Webinar: Innovations in Mobile Health

Date: October 26, 2011
Speaker:
Dr. Audie Atienza (NIH/NCI) - discussing how HHS is leveraging mobile health (mHealth) initiatives, and how the Text4Health Task Force is providing recommendations to guide HHS' strategic development of health text messaging.
If you have questions regarding this webinar or the HHS Center for New Media Webinar series, email newmedia@hhs.gov.
Transcript

My name is Audie Atienza. I am currently on detail from the National Institutes of Health to the Department of Health and Human Services, working under Todd Park, the Chief Technology Officer at HHS, and advising Secretary Sebelius and Deputy Secretary Corr on mobile health and health technology. 

Today, I just want to give an overview of the exciting area of mobile health and what HHS is doing. I’m going to break it up on a number of different parts. First, I’m going to give some background about mobile health and the growth of mobile health. Then I’m going to talk about the activates at HHS and how HHS is innovating in this area of mobile health. Thirdly, I’ m going to talk about future directions of mobile health. 

But, before there were cell phones, there was Star Wars. I’m a huge Star Wars fan. I love Star Wars. I guess growing up in the 70’s, Star Wars was the big Sci-Fi movie. It had so many incredible things in that movie. But, you ask yourself, who is the real hero of Star Wars? And some people say Yoda, some say Obi Wan Kenobi, and I want to make the argument that it was R2-D2! R2-D2 was the android that was always present and always helping out. And the reason why I think he was the hero of Star Wars is one, he has the really cool built in censors that scanned the environment, figured out what was around the environment, and let other people know if there were dangers. He was also able to integrate and optimize with other computer systems and optimize performance. You’d always see him plugging into X-wing fighters or other assets and getting information from these to really help the others know where things were at. And finally, R2-D2 stored and communicates critical health information. I argue that he was the real hero of Star Wars. And so, given this argument, you know, as I look at mobile phones, is it any surprise that the droid or mobile phones may be the real heroes here of health technology and information. 
 
But I also want to give an optimistic and a cautionary tale. First of all, I want to give the tale of two apps. The first app I want to talk about was the electric street lamp. So in the early 1900’s, there was discussion about whether we really needed these electric street lamps. Why do we need them? There was this one in the time dispatch. 

Somebody said, you know, electricity is not in any sense a necessity. And under no condition is it universally used of the community. And they’re arguing against this “app.” The killer app, they call it, of the 1900’s was electricity. As you see now, electricity and electric street lamps to which drove the use of electricity are just omnipresent. They’re everywhere. It could be argued that mobile phones are the killer app of health, and that they’re really going to drive the use of health technology. But, on a cautionary note, there are ringtones. When ringtones first came out, they were seen as these super hot things to have, and they’re going to drive the use of technology, of mobile phones, and everybody’s going to use a ringtone. That’s going to be the business model to which people will use with mobile technology. But as you see from the graph below that ringtones are fine, but they’re not necessarily essential. Not like electric street lamps. They’re essential for public health and public safety. But ringtones have fallen in popularity. So as we go about this presentation, I ask you to think to yourself, are we developing the electric street lamp of health and health technology, or are we developing ringtones. It’s an important question to ask right now. I don’t think we have the answer, but I think it’s an important perspective to keep in mind. So, right now, there is a mobile revolution. Mobile technology is everywhere. There are particular magazines focused on mobile technology, and iPhones and Newsweek. Not just mobile phones, but mobile technology, censors and others are in our everyday lives. And you see from this graphic from Fortune magazine, you look at the mobile U.S. subscriptions, and it has just exponentially exploded. The proliferation of mobile technologies has been amazing within the past ten years, particularly in the past five years, so much to the degree that there are now more mobile technologies being used then there are people that currently exist in the US.  CTIA, the wireless association, they find that there are over 367 million wireless subscriber connect ions, which is 104% of the US population, so an amazing proliferation of these technologies. And as you look at the Pew Internet studies, what you find that’s interesting is that the tradition gap and the traditional disparities that exist with health technologies do not seem to be existing here with mobile technologies. And actually, African-Americans, blacks, and Hispanics are more likely to own a mobile phone compared to the general population. But you also see some disparities that exist with respect to ages and generations, potentially, those ratios are expected to increase dramatically. So the use of mobile phones not only for older adults to stay in touch with loved ones to take care of them, as well as for those who  use them to take care of the aging population maybe a very important area for further discovery or further development. The Pew study also looked at currently, 2010 data, how many people are actually using a mobile phone to look up health information. In 2010, it was 17% of those who have mobile phones that looked up health information with their mobile phones. If you look at those who have wireless connections, either laptops, tablets, and cell phones, the number is higher with 67% of those have wireless connections and 78% have actually looked up information online about health. The use of mobile apps in 2010, only 9% of those who have smart phones downloaded mobile apps. More recently, in 2011, the numbers have increased with not just 17%, but now 26% of U.S. adults who use mobile phones now access their data, so a bit of a growth, but still only a quarter of the population have actually done so. But there is promise. You look at the sheer proliferation of medical and health apps, and this is only to December, 2009, and by now it’s probably increased even more dramatically. I think my last look at it, there was over 8,000 mobile health apps on iTunes. So this area, the number of mobile phone apps for health and medical use are again increasing dramatically, which opens up a number of opportunities because the growth of mobile phones is likely to increase to over 50% I believe by the end of 2011, beginning of 2012. 

