacy and health care information will remain and
use of this new technology will require specific attention to these security
issues. On the whole, connectivity and distance communications can be one of
the next booms in the health care mainstream.”
Elizabeth S. Dodds Ashley, PharmD, MHS, BCPS, an
infectious diseases pharmacist and associate director for clinical pharmacy
services at the University of Rochester Medical Center in New York, said
mHealth makes once time-consuming tasks more efficient, particularly
communicating medication reconciliation issues with patients and other health
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 interviewing patients, she uses her iPad to input any
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 a copy of the patient’s medication schedule directly from
the tablet to the printer on the hospital floor, and emails a copy to the
patient and the patient’s primary care physician or infectious diseases
specialist if desired.
“We are able to use mHealth right at the bedside
— that’s a huge step forward for us. We can also retrieve this
information later and share it with our colleagues,” Dodds Ashley said in
She also finds Lexicomp’s Lexi-Drugs app useful for
looking up drug information on the go. Lexicomp offers a suite of mobile drug
applications for the iPhone, iPad and iPod touch that range in price from $75
to $285. (Demo video for Lexi-Drugs app available to embed in the online
Other apps Dodds Ashley uses include Micromedex’s
Drug Interaction app, priced at $9.99 for both Apple and Android devices, and
free apps from major infectious diseases organizations to help stay organized
with information and scheduling at medical conferences.
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, because in her experience,
information reaches the “Twittersphere” faster than traditional email
notifications. On two separate 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
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 for
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.
“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 with Infectious Diseases in Children. 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
Whereas much of the Western world is enamored with the
high-tech aspects of mHealth, Jesse Coleman, MSc, an independent
consultant and mHealth expert who has held positions as the mHealth project
manager for the British Columbia CDC and performed considerable field research
on mHealth programs throughout Africa, said the utility of simple
text-messaging programs is important to improve access to health care.
“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, and, 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, dubbed WelTel Kenya1, that examined whether text messaging
between health care workers and adult patients initiating antiretroviral
therapy in Kenya could improve self-reported medication adherence and HIV viral
loads. The study results revealed that patients who received the text-message
support were more likely to report ART adherence and were more likely to have
viral loads suppressed below detection levels than those who received standard
care, Coleman and colleagues found.
This is the type of interaction that Ricciardi said HHS
wants to achieve with mHealth interventions for US patients with chronic
“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.
Ricciardi said specific groups of patients within the
United States are more likely to benefit from mHealth campaigns than others.
These groups include racial and ethnic minorities, and those living in urban
areas, which have some of the highest uninsured populations. For members of
underserved populations who may not have personal computers, mobile phones
often serve as the primary source of information as well as communication.
Other potential areas for developing infectious
diseases-related mHealth public outreach programs in the United States and
Canada, as reported previously in Infectious Diseases in Children,
include text-messaging campaigns to improve vaccine and asthma medication
adherence, reminders for hospital staff to follow appropriate hygiene and
infection control protocols, and alert systems to notify health care providers
and the public when there are disease outbreaks occur in their communities.
“MHealth technology is unique because it is almost
always accessible, and since most people own their own phones, this technology
has the ability to be much more personal than traditional means of accessing
the Internet through computers, which are often shared,” Ricciardi said.
Cloud computing and safety of data
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, and also offers solutions to security concerns about remaining
Health Insurance Portability and Accountability Act (HIPAA) compliant in an
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.
To help curb the theft of smartphones that should
eliminate concerns about stolen patient information, the Federal Communications
Commission and the International Association for the Wireless
Telecommunications Industry announced in April a new initiative. The new
program is designed to 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.
Future of mHealth
As more health care providers begin using their
smartphones in the clinical setting, ensuring that tools are reliable, accurate
and consistent through pre-implementation testing and post-implementation
monitoring are the goals for mHealth in 2012 and beyond.
According to Ricciardi, the three key requirements for
mHealth to be successful are: that it provide specific, actionable information,
that text services or apps be evidence-based and that mHealth programs 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.
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.
– by Nicole Blazek
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Kaiser Family Foundation. Mobile technology: smart
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Ponemon Institute. Second annual benchmark study on
patient privacy and data security. December 2011. Available at:
Mr. Coleman and Drs. Dodds Ashley, Franko, Ricciardi and Volberding
report no relevant financial disclosures.
Will the rapid proliferation of mHealth technology pose a threat to
Any technology — indeed, any device or intervention — has the
potential to be misused.
Whether this happens depends on the user. Technology
only facilitates to a greater or lesser degree, 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. If users of mHealth
technologies follow appropriate protocols, privacy will not be threatened and
confidentiality will be maintained. But 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 protect medical information and patients’ privacy are
well-known concerns and receive much attention in states’ statutes and
Innovative information technologies offer a spectrum of
health care applications, including the Internet, smartphones and tablet
computers, electronic health records, 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
mHealth 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 interest
in and the development of EHR increases, the need to assure patients’
rights is particularly important, especially since privacy can be breached
relatively easily in the digital era. 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, in Charlottesville, 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.