As a reminder to anybody interested in attending the mHealth Summit this year (December 5-7, Washington DC), early registration ends next Friday. If you are going and want to save $100, register before then.

I wrote a couple of posts (Part 1 and Part 2) recently about the overall mHealth landscape and included mobile apps for pharmacy, pharma, payers, and health systems. I didn’t really cover enterprise apps for health system, at least those used by providers, because it was just too big and broad.

For these posts, I’m defining enterprise apps as those used by health system employees or affiliates. These include clinical systems, practice management systems, clinical communications, RFID and asset tracking, data collection, patient care tools, and coding. I’m loosely defining enterprise to include entities from tertiary care centers to ambulatory clinics and everything in between. I’m also going to only cover, for the purposes of this post, clinical systems, patient care tools, and communications tools.

Enterprise apps aren’t really getting as much attention as all of the consumer-facing health and fitness apps. But in reality, enterprise apps are being used and will likely have a greater impact on healthcare in the short- to medium-term than anything designed to improve patient care outside of the four walls.

EMRs

EMRs vendors are increasingly going mobile, though most with limited functionality. Vendors Epic (Canto and Haiku), drchrono, AllScripts (Remote), ClearPractice (Nimble), Practice Fusion, GE Centricity (Advance), Capzule, and eClinicalWorks all have mobile offerings. I’m sure there are more, but these are the ones that I know.

I’m surprised by what some are calling mobile. Both Practice Fusion and eClinicalWorks (through easeMD) offer mobile apps that are just remote desktop applications. The experience does not take advantage of iOS or Android the way it should, leaving much to be desired. I know Practice Fusion demoed a native app for iOS and Android earlier this week, so at least improvements are on the horizon, even if still a few months off.

In looking at mobile EMRs, you can divide them into those that allow data access and those that allow both data access and data entry. For data access, which is what most are currently offering, both tablet and smart phone versions are probably fine. For those few that offer a true mobile EMR experience (both data access and entry), such as drchrono and Nimble, the iPad is the right form factor.

I’ve used both Nimble and drchrono in demo mode and neither really thrills me, but hey, they’re EMRs. I think data entry over mobile for a complete, meaningful use EMR is a challenge. That’s why I like that drchrono offers voice-to-text functionality, making it possible to dictate and edit at one time and all over mobile.

Voice is helpful, but what I’m really waiting for is a mobile EMR that leverages touch and mirrors clinician workflow. I had a demo of the new Epocrates EMR about a month ago and I have to say that I was impressed with what I saw. I saw the Web version and it was almost totally clickable with auto-populating of content, functionality that I imagine will work well on a touch device. It also followed the way a clinician is trained to do a patient encounter.

Epocrates is also working with Nuance to integrate medical speech recognition into its EMR. If they can combine touch, clinical workflow, and speech well in a mobile EMR, that seems like a winner. Couple that with linkages to Epocrates drug and clinical decision support, not to mention its brand name with providers, and I bet Epocrates will have good uptake in the small physician office market that it is targeting.

It’s probably no coincidence that the two most advanced mobile EMRs (Nimble and drchrono) and the most promising (Epocrates) are all built for ambulatory practices. It’s a much simpler market to penetrate than trying to unseat Epic, Meditech, Cerner, and a host of others in the hospitals. I’m curious to see how AllScripts, Athena, and eClinicalWorks respond in the ambulatory market.

Mobile EMRs have great potential and will likely change the way that providers document and encounter patients. Also, docs love iPads, so using them for EMR access and entry takes some of the sting out the transition to an EMR.

But EMRs are only one aspect of patient care, and a pretty limited aspect in my opinion (more next week on that.) Next week, I’ll cover mobile offerings for clinical communications and direct patient care (nursing, data collection, barcoding, etc,) It’s a bit of a departure from the consumer-facing stuff that I’ve been writing about, but it is very important for healthcare delivery organizations, providers, and ultimately patients.

Travis Good is an MD/MBA involved with health IT startups.

A new report by Kalorama Information, Remote & Wireless Patient Monitoring Markets (167 pages, $3,995 to download), forecasts the remote and wireless monitoring industry to grow at 25.4% annually from the current size of $7.1 billion to $22.5 billion in 2015. A key area of growth is found to be eICU. I still struggle with bundling everything from an eICU platform like Visicu (Philips) to consumer home monitors like MedApps under one umbrella. I realize these solutions are all remote, wireless, and patient monitoring, but the regulation, marketing, technology, users, and clients are just so different.