 Now this is not just in the US that mobile phones have been proliferating. In developing countries, internationally, you see a huge explosion of the use of mobile phones. Where in 2003, only 61% of the world population was covered by a mobile cellular signal, now in 2009, 90% was covered and I believe that number has probably increased since then. 

 And this is particularly seen in developing countries in which the use of mobile phones and mobile technologies has increased substantially. So much to the effect that there are publications now, for example the mHealth alliance and the UN foundation released in 2010 a publication that documents over 50 case studies that are programs that are using mobile technologies for health in developing counties, and it’s a nice summary of the various case studies and kinds of programs that have been established, and I recommend anybody interested in that take a look at that report, because there are number of exciting opportunities and programs that have been launched. 

The use of mobile phones in developing countries has been so prolific that it’s actually leapfrogging those of developed countries. In developing countries, they’re jumping straight to mobile technology to provide information to the consumers, the users, and the population, because they don’t have to deal with the legacy systems that developed countries have. 

I want you to think about 2007. There were no Android phones. There were no iPhones. The first iPhone was released in June, 2007, and the first Android phone was released in October, 2008. Before then, you had BlackBerry’s, and Palms, but not to the extent that these iPhones and Androids currently dominant the smart phone market. In less than 5 years, the use of smart phones has become so prolific and so dominant in this space, and as you think about it, with respect to a contract or a grant at the National Institutes of Health or CDC, they are typically funded within a 7 year period in which results are typically not available until after 7 years, and so within a particular lifecycle of a grant that is funded NIH, the development of smart phones have far outpaced that funding mechanism. 

 And you also look at health text messaging. In 2009, there were 1.5 trillion text messages sent in the US. 4.1 billion text messages sent daily. That is a game changer. That is amazing, because it consumer centered. It is the consumer who is using this technology and leveraging this technology to connect with others, to get information from others, and the question now is how do we leverage this powerful technology, powerful application in future phones and smart phones to improve health. 

Now, the question is, okay, there are smart phones, cell phone based technology, the question now becomes, what is mhealth? The question is not how do we leverage the technology for health but what are we actually talking about with mhealth. There are a number of different terms that have been put out there. There is mhealth. There is telemedicine. There is mobile, real time, remote technology. Connected health. Wireless health. Lots of different terms that have been put out there. And there are number of definitions  that have been put out there, in the blogosphere, in different publications, and I put up the different number of definitions that currently have been put forth on mhealth. And as you read these definitions, emerging mobile communications and network technologies for healthcare is one. And others, umbrella terms for wireless devices used in healthcare. What is clear is that there really is no consensus about what is mhealth, such to the point that Eric Dishman wrote a blog. In that blog, he is struggling with these terms of mhealth, wireless health, smart phones, and what he says is that if mhealth is all of these things, then mhealth is nothing. And so we have to be more precise and more conceptual about our definitions of what mhealth stands for. And for me, and this is my opinion, this does not represent the views of HHS, or NIH or the National Cancer Institute, or others, but for me, the critical aspect of mobile health is the use of mobile portal information technology; mobile technology that can transmit data and information to different places; to different people. And I like Don Jones’ distinction that mobile technology is different from wireless technology. Mobile health is different from wireless health. They are not the same thing. You can have wireless technology that is stationary, in the home that senses where somebody is, but it’s mounted on the wall. You can mobile technology that is not wireless. But that collects information such as a PDA or a heart rate monitor that doesn’t connect to other things. The distinction for me really has to be with this term, mobile. What’s important for mobile is mobile health is mobile. Portability of the technology. 

