MHealth

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Introduction

MHealth (also m-health or mobile health) as defined by The World Health Organization, is a component of eHealth, and involves the provision of health services and information via mobile technologies such as mobile phones, tablet computers and Personal Digital Assistants (PDAs).(1) The World Health organization defines it as: medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices.(2) It is generally considered to be a category of eHealth. e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.(3)

The promise of mHealth for the United States was stated by then Secretary of HHS Kathleen Sebelius in 2011 as "the biggest technology breakthrough of our time" and that it would "address our greatest national challenge".(4) It has also been proposed as a breakthrough for so-called low and middle income countries as a way to reach a large underserved population that may not have read access to physicians and quality medical care, especially for chronic disease management.

Mobile technologies have potential to be a more efficient way serve Healthcare to a wide population base but little has been studied to date. “It seems for now, that most studies have been done on a relatively small scale and still has many needs in developing ways to monitor patient activation and effective use over time”.(5) “Utilizing mobile phones for health management are promising tools both for the delivery of healthcare services, and the promotion of personal health.” (6) “Healthcare professionals, due to the high level of mobility they experience, require ubiquitous access to relevant and timely patient data in order to make critical care decisions.” (7) (Koufi V, Malamateniou F, Vassilacopoulos G.). Powell States that , “The integration of leading edge networking technologies, such as web services and mobile communications, with PHRs can meet this requirement by enabling easy and immediate access to patient data from anywhere and via almost any device (8)(Powell AC, Landman AB, Bates DW.) The end result is to “Help monitor an individual’s physiological parameters outside of healthcare institutions and store the results in a PHR in a way which is available, comprehensible, and beneficial to the individual concerned and to healthcare providers.” (9)(Simon SK, Seldon HL.) Submitted by (Marc Sweet)

Terminology

Significant work has been done on smart wearable systems (SWS) in order to communicate information about the patient to a mobile device which then sends the information to a server. that server may or may not be able to incorporate that information directly into an EHR for further use. Some of the following terminology will be useful to know in understanding the process of capturing and send the information:

  • SWS: smart wearable systems
  • WCNs: wireless communication networks
  • BAN: body area network
  • BSN: body sensor network
  • PAN: personal area network
  • WAN: wide area network
  • MEMS: micro-electromechanical systems

Devices

For example, sensing systems can be worn as follows:

  • as jewelry, wristwatch, ring, necklace,etc:
  • as an electronic patch or "second skin"
  • as a chest belt or shirt with sensors incorporated into the fabric
  • as shoes for measuring gait during rehabilitation
  • as eyeglasses or (experimentally as of 2014) contact lenses
  • as gloves in order to receive and stimulate movements
  • validation of data (10)

(Chan M, Esteve D, Fourniols J-V, Escriba C, Campo E. Artificial Intelligence in Medicine 2012;56:137-156)

The most widely used sensors are accelerometers that measure acceleration of objects in motion along reference axes to discern velocity and displacement by merging data with respect to time.(11)(Appelboom G, Camacho E, Abraham ME, Bruce SS, Dumont ELP, Zacharia BR, D'Amico R, Slomian J, Reginster JY, Bruyere O, Connoly Jr. ES. Archives of Public Health 2014;72:28-37). One of the most used applications is for patients with diabetes in order to continuously monitor serum glucose levels. An investigational contact lens developed by Google is a contact lens that can monitor intraocular glucose levels and has an embedded LED that can activate to let the patient know their glucose level is out of range. Others have been trying to implement decision support systems into their sensor-smartphone interface in order to utilize past information stored in the server (EHR) to provide context to recommendations to the patient (Michael Marschollek).(12) (Medical Informatics and Decision Making 2012;12:43-52).

Besides diabetes care, perhaps one of the most useful applications of mHealth may be hypertension which affects nearly 1/3 of all people in the U.S. Titration of blood pressure with real-time monitoring may facilitate pharmacologic therapy without the patient having to constantly come in to the doctor's office for blood pressure checks. This has been done with the Advanced Medical Monitor system (AMON) which is a wristwatch that can measure physical activity as well as blood pressure, oxygen saturation body temperature and electrocardiographic activity (Michael Marschollek. Medical Informatics and Decision Making 2012;12:43-52).(13)

Drawbacks and Limitations

The following is a list of potential obstacles to successful implementation:

  • User perception and acceptance of the device as well as usability
  • Privacy issues with implementing acceptable levels of security of transmitted information
  • Interoperability with the EHR and other sensor derived information
  • Reimbursement; currently there are no codes for reimbursing clinicians for monitoring the data
  • Social inclusion of wearers
  • Technological capabilities of the system including power requirements (14)