A new congressional act, Medicare Common Access Card Act of 2011, would issue Medicare smart cards to all beneficiaries and providers. The cards, when read together, would help assure that services were delivered, combating fraud. If CMS is going to pay — and I can’t imagine it will be cheap — to roll out smart cards and readers to providers, then they might as well load PHR data if they can agree on a source for it. I’m sure some patient rights groups would cringe at the thought.

Home monitoring tablet company Independa closes a round of funding worth $1.6 million. The new company offers a health tablet called Angela and a service for health reminders that integrates family into the care of patients. It’s a good idea and well positioned to be acquired if it can get some traction. The press release needs to be updated because I assume data from Angela is not still being sent to Google Health.

Another research group, inMedica, issues a report that finds the telehealth device market will grow from $163 million in 2010 to $6.28 billion in 2020. The drivers for the growth are aging, chronic disease, and health reform.

I thought this was a pretty cool story about games for medical sciences, though not really games for health. A team at University of Washington develops a game, called Foldit, that challenges players to create the optimal protein structure for an AIDS enzyme. In a matter of days, players were able to figure out the correct structure for the enzyme, something that scientists and computers alone had been unable to do.

A new Harris report finds that 74% of adults have gone online for health information at some time and 60% have looked for health info in the last month. Slightly more people use search engines than medical sites.

drcrhono releases a new version of its iPad EMR. New features include free e-prescribing, faxing, and FreeDraw, which allows providers to draw on any document, including radiographic images. According to the report, more than 10,000 providers are using drchrono.

A report by the Congressional Research Service finds social media to effective but risky for disaster response. It shouldn’t be surprising that people would post misleading or false information because well, people are people and I don’t think social network pressure or virtual identities are enough to restrict what people will do. It reminds me of the story of an airbnb customer getting their house ransacked and the ensuing PR disaster for airbnb.

This is a good story on telepsych services. Telephysh makes so much sense because a lot of services can be done virtually. Combine that with lots of these services being self pay and it’s a perfect setup. I went to Breakthrough.com, mentioned in the story, and it was pretty cool to see prices and availability immediately. The challenge if people pick therapists randomly based on availability is continuity of care. It would be nice if therapists were required to chart or upload notes to the site for future therapists to see.

With the mHealth Summit only about two months away, we’re starting to see press releases for different organizations and speakers. I’m betting this will ramp up shortly. EXTENSION, INC. CEO Todd Plesko will speak on the panel "Achieving Effective Healthcare Communications by Unifying Enterprise Phone Systems with Smartphones." EXTENSION offers smart phone apps for enterprise clinical communication as well as secure messaging services.

A McKinsey report finds that despite the many benefits of home care technologies, adoption is still very low. The reasons for this lack of widespread adoption are found to be financial, effectiveness, and accessibility-related problems. The drivers in the future will be healthcare reform and increased evidence for home monitoring. This seems right, but I think home care tech service providers will have to be more creative about where to find revenue and not count on ACOs or health reform to Kaiserize health systems.

Speaking of mobile summits, here is a link to a random Mobile Healthcare Summit in Tampa in a few weeks.

The FCC is hoping to update the legacy, voice-only 911 emergency system to receive texts, pictures, and video. I guess it would be nice in certain scenarios. The example given in the story was the Virginia Tech shootings when students tried to text to 911. Estimated costs would be $1.4-2.7 billion nationwide.

Travis Good is an MD/MBA involved with health IT startups.

I’ve intended to write a post about international mobile health for some time now, specifically mobile health in developing countries. I’ve even been jotting down notes for it in Evernote. 

I’ve had interesting conversations with US healthcare executives about international mHealth. In many ways, the developing world is ahead of the US, both in terms of impact and scale. It’s also possible, even with all the US hype about mHealth, that mHealth is getting more hype internationally in terms of potential to revolutionize health and wellness.

There are many reasons for the differences in stage and potential of mHealth between developed and developing countries. US healthcare executives I’ve talked to seem to get the potential of mobile health when they see it applied overseas, to the point international concepts and work I’ve done have directly resulted in at least one US partnership agreement and grant application.