For me, the mhealth tools include not just health text messaging and smart phone apps and tablet apps and the mobile internet web, but also things like heart rate monitors, blood pressure monitor, motion sensors, pedometers,  accelerometers , as well as global position systems and portable point of care diagnostics devices. There’s also this very interesting area of mobile games for health, and that is an area that many agencies and organizations are interested in. These are all mobile health tools because they involve mobile portable technology. Given this background about the explosion of mobile technology as well as my conceptual framing of mobile health, I just wanted to highlight many of the activities that HHS is engaging in, in mobile health.  

In November, 2010, Secretary Sebelius and Todd Park, the Chief Technology Officer of HHS launched the Text-4-Health Task Force. They recognized that there were a number of different health technology and health text messaging programs that were being developed at HHS and in their vision for innovation at HHS they wanted to further explore what was happening at HHS, as well as provide guidance and recommendations about how to move HHS forward in this area, in this really innovative, exciting space. 

The task force met for 6 months and provided recommendations directly to Sebelius about what was happening, and Sebelius was really excited about this area and was excited to hear the different programs as well as the recommendations for moving forward. She seemed to embrace the use of mobile technology as well as health text messaging for HHS programs. And you can read those recommendations on the hhs.gov/open website. They are there for public comment and I encourage you to look at those recommendations and provide comments and let us know what you think. But it was a signal to HHS as well as to the outside community that really health text messaging and mobile health is an important area for HHS and there are really some opportunities at HHS as well as in partnerships with others to innovate to meet the public health goals and to improve health among the population of the US. Some examples that were examined and came about because of the text-4-health task force are as follows. The CDC was one of the first innovators in this area. And they created mobile tips and alerts, and it was initially a mobile flu notification to let the public know about flu outbreaks and flu information, and that has turned into a broader mobile tips and alerts program through CDC. NHANES has now launched into a text messaging pilot in which their respondents to the NHANES survey are provided with text messaging to assist with adherence to diabetes testing, for testing for insulin and glucose and also provide information about results about some of the results of the testing of NHANES. 

NCI has launched a smoke free text program that is targeting teens and young adults, and so they are providing interactive, by directional messaging, that is tailored towards the individuals craving and mood state, that provides specific information to help those who wish to quit, and provide them with information that would be useful as they’re going about the quitting process. And there are a number of NIH and other grants that are being funded by HHS to develop projects, for example, the m-diet program by Dr. Ken Patrick, the University of California, San Diego, in which he’s using text messaging to assist those who wish to eat healthy and has shown scientifically effective results, using text messaging. And then there is the text4baby program. And this is an interesting program in which actually the government doesn’t own this program. We are engaging in a public private partnership in which health mothers, health baby’s coalition is the lead organization for text4baby and the pregnant women and new moms can text “baby” or “bebe” in Spanish to 511411 and receive free health text messages three times a week on pregnancy related or new baby mother related issues.  

It is one of the first programs to go national and what is interesting about this program is that health mothers/healthy baby’s is also working with CTI wireless foundation that provides the text messages for free to the user and they’ve had close to 250,000 people sign up for the program since February 2010, so it’s an area in which the government is playing a part as a sponsor. We’re not leading the area but we are engaging in this public/private partnership to provide these messages which are actually reviewed and some of them provided by HHS, embedded through HHS for accuracy and provided to the end user directly as they sign up for the program. And then there are a number of smart phone apps that are being developed. AHRQ’s  EPSS, looking at the preventive services selector. HRSA has an iPhone and Google find a health click app. NICHD, the National Institute of Childhood Health Development, and the National Library of Medicine came up with a really cool app that looks at embryo development. It has really cool pictures to show the progression of pregnancy. And the NIH has developed the “my dietary supplement” app that provides information about dietary supplements to the end user. And the National Library of Medicine has done an incredible job with a number of different apps, from emergency response, to getting health information out to the end user, and they have a whole website dedicated to mobile and kudos to the National Library of Medicine who has really been out front leading this area of mobile technology and mobile health.  

