By Salina Christmas

Telecommunication providers and mobile phone handset manufacturers need the medtech industry to penetrate the mobile health (m-health) market, it was agreed at the Mobile Healthcare Industry Summit 2010, whcih took place in London recently. Medtech is definitely where the opportunities for lie, the delegates concurred, but the question is, where should one deploy the mhealth applications, and how to make a decent profit out of it.

“The medical device makers own the mhealth market,” said Thierry Zylberberg, executive vice-president, head of Orange Healthcare Division, France Telecom, in his keynote speech at the summit.

Historically, medical device manufacturers form strategic alliances with telecomm companies (telcos) to integrate wireless, if not mobile, connectivity to their system solutions. An example is the Sorin cardiac system management which enables patients implanted with the company’s heart devices to be monitored remotely from home using Orange connectivity, Zylberberg explained.

The two business models identified by speakers at the summit – business-to-business (B2B) and business-to-consumer (B2C) – come with their own set of challenges. The B2B model, which focuses on health management, sees the physicians and health workers using m-health largely for administrative purposes and asset tracking, while B2C sees the patient using m-health to perform tasks such as blood monitoring and drugs compliance in domestic settings.

In state-funded healthcare markets, the B2B model can rake in the profits, but they are harder to penetrate, primarily because the payers have to contend with legacy issues, inadequate ICT support, and also because physicians, depending on their expertise, see little need in incorporating mobile applications into their tasks, especially when the admin duties are best left to the supporting staff.

The B2C market is aimed mainly at wellness, and will see some consumers using certain applications such as the smart phone app to keep tab on general fitness, or specific devices to maintain existing medical conditions. More importantly, this model will potentially see the patient, not the healthcare provider or the device manufacturer, footing the cost of network connectivity through a phone subscription.

Championing auto ID

The case studies, presented to the audience of healthcare providers, pharmaceutical companies, software developers, mobile operators, handset makers and system integrators, championed the effectiveness of data gathering via wireless – if not mobile – automated identification (auto ID) and collection of data.

There were several mentions of “data sets” throughout the summit. A qualitative analysis is no doubt useful to help the health worker or the patient make an informed decision on a medical condition, but this leads to the question: what to do with this deluge of data?

An uncompromising address by a University College London (UCL) academic did a good job in levelling the technologists’ enthusiasm over automated data collection.

“Techno-utopia”

Doctors don’t want to be swamped with more data, and more importantly, neither do they want their patients to be overwhelmed by too much information, cautioned Dr Henry Potts of UCL’s Centre for Health Informatics (CHIME). Healthcare still hasn’t got used to the idea of digitality, so don’t imagine that this target market will embrace the concept of m-health in a hurry.

“[The health providers] have too little manpower to look at existing data…. Connecting patients to health care professionals (HCP) could undermine the patient becoming self-sufficient.”

Doctors would, however, appreciate “new ways” of interacting with the patients, and for patients to find means to look after themselves more, Dr Potts suggested, indicating that m-health is most likely to be useful in facilitating the individual supply chain management of the doctor and the patient, not necessarily in massive pooling of data. He cited iTriage, a mobile app for iPhone and Android platforms. iTriage is a digital phenomenon that enables the HCPs to perform a series of checklists to monitor symptoms and to diagnose disease. This is the type of application that would help them make a reliable and quick decision on “what should I do next”.

Dr Potts also highlighted another problem with automated data collection relating to biosensors. The “idea” of biosensors being connected to automatic alerts is popular. However, automated alerts have a high rate of false positives, which could encourage HCPs such as radiologists to start ignoring what they perceive as false positives. Radiologists can’t afford to ignore alerts, especially in cases such as breast cancer detection. Installing a computer system might not improve cancer detection, but could lead to more women being called to the clinics for checks, and thus, costing more money to the health providers.

The lesson Potts offered: don’t get sucked into techno-utopia. System implementations belly-flopped in some cases because technologists failed to see that it’s the way people use the application that counts.

Nonetheless, it is worth nothing that the system interface provided by m-health could also be a good buffer that can ease the physician-patient interaction. Doctors don’t want to be overwhelmed by patient feedback. Dr Mike Stein, chief medical officer of Map of Medicine, pointed out in a panel discussion about the personalisation of healthcare that m-health can act as a filter of data exchange between the doctor and the patient.

