There's an app for that

An information technology executive glances at his e-mail inbox and sees a message from a physician on the hospital staff. He knows it's about the hospital's electronic health-record system.

Does his heart fill with dread? Not if he is Michael Skvarenina, assistant vice president of information technology at Holy Name Medical Center in Tea Neck, N.J.

“MicroHIS is a certified Stroke of Genius!” Dr. Alan Felsen gushes in a recent e-mail to Skvarenina about the mobile “app” he just started using that works with the iPhone, Android and BlackBerry operating systems to help doctors access patient information. “Just trying it out the other day, it had exactly the information I needed to keep in touch with the family of a very ill patient. Labs were really helpful. But the cell number for the family, too? Right at my fingertips? Very neat!” And those are only some of the functions available through the app.

Then there is Dr. Daniel Smith, director of gynecology oncology at Holy Nam. Smith says he “stumbled on” Skvarenina's no-pressure, in-house advertisement for MicroHIS on the hospital's EHR dashboard. “And so I went there and I signed up.”

“It's so cool,” Smith says. “When they page you, you get a beep on your phone, you open up to the patient and bingo. You hit the button and you're talking to the nurse. You can get vital signs and the labs, so you get a heads up about that. When you're on the fly, it sort of hits the nail on the head. It's efficient and it's very simple. It's sort of life-altering.”

Want praise like this for your IT system? Go mobile, says Skvarenina, who has basked in glory ever since the 318-bed hospital rolled out the self-developed app in March.

“We're thrilled,” Skvarenina says. “The physicians love our application. They've helped to build it. They come to us and say, it would be great to do this, and we build it.”

A common knock by physicians on EHRs is that their user interfaces are so clunky. In contrast, since the debut of the iPhone in mid-2007 and the advent of its imitators, a new breed of smartphones has been wildly popular largely because their user interfaces are so incredibly slick.

That's bound to boost physician adoption of mobile health technology, according to C. Peter Waegemann, vice president of mHealth Initiative, a Boston-based not-for-profit organization promoting mHealth applications. “The interesting thing is, for 25 years, people have been saying at the CIO level, if we could only get our docs to type or write on the computer, we'd have an electronic medical-record system. Now they, the docs and nurses, are saying (about smartphones), ‘I use those systems at home, with my children, I do my banking, why can't I use them here?' Even the older doctors say, ‘I love these things.' ”

It's ironic, Waegemann says, that “Most hospitals only three or four years ago had signs, no cell phones allowed. Now, they're saying this is the hottest tool to get our electronic health-record systems going.”

The federal government will pay about $27 billion in subsidies to induce hospitals and office-based physicians to adopt EHR systems. Meanwhile, providers, payers, the sick and the well are all snapping up mobile-health tools, such as smartphones and a variety of wireless devices, with no federal incentive payments required. These mobile-health users are ushering in a new era in medicine and wellness, mobile-health mavens say, while the government needs to do little more than take notes and get out of the way.

“There is an explosion of apps available to help docs, for all kinds of things,” says former health IT entrepreneur Todd Park, now chief technology officer at HHS. “The thing that would be important for us to do is to keep abreast of what's happening and, to the extent that we can, to unblock potential barriers.”

While the U.S. market is “saturated” with 234 million mobile-phone subscribers age 13 and older, according to researcher Stephanie Flosi, existing customers are rapidly swapping basic cell phones for smartphones. Flosi is a senior analyst with the market research firm comScore.

As of February, there were more than 69.5 million smartphone users in the U.S., compared with 25.5 million two years earlier, the comScore data show. And while text messaging, social networking and playing games remain much more popular uses than, say, perusing the Internet for healthcare tips, about 7 million smartphone users look up healthcare information on the devices at least once a month, according to comScore. At least 1.3 million people use them for health-related purposes nearly every day. And those numbers are growing.

The annual consumer market for remote/mobile-health monitoring devices, meanwhile, is estimated at between $7.7 billion and $43 billion, based on the range of what consumers told analysts at the PricewaterhouseCoopers Health Research Institute. The institute published a white paper in September titled Healthcare unwired: New business models delivering care anywhere, leveraging its survey and other research.