 And SAMHSA has put together a treatment locator for the iPhone, and these are just some of the examples of some of the innovative programs that HHS across the different OPDIV’s and agencies has put together. And then there is mobile web. And mobile web is different from mobile apps in that it’s really not located on the phone. There may be a shell of an icon, but really the information is really on a website, and the websites are optimized for the internet browser as well as the screen size of the mobile phone or tablet, and so it’s somewhat different than a native app that you get from an iPhone, which resides on a phone, they reside on the internet. We actually just put a blog up on the hhs.gov/open website that talks about these three approaches to mhealth and mobile phone technology. One, health text messaging. Two, mobile apps. And three, the mobile web. And again I encourage you to go to hhs.gov/open and read that blog. It provides a concise overview of different programs at HHS on these three different approaches. But again, you see here a number of different agencies, a number of different OPDIV’s at HHS who are using the mobile web to make the information accessible to the public and to the user. It’s not just limited to mobile phone use. 

 Here are some examples of point of care diagnostics that are really cool, developed at the National Institutes of Health. One is a chemical sensor, based on the Genes, Environment and Health Initiative, the GEI Initiative at HHS in which they could detect hydrocarbons and acid vapors in different areas, and this is done at Arizona State University, and it can sync with mobile phone technology, but it can detect chemical exposures to a very sensitive degree and there are also some being developed, I believe at the NIBIB at NIH in which they’re looking at using the cell phone and a connection to the cell phone that turns the cell phone into a microscope and can detect or look at infectious disease and diagnose infectious disease. And so there are some really cool things that are in addition to the cell phone that are being looked at. Also, there is some mobile technology. This is a pill box, that when opened sends information directly to a sever that tells it when the pillbox it opened. There are other technologies in the US that are smart pill boxes. Then, information can be sent to the user or to caregivers to say when the pill has been taken, if not taken, to prompt them to take the medicine. Mhealth is not just mobile phones, but also some other really cool technologies. 

Future directions. There are a number of important issues that remain that HHS can play a leading role in helping to answer or further develop. One, there is really not a consensus of what mhealth is. I have my definitions. Other people have their definitions. It will be important as we move forward that people have to come together to find, maybe not just a consensus, but a different operating definition of mhealth, so that we’re clear about what we’re talking about in this debate. 

Number two, is really how do we get off of these promising pilot studies? There are many pilot studies that have been developed in the US as well as internationally, but most of them have been case studies called pilot studies. Text-4-baby is one of the first to really scale up to a population level, and there is currently an evaluation being conducted by HRSA, and an HHS evaluation. But, we also need to think about as we develop these programs, how do we scale and make these programs go viral to reach the greatest amount of people in a target population as possible. And third, what would be important for scaling these programs is to figure out the comparative effective research. How do we know that these programs are as effect or not more effective than current pr4ograms, and what do we compare mhealth programs against? Do we compare them to usual care, do we compare them against internet programs, do we compare them with other standards of the care that already exist, and these are open questions that really need to be further discussed. 

And then, how do we optimize innovation and safety. This is where FDA comes in. They’re looking at making sure that when we look at this technology, that we keep populations safe from harm, but also how do we both as well as allow for innovation to occur. What are the business models for sustainability? It’s really important to understand who is going to pay for it? And there are different models that currently exist but there is no dominant model, and we need further research to figure out which business models work the best. And then what role should the government play in this area and particularly, how do we fund this technology? There are the grants and contracts that typically take a long time to fund and by the time the grants are funded the technology has moved pretty quickly. There are SBIR (Small Business Innovative Research) grants as well. Again, it takes a while for them to get funded. But there’s also this other mechanism of developer challenges. In December, 2010, the President signed an order, which was the American Reauthorization Act which provided the government with the prize authority to allow the government and HHS and others to provide awards and prizes for challenges. Something to the effect of an x prize. You develop an x prize, and ask people to develop technology to meet particular functions that you want. So this is another exciting area. And we’ve actually launched into this area recently and HHS has partnered with the White House Office of Science and Technology Policy as well as the Office of the Vice President on the Apps Against Abuse challenge, and this was launched in July, 2011 and just recently closed in October of 2011, and it encourages the development of mobile technology to help to prevent sexual assault and sexual abuse among young adults, ages 18-25. We launched this challenge and within several months of putting it together and vetting it through HHS and the White House, and in October we received over 30 technology applications or prototypes in response to our call for innovative technology, which is quite exciting. Some of the technologies that were submitted were quite interesting and innovative. You can go to the challenge website if you’re interested in looking at any of the prototypes and descriptions of the submissions. It’s all on the challenge website. I encourage you to look at it. 