It’s the meaning, not the numbers

Out of the numerous case studies on mobile practices and automated data collection designed to appeal to the audience’s rationale during the summit, it was a presentation by a group of product designers and app developers that made the most convincing case about the usefulness of the data collection and data sets.

Data is about meaning, said Gus Desbarats, chairman of product design firm The Alloy. Don’t put too much stock in the technology because it’s about information. Knowledge requires, to a degree, “belief”, or conviction. Data sets alone won’t get potential m-health customers to buy into m-health. They’ve got to be information that means something to the customers.

Sergio Fabio, executive creative director of Frog Design, underlined: “A sensor is only meant to do what it’s meant to do. People won’t buy a technology for technology’s sake, unless they’re early adopters. People would buy something that adds value into their lives.” For example, he illustrated, a smoker would stop smoking not necessarily because it is of medical importance to him, but because he is “motivated” to smoke in front of his son. It’s the “motivation” that counts.

Since the human brain and his five senses are not designed to cope with a high volume of data sets, the reliance on a computing system is unavoidable. This, however, means that product designers and apps developers for m-health will have to favour a method of interfacing that is more appealing to our cognitive abilities. So, expect more updates on data visualisation.

A very long tail

Some of the case studies, in particular those drawn from ethnographic research on the use of mobile phone in developing regions such as West Africa and Micronesia, and involving the national health providers, make very a useful point of reference, at least for the social scientist. But out of the many pilots presented at the summit, which one made the most business sense?

Galit Zadok, who presented a talk together with UCL’s Dr Henry Potts, reminded the audience that the m-health service is not like your average mobile content. “There is no head, only a very, very long tail,” she said. The revenue fragmentation is deep, making it hard for m-health to have a blockbuster solution. Most non-health mobile content is offered on an autonomous, one-off transaction, a model on which premium-rate services such as betting, adult chat lines and horoscopes thrive on, but not necessarily one that will go down well with healthcare practitioners, non-governmental organisations and consumer protection groups.

Developing regions lead the way

This is where seemingly anthropological non-commercial pilot projects come in handy. The rural case studies, which see the use of mobile phones as disruptive technologies, provide the comparisons which are essential in identifying the most appropriate m-health applications in a first world setting, and thus, helping the summit’s audience determine what Qualcomm’s Don Jones called “insertion points”. The mobile phone is not a mere technology – it is a sociotechnical activity.

As the vice-president of Telefonica O2, Dr Mike Ward said on the second day of the summit, in response to a delegate’s question: “We concentrate on projects that can potentially bring in revenues. Until we [find the right model], we will continue to do pilots.”

Indeed, it is the developing countries that are clearly leading the way in terms of m-health, even in the case of the Average Revenue Per User (ARPU) model for the telcos. David Doherty, co-founder of 3G Doctor, proposed an intriguing hypothesis for the m-health ARPU, drawing on the Avea AloDoktorum (Hello, Doctor) partnership between Turkish mobile operator Avea and Acibadem Mobile Healthcare Services. This initiative was rolled out earlier this year.

The ARPU with Avea Turkey costs TRY16 (US$11.03) a month. Avea’s AloDocktorum subscription costs an additional TRY5 (US$3.44) a month. The additional subscription level of customers who are prepared to pay for the AloDocktorumservice pushes the ARPU up by 31%. If, for example, Verizon USA, which has an ARPU of US$51 a month, could convert the equivalent proportion of subscribers – that is, 3.7% out of its 91.2 million subscribers – to take on a similar m-health service, Doherty said that would potentially earn Verizon USA $641m a year.

Of course, ARPU is a conservative estimate which presupposes the revenue per user, or per device, and there are things to consider such as operating costs and so on. Nonetheless, Doherty’s proposal makes a very good point of reference for an ARPU model during the summit.

Agency, apps, and that argument over Apple

The debate over the privileging of images as the main mode of knowledge transfer in disease diagnosis has been going around for some time in the social science sphere, and it was this method of knowledge transfer that Don Jones, vice-president of Qualcomm, a wireless systems provider, highlighted during his presentation as a potential key application for m-health.

He raised the possibility of picture archiving and communication system (PACS), which is used to store high-resolution medical imaging, to be deployed in cloud computing. Image transfer of PACS content could be the “big dollar play” once the images of slices and scans can be compressed and transferred using mobile devices.