PwC analysts found three distinct business cases for mobile-health applications. One is as a lookup and communications tool for clinicians to improve workflow and decision-making. Another is as a pure-play consumer health support device. And a third is as a hybrid linking clinician and patient.

According to PwC, 40% of physicians surveyed said they could eliminate between 11% and 30% of office visits by using mobile health devices and applications to e-mail, text or monitor patients. But the greatest benefit seen by clinicians, according to the PwC survey, is in data access and decision-making (see chart).

About half of consumers surveyed, meanwhile, say they would buy mobile health technology, and 40% would pay a monthly service fee for systems that could send information to their doctors. For now, though, consumers don't want to pay very much for these connections. The preferred prices were $10 a month for the service and $75 for the device, according to the institute.

At Holy Name, the mHealth future arrived earlier this year when it hitched MicroHIS, its suite of mobile-health applications, to an existing Web-based connectivity platform, WebHIS. Now both systems link clinicians to the hospital's largely self-developed EHR.

Skvarenina, the hospital's point man on the home-grown mobile app project, recalls he was out to dinner with a pediatrician when she got a call from the hospital. “She called back, she had a hard time trying to reach a nurse and then had data read back to her, and I thought, ‘Wouldn't it be great if you could do this on a phone?' ”

Development on the mobile application began last December. It was piloted in February and rolled out in March. In two weeks, 77 physicians were using the system. Doctors can use their smartphones to obtain new lab, radiology and cardiology results, basic patient demographics, admission information, diagnoses, and the latest vital signs, and can call the mobile phones carried by on-duty nurses with the touch of an icon.

Physicians are now asking for access to progress notes and medication lists, and surgeons want their surgical schedules, apps that are under development and should be ready in a couple of weeks, Skvarenina says.

Breathless pronouncements about the potential for mobile health technology might sound hauntingly familiar, harkening health IT veterans back to the inflated rhetoric of the dot-com boom in healthcare at the turn of the century. But the bubble burst in 2000, and the market collapse killed the buzz over handheld healthcare.

What's different now? “The reality is, 90% of our population has a cell phone and 20% (of those) has a smartphone,” says Serena Foong, senior manager of the PwC Health Research Institute and the lead author of the mobile-health white paper. “Before, a much smaller percentage of our population worked that way.”

Foong says one interesting finding of the survey, one of likely importance to healthcare policymakers, is the incredibly high percentage of Medicaid patients (nearly 80%) who communicate via text messaging on a mobile phone, higher than any other population group with insurance coverage.

“It's the culture, that's how people communicate,” Foong says. “They're more mobile. They need to connect.”

Last month, the American Medical Association joined in the push for mobile health technology. It introduced its first-ever smartphone application for physicians to help them quickly find the appropriate AMA-developed Current Procedural Terminology, or CPT, billing codes and select the correct evaluation and management code for a patient visit.

The software works on Apple's iPhone, iPod Touch and iPad products.

The physicians' association also launched the 2011 AMA App Challenge, “to find the next great medical app idea,” according to AMA Board Secretary Dr. Steven Stack. Three winners will receive $2,500 in cash, plus a trip to New Orleans to show off their handiwork at the AMA's November meeting.

The AMA is hardly alone in heralding the use of mHealth technology. For example, just last week, the Veterans Affairs and Defense departments released a smartphone app to help veterans manage post-traumatic stress disorder. It's one of several apps the departments have rolled out to manage veterans' healthcare.

Dr. Joseph Smith is the chief medical officer and chief science officer at the West Wireless Health Institute. The twin goals of the institute are to discover new ways to use wireless tools to improve care delivery and drive down healthcare costs, says Smith, who has an undergraduate degree in engineering from the Massachusetts Institute of Technology in addition to his medical degree from Harvard.

The institute was launched in 2009 with $65 million in seed money from the Gary and Mary West Foundation, a charity founded by the communications services magnate and his wife.

