Untethered Healthcare

On most cell phones, data usage represents thirty percent of average daily use. On an iPhone, data represents seventy percent of average daily use. Apparently, as a smartphone platform is able to support richer applications and app distribution becomes nearly frictionless, people’s usage patterns change. Or do they? This interesting slide deck from Pinch Media shows that most iPhone apps are essentially disposables –  less than five percent of the users of a typical app are still using it thirty days after download. The  sticky mobile apps are the basics: Web surfing, email, music and SMS together make up fifty two percent of daily use. What about those hundreds of thousands of apps in the app store and the millions of downloads? They represent only three percent of daily use for most users.

Clearly we are still in the “irrational exuberance” stage of mobile app development with people throwing everything against the wall to see what will stick. The vendors and carriers are encouraging all this experimentation because it helps drive use, but the economics for small developers building apps on speculation are still marginal. As for the buzz about smartphones replacing PCs and laptops, does anyone really do serious document creation on a 3.5 inch screen?

So what does it take to make a mobile app sticky? Mobility changes how people interact, collaborate, locate each other and transact business.  For the next generation of sticky mobile apps, look to Asia where smartphone use patterns are three to four years ahead of the US. The main focus there appears to be using smartphones phones as a payment vehicle and using highly optimized local search to facilitate transactions. This is in line with what I hear from custom mobile application developers who say the bulk of their business is e-commerce related. So one element of stickiness is “follow the money.”

On the mobile healthcare front, even though many of us expect smartphones to play a major role in wellness, I believe the  early, rapid growth in mHealth applications may occur in developing countries with SMS-based systems like this one from the non-profit FrontlineSMS. This central communications management system for rural healthcare runs on a laptop, uses $10 recycled cell phones, and is already helping save lives. It is sticky because it improves workflow in a fundamental way. It saves countless miles of walking and motorbiking by rural healthcare workers to follow up with patients and update their status. It allows a hospital with a catchment area of 250,000 people to track and manage their care more efficiently.

Your thoughts on making mobile apps sticky?

Given all the discussion about the difficulty and expense of converting a practice or hospital to electronic health records, it is refreshing to hear from someone at the front lines of digital health who says, in effect, “just do it.” Dr. John Mattison, CMIO for Kaiser Permanente,  speaks from experience, having gone through the conversion process five or six times in different settings. Dr Mattison spoke at the Telecom Council of Silicon Valley’s Mobile Health Forum last week. Under his leadership, Kaiser Permanente was able to convert all their fifteen thousand physicians to EHRs within three years. “EHR conversion is about leadership and change management.  I hear about a lot of first timers scanning paper into electronic records. The problem with that is that scanned images are not searchable. You just need to abstract the older records where necessary and only scan very selectively,” said Mattison. Kaiser Permanente’s kp.org  EHR which is based on Epic now has three million users.

Dr. Mattison also talked about the key role smartphones will play in healthcare. “Smartphones are the wellness delivery channel of the future. This is going to explode; it is big and it is soon,” he said, indicating also that the mobility of the consumer will drive the development of new solutions. He highlighted some gaps in current smartphone technology that will need to be filled in order to facilitate healthcare workflows: status aware protocols for SMS when someone is away from the phone and mobile standards for role-based access, for starters. Dr. Mattison also discussed the role of social media in mobile, participative healthcare and the need for a “sustainable, lifelong model of privacy” where health information is easily quarantined from other social media interactions.

If the smartphone is going to be the wellness delivery channel of the future, I would add that today’s phones as application development platforms still have a ways to go to fully enable this. In developing mobile clinical applications you quickly run into the problems like fast, secure roaming across disparate networks. Maintaining application state and secure user context when roaming from the hospital WiFi network onto a commercial cellular network –  when the physician leaves the hospital to go to lunch while reviewing patient data — can be problematic on a number of the main smartphone platforms. Currently Windows Mobile is the only platform with a full-on mobile VPN, though that is likely to change. Support for workflow applications, where a user is really interacting with multiple applications in a seamless way, is still limited for third party developers. As the dominant player in enterprise applications, RIM seems to understand this better than most.

Your thoughts on other barriers or enablers to widespread use of smartphones as a healthcare platform?

If 70% of clinicians are already carrying smartphones, then the obvious target for taking your clinical data with you is the smartphone. Everybody including the big telcos seems to be entering this space. There are already hundreds of healthcare apps for the iphone, including  one with FDA approval.  But suppose you are a network of hospitals and your clinicians don’t all carry iphones. Suppose you want to see your own data, your own way, on all your current phones. Developing custom apps for multiple types of smartphones is a headache. Smartphones are all different, with different screen sizes and ratios and different CPUs, and operating systems. Native applications must  still be custom designed for each platform. There are some promising technologies emerging to help overcome this hurdle, but then you have the risk of building your apps on top of a proprietary technology layer from a small company. Lots of big and little projects have gone south this way when the small company gets sold, changes direction or stops support. For now, the only real “platform independent” solution is still using HTML to build web applications. I put the “platform independent” in quotes because the mobile browsers are all different and so you will still have to test, tweak and perhaps optimize your app for each. Also, HTML is still insufficient for some types of streaming data.

The bigger issues with using mobile platforms for clinical and workflow data are usability, network security and FDA scrutiny. Good mobile apps tend to do a few things really well. Many mobile apps in the Windows world are really scaled down PC apps with the attendant problems of putting one hundred pounds of beans into a fifty pound sack. Also mobility creates new potential workflows like viewing real-time patient vitals remotely, even allowing off-site clinicians to check on patients from home and direct care, while remaining transparently behind the hospital firewall. (My group at a previous employer developed a mobile clinician notifer application for doing this.) The skills of capturing the most essential, actionable workflow data and marrying them to a well-designed user experience so that people can use your application with minimal or no training may be challenging for many IT departments. Thought leader institutions like Mayo and Kaiser are spinning up groups to understand the issues and create the new mobile apps to support their workflows, but most hospitals can’t afford that level of effort. I won’t address the issues of network impacts and FDA scrutiny here, but they are significant. Tim Gee over at www.medicalconnectivity.com has good discussion of  the enterprise network as a potential medical device here and there is a good summary of when FDA oversight is required for mobile clinical apps here.

I spoke with the CEO of a network of community hospitals and a new medical school in Oregon recently who said “our younger clinicians and incoming students already live and think this way.” The lifestyle driver is definitely there and lots of startups are entering the space. Uptake will depend on how well the mobile clinical solutions started with a need rather than a good idea, and thoroughly deal with the network security and regulatory impacts.

Your thoughts?