Earlier this week, I came across a spectacular article specifically on mHealth lessons and limitations from international models. Yes, it was spectacular. The author, Jaspal Sandhu, has an impressive resume and I’m sure he’s written similar reports for some of his recent clients that include Microsoft, Clinton Health Access Initiatives, and the mHealth Alliance.

It’s worth a read if you want a good, concise picture of international mHealth innovation, both in terms of fit and lack of fit for the developed world. It covers a lot of the more well-known mHealth projects and players and has some cool tidbits, like that GlowCaps was an imitation of a South African medication adherence system. I’ll try not to repeat too many points that Mr. Sandhu made in his story and will try to expand on the subject based on personal experience and research.

My personal journey in international mobile health is based on experience with a for-profit mobile health company from founding to first contract. My co-founders and I felt strongly that a for-profit model was essential to scale and go beyond the current environment of grant-driven programs.

The company was launched as a joint venture with a global licensing agreement for a mobile, SMS-based platform that runs on feature phones, about 200 different models. Feature phones are low end, non-smart phones, or dumb phones, by extension. The platform was built to bring a smart phone-like experience to mobile services on low-end devices. It was also natively SMS to provide certain remote push capabilities as well as security features.

Our idea was to license the platform, which is still pretty new though it is on about a million devices in Africa and India, for healthcare. That seemed like a good pitch for scale, especially given the newness of most mHealth companies and technology, and also made development and startup costs very low. We also forged a partnership with a smallish hardware maker in Africa to offer a bundled package to organizations.

The initial idea was a community health worker phone, both hardware and software, that would integrate with OpenMRS, the most widely used EMR system in the developing world. We found this pitch to be too hard to sell, especially as we were not academically affiliated and had missed the Gates Challenge that had funded two similar companies. As we were told by an mHealth Alliance board member, we were much further along in terms of OpenMRS integration and links to mobile payments, but Gates money had already been spent and those organizations would be hard to unseat. That seemed understandable.

We transitioned from community health and clinical offerings to retail health, something that is growing in Africa, and eventually settled on mobile supply chain and monitoring and evaluation (M&E) services specifically for healthcare organizations.

The contract we eventually got, right before I decided to step back into an advisory role, was with a health delivery organization in Uganda that is using the platform and modules we designed to track clinic data in aggregate and health-related supplies (meds, bed nets, reproductive health) from the national level down to clinics and small pharmacies/retailers. I actually don’t think it’s terribly innovative, but we had a good USAID connection in Uganda that sealed the deal. The vision is much bigger than the initial contract, so hopefully it will evolve into something extremely novel and valuable. We’ll see.

I was planning on writing this post with lessons learned that can be applied to the US, but I’ll use what Mr. Sandhu wrote as a starting point. His five lessons learned are below.

Go Beyond Apps

I could’t agree more. The article cites the same Pew Internet data I’ve mentioned before, but comes to a slightly different conclusion. I think text messaging and interactive voice recognition have very limited applicability to impact health and wellness in the US. It might work for basic functions such as med adherence, which I acknowledge is a major problem.

My opinion, though, is that text messaging for chronic disease care is not a viable way to create behavior change because it is such an isolated, static event, not giving the patient access to their full health picture and status on an ongoing basis. To create change and engage patients, they need to know, at all times, what happened previously or what is going to happen in the future.

Text messaging services overseas, for things like medical education games, are perfect because they provide users with relevant information to which they otherwise would not have access. We have regular access in the US to healthcare information and consumers are increasingly going online to get it.

OK, so I realized I didn’t answer what else needs to be done to go beyond apps. I think it involves connected health devices, like MedApps and Telcare and others that will be launching very shortly. I also think it involves suites of solutions and services instead of individual offerings in isolation.

Target the Underserved

Well said. I know Denver Health has some promising results related to mobile health for an underserved, Cricket-using population (Mr. Sandhu mentioned Cricket in his article as well.) A Denver Health  presentation out there somewhere (I think by Andy Steele, MD, or Susan Moore) gives more info about the SMS trial, but I can’t find it. Is there anybody that has it and can send a link?