Another insertion point to consider is the personal emergency response service for patients who have been released from hospital to be taken care of at home. Jones says this is an instance where patients and their families can be receptive to the use of mobile phones in m-health.

Professor Chris Taylor of University of Manchester proposed that mental health is where the biggest savings opportunity can be done using m-health. Indeed, works have already been undertaken by medical device companies such as Intel Digital Health in examining the use of software as a loneliness intervention strategy.

A potential agent considered by which m-health can be adopted by the consumers is sports, but it was the keynote panel discussion over sports and wellness that a debate took place over the type of mediation used to monitor sports performance digitally.

Sports were mentioned as a key market for B2C m-health, with the Nike + iPod personal trainer cited as an agent. This, however, caused a European delegate to question the summit’s favourable slant towards Apple innovations such as the iPad and iPhone apps. An explanation by the chairman about the rationale behind the use of such innovation in turn invited a cutting remark by the same delegate: “You Americans are so positive…” And with that, Apple became the unexpected actor in a heated exchange about apps and American technological imperialism between several of the delegates and speakers.

The lowest common denominator

Technological imperialism is probably best discussed in another type of summit, but the irate delegate’s concern over technological determinism is not entirely unfounded. Saad Hussain, head of commercial management at BT, reminded the audience in his presentation on how mobile healthcare can be monetised for all players”, that mobile operators and system integrators should always aim for the lowest common denominator when targeting B2B and B2C m-health customers. The short messaging service (SMS) does the job well in alerting patients and getting HCPs informed.

It makes sense. For example, GE Healthcare, a leading medical device company, reversed its traditional business models when innovating for the rural populations in developing countries.

In the same discussion, Jason Goldberg, CEO of m-health system provider Ideal Life, explained to the audience about the three components to consider in applying m-health to the existing ICT infrastructure: the scale of access, accountability of the m-health application, and action. Action should be acted on, for example, over the absence of a smart intelligence that delivers the right solution to the right people at the right time.

There were also other questions raised such as the sustainability of m-health products. The disposal of single-use devices via means that are not environmentally friendly is well acknowledged and in many cases, unavoidable. Thus, the emphasis on sustainability often falls on ICT, or the electronics side of things. This is not an easy matter to address, as innovations such as long-lasting batteries using tantalum capacitators – supposedly the more economical alternatives to some electricity-hungry devices – also come with a socio-economical baggage. That sustainable solution is not there yet, but it could only mean that m-health is well-placed to be the opinion leader in this area.

An app is not a medical device – yet

Plenty was said at the summit about the potential of mobile phones being not just a cheaper alternative to expensive, power-guzzling medical devices, but also a diagnostictool in its own right. But telcos who are already in partnership with medical device companies are not going to upset the apple cart by promoting mobile handsets as the alternative. Nonetheless, Orange’s Thierry Zylberberg was correct: for an app, for example, to be fit for use in a healthcare setting, it has to be certified by the US FDA and the relevant notified bodies as a “medical device”. Of course, the line is increasingly blurred now that it is evident that the software, not just the hardware, is instrumental in determining the data capture capacity of the device.

Take, for example, the iStethoscope iPhone app, developed by UCL computer scientist Prof Peter Bentley to collect heart sounds for a cardiology research project. Prof Bentley told Clinica that the app was initially launched on Apple App Store to promote his book, The Undercover Scientist. Although the app works very well in recording heart sounds, it is not a medical device. For that to happen, the app would have to go through a different bureaucratic process, not via the approval of Apple.

This is where the medtech regulatory experts could be involved in the next summit to explain the intricacies of medical device legislations. There are quite a few sets of legislations to consider, some unique to a particular economic region. Also, if mobile handsets harbour ambitions to be, for example, a blood monitoring device, then the designers would have to figure how to make them measure an organic sample, too. Another group of scientific experts would have to be roped in for this. But do mobile phones want to diversify that far? Hypothetically, a smart phone can be placed within a similar market in which the GE Healthcare Vscan operates in, but the technology has to get to that stage first. Maybe it already can. M-health will be most useful in helping the healthcare workers manage their workflow, and helping patients to monitor their conditions remotely. The focus, for now, is on the individual supply chain management.

First published on Clinica