Other important areas for future development that should be considered are again FDA regulation of mobile technology. They currently have a guidance draft that is available for people to take a look at. They’re trying to come up with guidance on what is a mobile medical application and what will require clearance. As HHS innovators and entrepreneurs think about further developing in this area, this is an important space to keep your eye on. There’s also HIPPA. HIPPA is currently in the process of being revised. There are some proposed changes currently in the works. When HIPPA was first released, it didn’t envision this area of mobile technology being everywhere and mobile technology being at the hands of consumers. This is an area in which HHS is very relevant because the Office of Civil Rights is one of the main agencies that is responsible for enforcing HIPPA. It will be very interesting to see what new changes come about. OCR is not the only group to deal with privacy and security. The federal trade commission also deals with privacy and security, and they have their own requirements about consumer privacy and security that need to be considered, and looking at both HIPPA and coordinating that with FTC will be an important area for further development at HHS as HIPPA rules are being modified. 

And finally, there’s the issue of 508 compliance and looking at those with disabilities, and how mobile technologies will be fitting into this area, particularly prototypes, and what requirements are necessary for prototypes of technology and development of applications. Currently, again 508 is going under some revisions. There’s a 508 refresh. The website is there for you to look at if you’re interested in this area. It’s important that as we develop these technologies at HHS, that we take into consideration these issues of 508, as well as privacy and security.  

So you may ask yourself what can I do to get involved. This is an exciting area. There seems to be a lot happening. There are many different text messaging programs, mobile apps, mobile web, other types of initiatives being put forth. What we’ve done is organized this HHS mHealth community of practice. The community of practice is a forum for sharing information, for helping to evaluate what is currently happening at HHS and what are the practices and standards that people are using as they develop the technology, as well as looking at different policies. What policies currently exist as the different agencies and innovators and entrepreneurs at HHS look to develop additional programs and how can we learn from each other.  

There are also a number of other really interesting and useful groups that established. HHS has the mhealth interest group, SAMHSA has a mobile working group in which they invite speakers to come talk about mobile health and then there’s this text-4-baby evaluation group for HRSA that is looking at how we best evaluate a program that scales nationally. Then there are a number of cross federal groups that you may be interested in. There is a wireless medical technology group run by NIBIB. There is a federal mhealth collaborative run by the Office of the National Coordinator of Health IT at HHS and HRSA in which it involves the Federal Communication Commission and the VA and others outside of HHS who meet to discuss cross federal initiatives, sharing information across different agencies.  

Then there is also the telehealth group, and a mobile gov community of practice that is organized by GSA. So, if you’re really interested in this area, or this area is something that really excites you, I encourage you to connect with these various groups or organizations, and it will give you a sense of the different activities that are currently happening. 

This is an area that is again moving very quickly. The technology is proliferating at a rapid pace and these groups are put together in order for HHS to stay on top of the changes that are occurring in this technology state and all the programs that are being developed outside of HHS. The mhealth community of practice in particular, we are looking at how to better coordinate and leverage HHS resources so that we’re not reinventing the wheel, so that we are creating synergy and sharing resources, because as you know, the federal budget situation is one such that we need to share resources and align our interests so we can move forward in this area. 

With that, I thank you. Again, I hope we are creating the electric street lamp and that we’re doing it with a really cool technology that is mobile and that shares information like an R2D2, a Droid.
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Webinar: Innovations in Mobile Health

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