The article discusses, although not in terms of relevance to underserved groups in developed countries, is the use of mobile incentives. Mr. Sandhu writes about the promising links between health and mobile money or incentives internationally. I also found a proposal by his company that is largely based on mobile incentives to improve health, so I’m sure he’s very well versed in this type of incentive.

Why not use the same thing in the US with underserved groups? You submit your weight (or glucose or blood pressure or steps or whatever) each day and at the end of the month, if you meet some goal for self reporting, you get a bunch of Cricket credits. I guess you could do the same thing with smart phone users if you used things like iTunes credits. I’m not sure about regulatory limitations on incentives like this, but it sounds like it would be worth trying. Does anybody know anybody doing it?

Engage Smaller Operators

I think this is the same as the lesson above. The article differentiates by looking at smaller wireless carriers as great partner targets for mHealth service providers because health services represent new streams of revenue in a very competitive environment. Good points. I think this is how GreatCall operates.

Mix Digital and Tactile

Again, great lesson. The examples of Sproxil and X Out TB are perfect. I imagine there are some very cool imitations of X Out TB that could be used in the US. The issue again is incentives. I’m not sure who would pay for it in developed countries, but you do need incentives, such as free supplies or lower premiums, to get people to use services like this.

Completely Rethink Business Models

Internationally, many mHealth business models are dependent on mobile incentives, mobile money, or mobile payments for things like micro-insurance. Mobile incentives alone will not work for all populations in developed countries, though underserved groups might be a good group to target if you wanted to copy the international model.

I think the point made earlier in the article, "multiple stakeholder groups might also collaborate to pay for a single service", is extremely relevant here. Healthcare financing in developed countries, most especially the US, is extremely complex. It is not as easy as getting the big funder, like USAID or PEPFAR, to sign on. I think many sustainable business models in the US will engage multiple entities to fund individual services.

Other Challenges

I think there are a couple of other challenges in developed countries that companies operating internationally don’t face. First, regulation and policy related to security and privacy, while generally well-intentioned, hinders innovation. We sold a mobile platform for patient data collection in Africa without any discussions about Meaningful Use or patient privacy. The only concession was that the servers had to be housed in Africa and not with Amazon.

This is probably not ideal at this extreme, but the point is that new mHealth offerings are a lot easier to test and roll out without such high penalties and such ease of legal action. This is why we’re seeing such a dizzying array of offerings internationally.

Second, the centralized nature of health funding in developing countries makes who you know very important. Of course who you know and have access to in the US is important, but generally one organization cannot push mobile health programs onto others.

Well, I guess HHS did it with Voxiva and text4baby in the US, so I know that there are exceptions. But from my experience, getting the number of signoffs for a sale with a health system in the US is considerably more challenging than having the org that funds 100% of operations for another local org tell that local org that some mHeath program should be a part of the next budget.

I hope this was interesting and I’m sorry if it went long. I do find the subject fascinating and wish developing countries weren’t so hard to commute to. I’d love to hear from others that have had experience with international health tech work.

Travis Good is an MD/MBA involved with health IT startups.

An impressively analytical study of telestroke in rural emergency departments finds it to be cost effective when looking at the benefit in quality-adjusted life-years (QALYs) over an entire lifetime (~$2500/QALY. The conclusion of the authors, and most people it seems, is that telestroke can help reduce disparities in stroke care between urban and rural settings.

National telehealth provider Teladoc gets $18.6 million in investment from Kleiner Perkins Caufield & Byers. Teladoc’s network of providers enables it to offer nationwide teleconsultations, both voice and video, with an average response time of 22 minutes. With investments like this and the recent $50 million to ZocDoc, both from blue chip investors, we’re going to be seeing a lot of aggressive marketing to push these companies out to all corners of the US. I’m waiting for the deal between a scheduler like ZocDoc and a telehealth company like Teladoc or American Well.

Speaking of American Well, OptumHealth and Rite Aid forge a partnership to offer Optum’s virtual health service, called NowClinic, in Rite Aid stores in the Detroit area. American Well is the telemed platform that Optum uses. Rite Aid customers can access remote care via terminals in stores or at home by visiting www.mynowclinic.com/riteaid. Consultations with nurses are free and it’s $45/10 minutes with a doctor. I believe American Well – and by extension, Optum – offers mobile access only for providers.