(Chan M, Esteve D, Fourniols J-V, Escriba C, Campo E. Artificial Intelligence in Medicine 2012;56:137-156)

Acceptance may be dependent on the age and operational understanding of the patient. One study looked at both patients and physicians in terms of their acceptance of these devices. They found that male physicians use of mobile devices was more common than that of female physicians. In fact, physicians overall were more likely to own and use a mobile device than their patients. For patients, there was a strong correlation between the use of mobile devices and age as well as level of education. As expected, younger patients were more familiar and comfortable with device use than the elderly. This was mirrored with level of education as well. Doctors were concerned of loss of physician-patient interaction as a potential problem. Both patients and physicians were wary of privacy issues.(15) (Illiger K, Hupka M, von Jan U, Wichelhaus D, Albrecht U-V. Jmir Mhealth and Uhealth 2014;2:e42).

Critics of the technology claim it is "overhyped". From a global health perspective, this technology was envisioned to become a basic tool for community health workers, especially in regions where few doctors can travel long distances to serve their populations.(16) (CMAJ 2014. DOI:10.1503/cmaj.109-4861). Unfortunately, there is sparse literature demonstrating major outcome successes using this technology.

Update as of October 2016:

Standards and specifications are being created as of the time of this writing (October 2016) within the ONC for Health IT’s Office of Science & Technology (OST) to support the fundamental building blocks of interoperability. Standardization in the areas of meaning, structure, transport, security and services are being written to support different providers who have differing uses for these mHealth technologies.

  1. meaning through the use of standardized healthcare vocabularies,
  2. structure by leveraging standards in HL7,
  3. transport using secure email protocols,
  4. security through the National Institute of Standards and Technology
  5. (NIST)-adopted encryption standards and
  6. services through open, and accessible application programming interfaces (APIs).(2)

“ONC is working to enable the health IT community to convene and rapidly prioritize health IT challenges and subsequently develop and harmonize standards, specifications and implementation guidance to solve those challenges. ONC is also responsible for curating the set of standards and specifications that support interoperability and ensuring that they can be assembled into solutions for a variety of health information exchange scenarios.” [1]

“The Standards and Interoperability (S&I) Framework enables healthcare stakeholders to establish standards, specifications and other guidance to facilitate effective HIE. This Framework creates a forum which focuses on interoperability challenges.” In addition, “In order to meet Meaningful Use (MU) objectives, developers may use the NwHIN 1.0 Portfolio. A standardized set of tools called the Standards Implementation and Testing Environment (SITE) is available to assist developers of Health IT to meet the criterion for EHR technology and for interoperability. SITE includes a live testing environment with validation and transport tools to assist developers. The SITE environment consists of a knowledge base including authoritative answers to frequently asked questions, a forum where developers may pose questions to the community, and an issue tracker for developers. Developers may submit questions to the issue tracker and subject matter experts resolve answers using the appropriate standards body. A sample data repository is also available to find and contribute document samples.”

Notes

  1. S&I Framework, "Standards & Interoperability Framework", Available from: http://wiki.siframework.org/. Published 2014. Accessed October 21, 2016.

2. HealthIT.gov HIE Standards and Interoperability. [serial online] 27 Feb 2014. [cited 2016 Oct 18]; Available from: https://www.healthit.gov/providers-professionals/standards-interoperability


Submitted by (Tamer Abd El Wahab Etman)

Submitted by (Allison Owen)

Patient Monitoring

With the advent of smart phones in the past decade, patients can use their mobile phones to monitor their personal health and upload that information to an EHR for healthcare providers to review. For example, an iPhone 6 has the following types of sensor:

• Accelerometer

• GPS

• Ambient light

• Dual microphones

• Proximity sensor

• Dual cameras

• Compass

• Gyroscope

• Barometer

• Heart Rate Monitor

• Touch ID/fingerprint scanner

• 3D Touch: enables pressure-sensitive touch inputs(17)(wikipedia.org, 2016)

An iPhone 6’s (stylized as iPhone 6S and 6S Plus) built-in accelerometer can be used to characterize the physical movements of the person carrying it, including specific movement patterns including sitting, standing, and walking (Nolan, et al., 2014).(18) The cameras and microphones can be employed to collect information about the patient’s daily routine and environment. The compass, GPS, and accelerometer can be used to collect information related to a person’s preferred mode of transport and daily activities. As of September 7, 2016 they were replaced by the iPhone 7 and iPhone 7Plus.(19) (wikipedia.org, 2016)