“We are really empowered to go and be an ecosystem champion to drive innovation in healthcare toward the unmet need and cost of healthcare,” Smith says, adding that about 75% of national spending on healthcare goes to treat patients with chronic diseases. “This is where wireless technology offers an imperative to meet the opportunity,” Smith says. A list of conditions in which patients could benefit most from mHealth services would include asthma, depression, sleep disorders, obesity, Alzheimer's and chronic obstructive pulmonary disease, but “I think any list would have congestive heart failure at the top,” Smith says.

In early April, the Office of the National Coordinator for Health Information Technology at HHS released an update of its national strategic plan for health IT. One of its five goals was to “empower individuals with health IT to improve their health and the healthcare system.” That section of the 80-page plan was filled with references to mobile health.

“I think that mobile is going to become an essential part” of how IT contributes to the improvement of health in this country, says Park, co-founder of Athenahealth, a provider of Web-based revenue cycle management and EHR services, who became HHS' chief technology officer in 2009.

Rebecca Willett, national director of online services at Planned Parenthood Federation of America, says the organization has three mobile-health initiatives they have been working on over the past 18 months. Last September, the organization optimized its website for mobile devices. Of the 2.6 million site visits in March, 21% were from mobile seekers of information, she says.

The organization also is adapting its call-center program for two-way, text-based chats between clients and with counselors. “Teens in particular, when they have a crisis moment, they're not going to spend a lot of time digging through FAQs. They want to ask a personalized question and get a personalized response.”

A third program, Planned Parenthood Global Mobile, will target the estimated 5 billion cell-phone users worldwide, providing access to information and other resources. Already, 10% of the organization's Web traffic comes from outside the U.S., Willett says. “With the explosion of mobile technology, especially in developing countries, this is a great way to leverage what we've learned here. We just think there is a huge opportunity there.”

Another cutting-edge user and researcher of mobile-health applications is Dr. James Heywood, director of the heart failure recovery and research program at Scripps Health in San Diego. Heywood is currently working with heart patients using three different implantable monitors that communicate to and through wireless mobile devices.

One of the most promising, according to Heywood, uses a tiny chip implanted via a catheter in an artery in the patient's chest. The patient has a special pillow with an antenna in it, which sends a radio wave to the chip and powers it up. The chip measures pressure in the artery and sends a reading back to the pillow, which then dials up the Internet.

“If the pressures are out of range, it sends me a message on my smartphone,” Heywood says. The chip is “easy to put in. The complication rate is extremely low and it's been proven to reduce hospitalizations.” Work on wireless heart-monitoring technologies has gone on for 15 years, Heywood says, but only now is it coming into its own. “I think it's the wide availability of the Internet and the miniaturization” of implantable devices, he says. Waegemann, of the mHealth Initiative, says one of the few barriers to more rapid adoption of mobile-health apps is, for now, the lack of connectivity to many main-stream EHR systems, but that's only temporary.

“In the next two or three years, they'll solve the problem with interfaces,” Waegemann says.

Chuck Parker, executive director of the Continua Health Alliance, a 240-member trade group promoting the adoption of common communication standards by medical devicemakers, notes progress already made. Parker says the makers of 35 devices, including pulse oximeters, thermometers, blood pressure cuffs and weight scales, have certified their systems as compliant with Continua's interoperability standards.

According to Parker, one stumbling block to rapid innovation in mobile health could come from the federal agency tasked with protecting patient safety—the federal Food and Drug Administration, which regulates medical devices.

Parker says that even though a monitoring system may be an application on an unregulated, common smartphone, “if you have clinicians making decisions on the information from these devices and they're attached to human beings, generally speaking, they become regulated devices. He sees some progress in maintaining a regulatory divide between health applications and the mobile phone and the telecommunications network they employ.

And, if the new mobile application is a variation of an exiting device that's already FDA-approved, that's not such a problem, either. A “me-too” approval from the FDA could come in 30 to 90 days, Parker says, but “if nothing has been done in the past with a similar device type, that could take two to three years.

“We're working with (the FDA) on creating virtual devices and how to go through the certification process,” Parker says.