More telehealth news and more business for American Well. Mount St. Mary’s Hospital and Health Center (NY), in collaboration with BCBS of WNY and Ascension Health, launches an online primary care practice using American Well’s platform. The telehealth practice will be an integrated part of Mount St. Mary’s system, offering patients telehealth access when they are searching on the web for a Mount St. Mary’s physician. Additionally, and I thought this was very cool, kiosks in the lobby of the hospital will offer access to the online practice, which is a nice and cheap ($25) alternative to an ED visit.

Some international mobile health news. PharmaSecure gets $200,000 from HealthTech Capital. PharmaSecure stamps pill containers with a unique code and phone number that a consumer can check via  SMS to validate that the medication is authentic. Counterfeit medications are a massive problem internationally. PharmaSecure has good traction in India and I recently read that it is moving into Africa. What is interesting to me about this story is that PharmaSecure got the investment from a US-based investor instead of an international investor like Acumen Fund, which funded PharmaSecure’s big competitor Sproxil several months ago.

On the heels of raising capital, iPad EHR vendor drchrono is featured on Apple’s website with a case study of an urgent care center in St. Louis that uses the mEHR. That’s pretty good publicity for an iPad-based EHR vendor.

After the recent release of FDA’s guidance for mobile health app developers, the American Medical Informatics Association (AMIA) issues suggestions about how the FDA should approach apps. The main issue to consider, they say, is whether clinical decision support is automated or mediated by a human factor.

Home health workflow and mobile operations solutions provider CellTrak (video above) acquires home health documentation company MedShare. The combination of CellTrak’s workflow tools with MedShare’s point-of-care documentation and clinical support makes for a complete offering for home health and hospice.

I think I mentioned before how everybody is making infographics these days, so why not have one for online and mobile fitness applications and devices?

The HHS Text4Health Task Force issues recommendations to HHS for mobile messaging and mHealth: a) build and store evidence-based health message libraries (presumably with an open API); b) increase the amount of evidence related to the use of SMS for health; and c) create partnerships to "create, implement and disseminate health text messaging and mHealth programs." The rest of the announcement is about messaging services that HHS has helped create related to smoking cessation.

The Quit Forever app from The University of Tennessee is helping users quit smoking. It’s nice to have an academic name attached to your app if you want your app to be "prescribed."

Health-related startups featured at last week’s Demo Fall Conference in California include LumoBack, which offers a small, connected posture sensor linked to a smart phone app that vibrates when you slouch; Poosh, an SMS subscription service that sends users motivational messages from elite athletes; and MedKenya, which sounds like WebMD for low-end phone users in Kenya.

A new venture fund is launching focused exclusively on health technology. The fund, a part of DC-based Hickory Ridge Group, will have $50 million to invest in new HIT startups.

Travis Good is an MD/MBA involved with health IT startups.

Last week I wrote a post covering mobile health solutions from payers and big pharma, two of the major players in the mobile health space. Today I’m going to continue with the state of mHealth with retail pharmacies and health systems. After that, I’ll try and see if can come up with some coherent thoughts to tie it together. It’s really not easy because of the range of activities in the mobile health space.

Retail Pharmacy

Retail pharmacy is a huge and important part of healthcare delivery in the US. Providers prescribe and consumers consume tons of prescription medications worth about $300 billion each year, or close to 13.4% of total healthcare spending. Pharmacies offer flu shots and urgent care to take advantage of the facilities they already have and try to get more people through the doors.

Additionally, medication therapy management (MTM) is seen as a viable and high-impact way to reduce costs and improve care for patients. Pharmacists are perfectly suited to deliver this kind of care, ideally in a documentable way that gets added to the patient record (PHR, HIE, mobile app?) so that other providers have access to it.

I covered retail pharmacy attempts at mobile consumer health apps in my post about Walgreens Mobile. Walgreens is far ahead of the other retail pharmacy chains in terms of mobile tools for consumers. It has apps for all major mobile platforms, does text notifications when refills are ready, and even does "Refill-by-Scan" if you take a picture of the bar code on the pill bottle.

I’m sure the other retail chains, several of which already have mobile apps, will catch up to Walgreens soon enough to start offering services people need. Namely, the ability to order refills and get pick-up notifications over mobile.