Specific apps can be downloaded to improve the effectiveness of this monitoring, and also allow for community sensing. Community sensing applications allow people to access information about recent outbreaks of disease, what general area or areas those outbreaks have occurred in, and what they can do to limit exposure (Lane, et al. 2010).(20)

Apps and patient monitoring require a different approach to privacy and security to be compliant with privacy practices. HIPAA requires that electronic protected health information be encrypted at 128-bit blocks or better. Some commercial entities program to higher tolerances – Skype uses 256-bit encryption. Virtual private networks (VPNs) provide a secure way of transmitting information between authorized users (Luxton, Kavl, & Mishkind, 2012).(21)


Submitted by (Christopher A d'Autremont)

One of the benefits to mobile technology, especially in Smartphones and Tablets is the use of apps. Apps are programs offered usually by a carrier or phone manufacturer. Apple App Store, and Google Play are two examples of ways consumers download apps. You can find any kind of electronic media available on an app store. Anything from games, movies, and premium features that expand services are sold or unlocked in these two app marketplaces. These apps enable the ability to connect to Biosensors to read data on various vital signs. Some examples of biometric sensor capabilities are: Heart Rate Monitor, Blood Pressure Monitor, Respiratory measurement, Scales for weight loss tracking, and Blood Glucose monitors used in diabetes monitoring.

Submitted by (Marc Sweet)

Submitted by (Allison Owen)

Clinical Decision Support (CDS)

“Mobile technology holds enormous potential for transforming healthcare delivery systems which currently involve cumbersome processes that slow down care and decrease, rather than improve safety.”( Koufi V, Malamateniou F, Vassilacopoulos G. ) (7) Software like EPIC has been developed by vendors to the healthcare industry that assist in day to day clinical workflow including CDS. These software technologies are a means to enhance the patient care without having to have on site expensive machines or specialized knowledge, Mobility assists in the issue of relevant retrieval of relevant data in real time.

Submitted by (Marc Sweet)


MHealth Regulation

Beginning with "Medical Device Data Systems" regulations (6) issued on February 15, 2011 with later MHealth Regulation guidance issued on September 25, 2013 and February 9, 2015 the Food and Drug Administration has provided an approach for development of MHealth.

Because of these ambiguities in legitimacy, “The US Food and Drug Administration (FDA) has paid close attention to mHealth apps because it has the regulatory authority over their safety.” (8) ( Powell AC, Landman AB, Bates DW.) “mHealth apps acting as medical devices as accessories to medical devices will require FDA approval, whereas apps that provide users with the ability to log live events, retrieve medical content, or communication with clinicians or health centers will not be regulated under its jurisdiction.”(8) ( Powell AC, Landman AB, Bates DW.) Public opinion is a not scientific or accurate way to gauge the effectiveness of a device. “There is a need for alternative models for app review and certification that are sustainable and free of conflict of interest.”(8) ( Powell AC, Landman AB, Bates DW.) Without this governance false and damaging claims could be made. Currently the mHealth training institute of the national institutes of health is developing curriculum to encourage researchers to further the potential for mHealth and the ability to give thorough examinations using the intervention of mobile technologies. (8)(Powell AC, Landman AB, Bates DW.)

Submitted by (Marc Sweet)

Summary

Mobile Handheld Technology has heralded the opportunity to provide physicians with access to information, resources, and people at the right time and place. Mobility is an important component for health care delivery (22). Mobile technologies provide benefits of paper charts and desktop computers in their portability and support for information access anywhere and anytime (23). Handheld devices include tablet computers and personal digital assistants (PDAs). These devices are generally small, portable, lightweight computers with wireless network capability. A review demonstrated adoption among health care providers who are primarily hospital-based at 45% to 85% (24). Handheld devices uses include: administrative support (e.g., billing and scheduling); professional activities (e.g., patient tracking and electronic prescribing); documentation; decision support (e.g., clinical and drug references); education and research. Potentially benefits include improved productivity, increased information access, better communication, fewer medical errors, greater mobility, and improved quality and care. Another advantage of handheld devices is providing information and decision support access at the point-of -need. Disadvantages related to entering data, which is slower with a stylus, more erroneous and less satisfactory. Other limitations include smaller screen size designed for individual use so can limit collaboration, present challenges in viewing and entering data, which can lead to errors. However, the literature is limited on demonstrating that handheld devices improve outcomes and workflow efficiencies because of their mobility. Additional research needed to evaluate further the questions related to impacting these mobile devices has on work practices and outcomes (25).

Related articles

Bibliography

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Submitted by (Larry W. Holder)


Submitted by (Richard A. Friedman)

Submitted by (Eric J. Vinson)

Submitted by (Marc Sweet)

Submitted by (Allison Owen)