One feature I’m a little surprised I haven’t seen from retail pharmacies is medication reminders like those offered by GreatCall. The biggest challenge from my perspective is that users must manually enter information about medications and schedules. I have to assume that retail pharmacies could easily and automatically load medication schedules into a mobile app or into a reminder service. This would certainly be a nice offering for lots of consumers, especially if adherence reporting, like GlowCaps reports (pictured above, was provided.

Maybe pharmacy and prescription data will become more readily available as a higher percentage of prescriptions are electronically sent. I’m sure Surescripts will love that. Until then, retail pharmacies have a rich set of patient data that is valuable both to providers and patients and could easily be made available over mobile.

I’m not aware of any retail pharmacy apps for providers. The one app that I’ve used is called Generics. This is not from a retail pharmacy, but aggregates retail pharmacy generic medication program information. Providers, and presumably patients, can find good cheap alternatives for meds. I’ve seen providers look up generic medication lists for patients online, so this at least makes that process more convenient.

I’m not sure what else a retail pharmacy would offer a provider other than maybe information about patient medication lists (since medications can be prescribed by different providers) or the ability to get patient adherence info based on refill data. I’m sure this would open up lots of security issues around patient data.

Health Systems

Health systems have a lot to gain by effectively using mobile technology to engage consumers. They can do anything from answering questions about hours and locations to helping improve self care. I covered mobile apps from healthcare orgs pretty extensively in a post a few months ago. The key functionality of these apps then and now seems to be basic facility information, such as provider directory, addresses, and phone numbers. Some offer emergency room wait times and pre-registration, though this is not the average app. Of course there is iTriage, which is starting to do scheduling and registration.

Newer offerings, like the one from Ohio Health, attempt to create a tailored experience for patients, linking them to providers and semi-customized data. Ohio Health is focused initially on pregnancy, with a nice timeline in which you can feed relevant patient education. The design of the Ohio Health app is interesting in that it is built around patient relationships with providers (pregnant patient and OB, for example). The data entry is manual and based on user-entered dates. I’m curious to see how this evolves to more general and chronic care as well as linking mobile app users to medical records.

EMR vendor Epic has MyChart Mobile that is a mobile PHR for patients with lab results, medication information, and appointment schedules. It seems like more and more health systems that are using Epic and MyChart are starting to roll out MyChart Mobile. I think the key will be integrating this with some self-care tools (reminders, evidence-based education, relevant health classes) to make it more than just an mPHR, thus avoiding the fate of Google Health.

I’d also consider appointment booking services, like that of ZocDoc, as a health system, or provider, mobile health tool for consumers. It serves as a mobile interface between consumers and provider schedules, assisting to link healthcare supply to healthcare demand.

The topic of health system mobile apps for providers is a devoted post in and of itself. They include different form factor devices and functionality for secure messaging, accessing patient records, RFID asset tracking, barcode scanning, vitals recording (outside the EMR), patient alarms, coding, and a bunch of other functions that I’ll devote more time to in another post.

How / Does it come together?

Unfortunately I don’t see there being a convergence of mobile health offerings from all the different stakeholders. Each group is trying to target key users — providers and consumers. With both, organizations will want to brand the app for themselves and not roll up functionality into a broader app. At least you can group icons now, at least on iOS. In fact, I had a group of about six apps that I used daily  when I was working in the hospital. They were mostly reference and medical calculators because I didn’t have mobile EMR access.

Healthcare consumers will likely end up with whatever their health provider, payer, and/or pharmacy tells them to use. The one caveat might be those mobile health developers that are working through employers, which seem to be a potentially viable business model for mHealth, and those organizations like Kaiser that are the provider, the payer, and the pharmacy all rolled into one.

I think there is potential for HIEs, if they can start aggregating good amounts of data, to offer consumers access to good, personalized medical and provider info. HIEs may be able to create linkages to pharmacies for refills as well and offer the pharmacists the ability to enter relevant patient information back into the HIE. While HIEs are at it, they could do provider scheduling as well. All of this would require exceptional and unprecedented deal-making for an HIE, something I doubt is even possible. I think they first need to figure out how to keep the doors open.

Travis Good is an MD/MBA involved with health IT startups.